The doorbell

About 20 years ago, maybe more, I was brushing my teeth when I heard the doorbell. If I heard that doorbell today, it would make my heart sink into my stomach as it most often did back then. I was working in a rural emergency room, on a 24-hour shift. After 11 p.m., when the ER emptied, we’d turn down the lights and I’d make the long walk to the call room at the other end of the hospital.We were open 24 hours because the community often needed urgent care around the clock. But over the course of my decade there, I’d seen much more nonsense than illness between 3 a.m. and 5 a.m.: stubbed toes, warts that had been a nuisance for years, a request for a Band-Aid and, one time, a truck-driver stopping in and looking for a physical exam so that his driver’s licence could be renewed.I spit into the sink and went back toward the ER. I unlocked the hospital door myself and asked the couple for a health card as I walked them to the registration desk. I handed the overnight nurse the woman’s card and when the chart was ready, I took them into room one.Sarah Bell (not her real name) was 32, and she’d had a gradual-onset headache, on and off, for about a week. She was otherwise healthy, took no medications, denied previous surgeries or hospitalizations and didn’t smoke and only drank socially. I glanced quickly at her chart and saw that she lived in a town about an hour south of us—one with a much larger, much better-equipped hospital.I tried not to sound annoyed when I asked why she came all the way here, at this time of night. She was about to speak, but her husband interrupted. “Let me,” he said. “We went to our hospital earlier this evening. They said it was likely a tension headache and prescribed anti-inflammatories and that was it. No tests. No CT scan, no nothing.”Sarah worked in a suburb of Toronto as an accountant. She’d been working long hours and had a long commute to work, about 45 minutes each way. Her symptoms hadn’t kept her from driving, going to work or completing her daily tasks. She’d taken Advil and it dulled the headache, but once the medication wore off, the headache returned.I examined Sarah. She walked briskly to the registration area, and then to room one, following my lead. Her pupils were equal and reactive, and she didn’t flinch when the light shined in her eyes. A screen of her cranial nerves was normal. Examination of the heart and lungs were normal. I used the diaphragm of my stethoscope to elicit lower limb reflexes. Brisk and equal. Finally, I turned off the room light and performed a fundoscopy. There was no papilledema. The pain seemed to be coming from her neck musculature and radiating upward.DiscussionI sat down across from Sarah and her husband. Before I could speak, she told me that her grandfather had died of a brain tumour and her cousin, on the same side, had just been diagnosed with the same.“I’d have to agree,” I said. “This is likely a tension headache. I can give you a prescription for some anti-inflammatories, you can try some massage therapy or physiotherapy, and see how things go. If things aren’t improved in a week, or you develop new symptoms, you can follow up with your family doctor or come here.”Sarah closed her eyes and shook her head. Her husband’s eyes opened wide with shock. “What about the seizure then?”“Seizure,” I said. “You didn’t say anything about a seizure.”“It should be on the chart,” he said. “We told the registration clerk. That’s why we’re here now. After we left the other hospital, we went home, and then to bed, and then she had a seizure.”It’s true, in my haste to see Sarah quickly so I could get back to the call room, I hadn’t reviewed her chart. I turned over the papers and read the nurse’s note.“Seen at hospital earlier this evening for headache, no tests done. Husband woke to find patient seizing in bed.”I checked my watch. It was 11:30 p.m. “What time was this seizure?”“She had the seizure and we came straight here,” her husband said. “So about 10 p.m.”“What time did you guys go to bed?”“We were pretty tired after waiting five hours to be seen at the other hospital. We went to bed around 9:30 p.m.”“And then what happened.”“Just exactly what we told the nurse,” he said. “I was asleep and then I felt some rumbling beside me. I woke up and saw Sarah foaming at the mouth and convulsing, not responding to me at all.”“Was her whole body convulsing?”“Everything—her arms, her legs, her chest, bouncing off the bed.”“And she was unresponsive?”“Totally unresponsive.”“How long did it last?”“Three to five minutes.”“Did she urinate or soil herself during the seizure?”“No.”“Was she confused after?”“Yes.”“And then you got up, got dressed and came here?”“Yes.”“How quickly after the seizure?”“Almost immediately,” he said.“If someone has a seizure, especially one lasting that long, they’re usually in a postictal state, and usually for 15 to 30 minutes. It would be very difficult for someone in that state to get out of bed, get dressed and get into the car and come immediately to the hospital.”