What Seems to be the Problem?
“I’m on Highway 17 about twelve miles south of Columbus and just had a flat tire.”
“The entire east side of town is out. We’ve been without electricity now for about 24 hours.”
“We spent six months planning this trip to Cancun and now it is starting to rain.”
“Dad seemed confused this morning and now we can’t even wake him up.”
The above situations all have something in common, and it is not just that they are distressing. They all are followed by a question, which can be asked in many different tones, but is always composed of the same five words:
“What do we do now?”
Of the four problems mentioned the last is the one I encounter in my profession, and as one might guess the development of mental status changes can challenge even the most experienced physician. Before revealing how I would attempt to solve this crisis I might take a moment to explain what the first three problems have to do with the case of the comatose father. After a vigorous bout of head-scratching, (and thanks to our highly evolved intelligence), one might suddenly realize that the first three predicaments represent a certain pattern. For example, the highway crisis can be solved by one person in most cases - either by the driver or his rescuer if the driver hasn’t a clue how to change a flat.
The second crisis, however, is unlikely to be corrected by just one individual. After a storm bulldozes through a city it takes dozens of workers clearing trees throughout the night to restore electricity to the hundreds of darkened homes. A team of professionals is required to solve a dilemma as big as a power outage.
This makes perfect sense - some problems can be corrected by one person and others require teamwork. What then of the rain shower now pummeling the abandoned Yucutan beaches? Is there a way to stop the skies from emptying on young lovers? Can we ever hope to control the weather? And why do stars fall down from the sky every time you walk by?
Ahem…let’s not get distracted. The ruined tropical vacation is a perfect example of a problem that cannot be corrected no matter how many entreaties are made, or goats sacrificed. Some facts of life just cannot be changed, although they did finally take “Hee-Haw” off the air. What makes the conundrum of the obtunded slumberer unique is not that his malady is difficult to diagnose. Au contraire, it should be easy to find out the cause of his hibernation - it is the solution that represents the sticky wicket. Those of you who have been paying attention undoubtedly have realized the connection between the first three crises and that of our patient, namely that unlike the others, this problem seems to have three possible outcomes. It could be solved by one individual working alone, or only by a team of health care angels toiling throughout the night - or it may be clearly insuperable. Examples of each respective cure include the solitary caregiver reducing narcotic or sedative usage to correct the effects of overmedication, or the team of specialists called in to remove a subdural hematoma or begin radiation therapy for brain metastases. The worst of all possibilities is if the patient has slipped into an irreversible coma due to a cerebral hemorrhage or some other catastrophe.
Not that I need more tension in my life, but when it’s me standing over the obtunded patient, I do get excited and wonder what on earth the final answer will be - is there a simple solution, or is the patient doomed to drift off to the heavens as we all stand hopelessly by?
In the example above the crisis was precipitated by the patient’s calcium level rising from 9.8 (normal) to 19.8 (Holy-Mother-of-God-Batman!) in one week. Hey, at least I found out quickly what the cause was by reviewing a standard blood test. Fortunately for the patient this complication can be corrected - first by one person writing the proper orders in the chart, then by the team of pharmacists, techs and nurses who give the treatment promptly and skillfully. In my patient’s case after receiving treatment he awakened from his visit to the Sleepy Isles, and all was well - for now.
I say for now because whether I like it or not, being an oncologist is all too frequently like lying on the silky sands overlooking the turquoise waters of the Gulf of Mexico - and hearing the distant rumble of approaching thunder.
