`Not Like Herself at All`

      The Attack One crew arranged a special lunch for a member who had to spend his birthday away from his family. After finishing lunch in the restaurant, the crew is waiting for the small cake that will mark the event. But as their waitress approaches the table, she has no cake in her hands. She asks if one of the crew members could step back to the kitchen to help an employee of the bakery across the street, who had just delivered the cake. The paramedic leaves the table and follows the waitress back to the kitchen area, where there's a woman in the employee restroom. The waitress tells the paramedic, "That lady is just acting strangely—not like herself at all." From outside the door, the paramedic can hear the woman in the restroom vomiting. Another female restaurant employee is in there assisting her, and when the vomiting stops, the paramedic can hear their conversation through the door. The ill woman makes no sense as she talks to the restaurant worker.

   The paramedic knocks on the door, identifies himself and asks if he can help. The restaurant worker invites him in. "This lady," she says, "is just not acting like herself at all." The medic thinks it notable that both employees used almost the exact same words.

   The woman has stopped vomiting and now sits restlessly on the toilet. As the medic interviews her, she intermittently speaks coherently, then mumbles a few words, then makes no sense at all before returning to coherence. He asks if she's diabetic, and she says she has no medical problems. She adds she has some pain in her head, but has a history of headaches.

   The paramedic calls for his partners and reports on the radio a patient encounter and the need for a transport ambulance. His partners arrive and initiate routine assessment. The paramedic asks if one of the restaurant workers will go across the street to get another bakery worker to come over and assist in giving history.

   They move the patient out into the restaurant and sit her upright in a chair. Her behavior is very erratic: At times she sits with her eyes closed, at times she seems unable to speak, but then emits a burst of speech. The EMTs ask her again if she's having pain, but she reports no headache, and no chest pain, neck pain, palpitations, fever or nausea. Then, abruptly, she vomits violently.

   The paramedic makes an immediate decision: It's time to move the patient to the ambulance and head to the hospital. Carrying the airway bag, he takes the position closest to the patient.

   The patient's coworkers arrive at the front door just as the cot is being wheeled out. The patient barely recognizes them. They all agree, this woman is not, in any way, acting in her usual fashion. They provide additional history: no medical problems, not diabetic, no recent trauma or illness, never used alcohol or drugs. She occasionally complains of a headache, but that's all. They agree to contact her family. The paramedic advises that she will be removed to the local tertiary care facility, which has an excellent stroke program. The coworkers want to know what else to tell the family, and the paramedic communicates that the woman is likely having some kind of a stroke and will need a rapid workup in the emergency department to determine the exact cause of the problem.

   The crew notifies the hospital that they have a patient with a very rapid onset of unusual behavior who is a candidate for activation of its stroke alert program. The paramedic describes the unusual symptoms, the sudden episodes of vomiting, and the restless and erratic behavior. They transport the patient in an upright position. She vomits once more en route to the hospital.

Hospital Management

   The ED is prepared, and upon arrival the patient is taken immediately to the resuscitation room and to have a CT scan performed. The emergency physician hears the history and is most concerned the patient has suffered a sudden bleed in her head.

   About 25 minutes after arrival, the CT scan technician appears in the ED and communicates a message from the radiologist that the patient is, in fact, bleeding inside her skull, likely from a ruptured aneurysm. The neurosurgical team is activated and arrives to provide care, taking the patient quickly to the radiology suite to determine exactly what is bleeding. After their assessment, the emergency physician administers medicine to put the patient to sleep, intubates her and inserts other necessary tubes.

   A complete evaluation finds a ruptured aneurysm, blood around the brain and swelling in the area that needs to be reduced. Neurosurgery is performed, and a large aneurysm clipped. The patient is in the hospital and rehabilitation facility for almost a month, but eventually makes an excellent recovery. She has no recollection of the event, but her family and coworkers determine it must have happened while she was delivering the cake. Any delay in recognizing the bleed, the neurosurgeon observes, would have resulted in a terrible outcome.

Case Discussion

   There are several types of emergency events that occur in the brain that are collectively referred to as strokes. This patient suffered a particularly dangerous form of stroke where there is a malformation in the arteries of the brain that ultimately weakens, ruptures and bleeds. This is called a subarachnoid hemorrhage. Most stem from ruptures in arteries outside the brain, resulting in bleeding into the subarachnoid space—the area between the arachnoid membrane and pia mater. Some subarachnoid hemorrhages result from trauma, but most occur from sudden rupture of a cerebral aneurysm, as in this patient.

   This form of acute neurologic event does not cause the symptoms typical of the more common stroke (difficulty speaking, weakness, facial droop) resulting from blockage of an artery by clot or atherosclerosis. A sudden bleed causes very rapid onset of symptoms, including headache (often with projectile vomiting), altered level of consciousness, unconsciousness or seizures. Subarachnoid hemorrhage is a major emergency with high rates of death and severe disability. Diagnosis is generally made in the emergency department with a CT scan of the head, and occasionally through a spinal tap finding of blood in the cerebrospinal fluid. Treatment in the past, through neurosurgical closure of the abnormal blood vessel ("clipping" of the aneurysm), has been very difficult. There are now radiology-guided interventions done through the femoral arteries to close aneurysms without surgery; the neurosurgeon places a tube in the spaces around the brain to evacuate the blood. These modern approaches can result in some miraculous recoveries of severely ill patients, as long as the condition is recognized, the patient taken to a hospital that can do the treatments, and care is provided to prevent recurrence of the bleeding and complications.

   Acute change in mental status or level of functioning is a very dangerous event for a patient, and often indicates severe injury or illness. Sudden bleeding in or around the brain may cause a sudden change in behavior that EMS personnel must recognize as a form of stroke that requires rapid intervention.

Initial Assessment

   A 64-year-old female acting in an unusual fashion.

   Airway: Intact and uncompromised.

   Breathing: No distress.

   Circulation: Normal capillary refill, pink skin.

   Disability: New and apparently sudden onset of erratic behavior. Patient suddenly became very disoriented, with an erratic speech pattern. She moves extremities without deficit, and overall is restless, moving around on the chair and cot.

   Exposure of Other Major Problems: Sudden vomiting.

   AMPLE Assessment

   Allergies: None.

   Medications: None.

   Past Medical History: Intermittent headaches. No history of substance abuse, trauma, heart or vascular disease.

   Last Intake: Breakfast.

   Event: Acute change in mental status.

   Customer Service Opportunity: Communication with family, bystanders and coworkers will often provide great insight into sudden changes in behavior or functioning, and how quickly symptoms evolved. Such details will assist in determining the cause of the problem and how much the patient's mental status has changed from their baseline.

   Learning Point: Acute change in mental status or level of functioning is a very dangerous event for the patient, often indicating severe injury or illness. Sudden bleeding in or around the brain may cause a sudden change in behavior that EMS personnel must recognize as a form of stroke requiring rapid intervention at a hospital prepared to manage a neurosurgical emergency.

James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He is the director of clinical operations at EMP Management in Canton, OH, and serves as assistant fire chief and medical director for Washington, DC, Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, and a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

EMS EXPO

Jim Augustine is a featured speaker at EMS EXPO, October 26-30, Georgia World Congress Center, Atlanta, GA.