“It wasn’t easy,” her husband said. “I had to help her get up and get changed.”“You didn’t call an ambulance?”“I wanted to,” her husband said, “but thought that they’d just take us back to our local hospital.”“OK,” I said. “You’ve had a headache for a few days and you just had a seizure. I’m going to call in our lab technician to get some blood work and you should have a CT scan of your head.”I called the radiologist at the regional lead hospital. Their scanner had been down earlier in the day and they were backed up. He asked me if I could hold her overnight and they’d get her CT done first thing in the morning. Sarah looked well now, so it sounded reasonable.I asked the nurse to start an intravenous line just in case she seized again, and I considered a loading dose of Dilantin. I explained the plan with Sarah and her husband. They asked if they could leave once the blood was drawn and then return for the CT scan in the morning. I told them that I’d prefer keeping her overnight and if there was no further seizure, her husband could drive her to the hospital for the CT. If she did seize overnight, I’d likely call back and have her sent sooner, and by ambulance.They agreed.I wrote ER holding orders, and before heading back to the call room, I went back into room one. “I’ve ordered some lorazepam for you. It will help you sleep and has the added benefit of lowering the chance of another seizure.”“OK,” Sarah’s husband said. “I’ll probably head out and be back in the morning.”“Come at six,” I said. “The scan will be at seven and it’s 30 minutes up the road.” I took one step out, then returned. “One more thing, Sarah. You can’t drive.”“No, no,” her husband said. “I’ll do the driving tomorrow.”“No,” I said. “I mean you can’t drive. I’ll have to inform the ministry of transportation that you’ve had a seizure and you’ll have to be seizure free for several months before you can get your licence back. I’m not sure exactly what the process is, but it’ll be a few months at best before you can drive again.”They looked at each other and didn’t say a word. Finally, she nodded slowly, “OK.”Another discussionI made the long way back to the call room and when I entered, the bed-side phone was already ringing.“Can you come back,” the nurse asked. “They have a couple of questions.”“What is it?”“I’m sorry. I don’t know. They won’t tell me. They’re whispering in the room right now.”When I returned, they were both suddenly wide eyed and alert. It was as if it was suddenly mid-day and not midnight.“She didn’t have a seizure,” her husband said. “We just said that because we wanted to get a CT scan.”“Why are you telling me this now?”She spoke. “Because you can’t pull my licence. I need it to drive. If I can’t drive, I can’t work. I have a 45 minute commute either way and there’s no public transportation. I can’t lose my licence.”“But you told me she seized. For three minutes. And that she had a headache for a few days and that you went to one hospital, then went home and then she had a seizure in bed.”“I know,” he said. “It’s all true. Except for the seizure. We just said that so that she could get a CT scan of her head.”“How do I know you’re not just saying this just so you can still drive?” I continued before they could speak. “You rang the doorbell, you got me out of the call room, you made me wake up our lab tech at home and call her in, I had to call the radiologist on-call at another hospital to book a CT scan for the morning, and now you tell me that none of it’s true?”“Everything’s true,” she said. “Except the seizure.”“The seizure is the basis of this entire clinical encounter. Why else would you drive almost an hour to come here in the middle of the night?”Sarah’s husband stood up and motioned for her to do the same. He wasn’t apologetic. If anything, he appeared annoyed with me. “I think we should go.”“I think so,” Sarah said.They walked out of the ER and down the hall toward the exit.Ten minutes later, I was on the phone with the radiologist, cancelling the morning scan. I told him the story. “And they just walked out.”“So,” he said. “Do you think she had the seizure and then lied so that you wouldn’t pull her licence? Or, do you think she didn’t seize and lied about it to get the CT scan.”“Honestly,” I said, “I don’t know. But my chart is written in pen, and they seemed pretty distressed when they came in, and I already told her that she shouldn’t drive and that I’d have to inform the ministry of transportation about the seizure. I feel like I have to do it.”“You do,” he said. “Crappy situation if she never had a seizure, but if she did, and she has a seizure while driving, you’re on the hook.”The next morning, I completed the form and faxed it to the ministry of transportation. I kept her name on my clipboard for months, periodically checking to see if she ever returned to our hospital. She didn’t.Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from 25 years of practice.

The doorbell

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