When Everything That Could Go Wrong, Goes Wrong

About one week before Christmas I picked up a new patient from night float, a 48 year old woman named A.M. who presented to the hospital with a 5 day history of headaches. Her PCP had prescribed Fioricet with no relief. The admitting diagnosis was hyponatremia (Na of 126), and while she did seem confused at times and held her head at a stiff angle, she was mostly oriented x 3. I put her on NaCl for the day and later spoke with her husband by phone about what I wanted to do for her. He asked when he thought she'd be able to leave the hospital, and I said once we find the cause of the hyponatremia, maybe a few days.

The next day her sodium had dropped even lower despite being on IVF, so I consulted nephrology to evaluate her. She was diagnosed with SIADH and transferred to the ICU to get hypertonic 3% saline. I told the patient and her husband that she was not going to the ICU because she was sicker, it was so we could keep a close eye on her sodium. Even on the hypertonic saline, her sodium was slow to improve. It made no sense for a previously healthy woman to develop SIADH out of the blue, so I looked up causes of SIADH as a refresher. One thing jumped out at me: infection. Specifically, meningitis.

Suddenly everything became terribly clear. The headaches, the stiff neck, the "new" onset fever of 103 and her WBC jumping from 7 to 21 in less than 48 hours. The woman had meningitis; I was sure of it. I immediately ordered an LP, which was delayed b/c she'd been receiving Lovenox for DVT prophylaxis, but it showed a WBC of 400 and glucose of 12. Even still, her CSF didn't grow any organisms. I consulted ID, who believed that because she'd received Augmentin as an outpt for UTI, her meningitis was likely partially treated even before she came to the hospital. I explained the findings to the patient and her husband, who seemed surprised but accepting of the news. Her husband asked if he needed to be vaccinated against meningitis; fortunately the answer was no.

Over the next few days, the patient continued to spike fevers of 103 on a daily basis, but her WBC was falling and her sodium (I wish I hadn't let myself get sidetracked by the admitting diagnosis) improved. The MRI showed that her ventricles were slowly getting larger (compared to prior CT), and the ID attending warned me to be on the looking out for neuro changes. Then on Christmas Eve, her right pupil was noted to be more dilated so I called neurosurgery to see her. He didn't seem too impressed at first; except for a few instances of confusion where she asked her husband to hand her papers to grade (she was a teacher), she was fully awake and oriented. In any case, she was still getting Lovenox for DVT prophylaxis, and the neurosurgeon called me to flat-out say that "Lovenox and neurosurgery don't mix. My hands are tied." I felt horrible (you'd think I would have discontinued Lovenox after the LP), but again, the patient was stable and symptomatically improving so everyone felt that watchful waiting was the right approach. The neurosurgeon did, however, give the nurse a list of warning signs to watch for and to call him if anything changes.

That night everything went to hell. According to the RN, the patient was in her usual state of health at 10pm, eating KFC and talking to her sister on the phone. Then within 5-10 minutes she became completely unresponsive and her pupils became more dilated. The neurosurgeon was immediately called, and by the time he arrived my patient was on the verge of brain death (both pupils fixed and dilated). According to reports he immediately rushed her to the OR, shaving her hair off while doing so, and proceeded to place a ventriculostomy even before the rest of the OR team arrived. (It was very "Grey's Anatomy," as one RN put it). As he later told me, had he been even 2 minutes late in placing the ventriculostomy, she would have died. In all his years of practice, he had never seen someone decompensate so quickly; usually the neurologic changes are more gradual, easier to pick up. My partner said he was cursing himself for not putting the drain in sooner (and he even apologized to me for not doing so), but surely he'd forgotten about the Lovenox. Had he placed the drain in that morning, there was a risk of bleeding. Neurosurgery and Lovenox don't mix. There was nothing either of us could have done, yet in ways we both felt responsible (me for the Lovenox, him for believing it was safe to watch and wait, which really was reasonable at the time).

I told the husband that perhaps it was a Christmas miracle that allowed her to survive (all this happened right before midnight on Christmas Eve), but even then I didn't know how much she could improve. She was intubated and moved her arms and legs to painful stimuli, sometimes opening her eyes, but I wondered if she would recover. Most people showed signs of improvement immediately after the procedure, but she did not. I thought about her two children, one in high school, the other in college. How would they deal with this? And her poor husband, who has rarely left her side since her ordeal began. I didn't know what to say to him. I was off for five days for New Years, and I told him I would see him again once my vacation ended.

When I returned to work New Year's Day and our entire census was redistributed, I was disappointed to learn that my partner who'd taken care of some of my patients while I was gone had kept several of them, including my meningitis patient, on her service. In some ways it was better; she was more experienced than me. One of my former patients under her care actually coded and died on New Year's Day (his second PEA code in 2 weeks), and I was (selfishly) relieved that I didn't have to be the one to oversee the code. I asked her how my meningitis patient was doing, and the news was not good. Since I last saw her, she had become completely unresponsive even to painful stimuli, and both pupils were fully dilated and nonreactive. Brain death was confirmed shortly after midnight by the neurosurgeon, and after her family members gathered to say goodbye, she was extubated and pronounced dead at 0340.

I didn't learn that she died until this morning from my partner who had taken over her care, and we were both saddened by the news. "That was a crappy case of meningitis," said my partner. I was slightly relieved that she passed overnight; I don't know I would have been able to look her husband in the eyes after everything that's happened. To think she came in with headaches and hyponatremia (in a bitter twist of irony, her sodium had shot up to 160 the day before she died), only to be diagnosed with meningitis with the worst possible outcome. I think both the neurosurgeon and I will be haunted by this case for a long time, if not for the rest of our professional lives.