Ok, so, we have a 38 year old man who presents with his sister-in-law, who’s taking matters into her own hands because this guy, we’ll call him Yury, he’s just working all the time and ignoring the fact that he’s declining. He’s moody. He doesn’t want to tell you much. Does this ever happen? His significant other does most of the talking.
For a few months now, he’s had severe headaches on an intermittent basis. He’s been smelling strange things; on a train platform in Detroit he smelled burning garbage, which, for Detroit, probably isn’t that surprising, but no one else smells it. He’s intermittently smelled burning rubber as well when no one else does.
This was all sort of ignored for a while, but during a recent performance–he’s an excellent piano player–he had some significant trouble playing, and even seemed to black out a bit during the performance. His appetite’s been down, and she’s noticed that he’s having weird mood swings and acting erratically. He seems to be withdrawing, and seems very flat at times.
Well, to give us a bit of a clue, despite what you just said you’d want to do, it’s 1937, so there was no more testing at this time, and he went home. You are working a week or two later when he’s brought back to the hospital after sudden neurological changes and unresponsiveness while on the toilet.
On exam now, he’s got what’s described as right facial paresis, reported miosis (??), decreased responsiveness, papilledema, and retinal hemorrhage. At first he has increased reflexes, then decreased reflexes, and then develops a Babinski sign! Ah! Let’s go through these terms.
Babinski indicates upper motor neuron damage. Why haven’t I done this since medical school? Stanford Medical school says the Babinksi sign is proof that doctors can make confident decisions with just a thorough physical exam!
Since it’s 1937, they did a lumbar puncture. Thoughts? Given the limited information above, would you do this?
Well, they did, and the opening pressure was 400 mmH20. Jesus Christ. Normal is a range from 6 to 25.
Soon after he slipped into a coma. Guesses on his vital signs and subsequent mental status? Let’s discuss the PTSD we all have from the Neuro ICU.
To back up a bit, assuming we see the problem on CT scan, what sorts of things would we do these days?
Well, to their credit, although I don’t see the actual records online, they did try to get a Neurosurgeon! This case happened in Los Angeles; the sister-in-law called her friend, Emil, who called his friend Harvey the fancy Neurosurgeon in Boston, but Harvey was retired. Harvey recommended his protegee Walter, but said Walter was fishing in the Chesapeake Bay with Harry, the Governor of Maryland. Emil called the White House, and I like to imagine that FDR himself called the Coast Guard to pull Walter off the boat and fly him to LA. This is beyond the typical 30 minute response for emergent surgical staff on call. Even with Walter on the way, doctors at the actual hospital where Yury was operated and removed a large brain tumor, thought to be a glioblastoma; despite this, Yury died.
The leading theory is that this patient had herniation and Duret Hemorrhages, or bleeding in the brainstem, from the herniation. Regardless, this is devastating and, frankly, not survivable.
Herniation? What’s it mean? How does it apply to the ED?
Duret hemorrhages were described by Henri Duret, an old, apparently racist Frenchman who didn’t do a lot of surgery himself but did a lot of anatomy work and recognized the importance of the smaller blood vessels that come off of what’s called the Circle of Willis and feed the brainstem as well as multiple key parts at the base of the brain. Discuss how bleeding in the brainstem or the base of the brain can range from silent to completely devastating. He recognized, in 1878, what we now refer to as diffuse axonal injury; when you have a severe traumatic brain injury, the shear forces at the base of the brain lead to multiple areas of small hemorrhage that make the injury much more devastating than it would otherwise be. He totally got this right, given how we now know about how the brain sort of torques at the base.
This is the story of George Gershwin, one of America’s most famous musicians. Gershwin was born poor to Russian Jewish immigrants in 1898, after his family fled Russia due to prejudice and threatened military service. Thankfully they completely escaped anti-semitism in the US.
He left school at 15 to earn a living writing songs after multiple members of his family, George included, demonstrated significant talents for composing, song writing, and musicianship. He and his brother Ira managed to write multiple musicals, and he’s known for Porgy and Bess as a musical, and Rhapsody in Blue, which combines both Jazz and Classical music and was a big hit at the time. He was 38 when he died, and was writing musicals and new songs the whole time. Jazz standards that Gershwin wrote include ‘Embraceable You’ and ‘I Got Rhythm’, along with his brother Ira. In this story, it’s Ira’s wife that tried to help him when he got sick, and Yury is a Russian nickname used for the Russian version of George. He died 10 years too late to be included in the 27 club, but still way too young.
Silver Fox Doc