Friday, July 23, 2010

Where was I? Oh, yes: NSTEMI and clotting. That's right.

Ah, yes. The promised on-subject post.

A couple of definitions for those of you who aren't well-versed in Medicalese: NSTEMI (pronounced "enstemee") stands for Non-ST Elevation Myocardial Infarction, which means basically that it's a heart attack that lacks a hallmark of heart attacks when they're found on an EKG (that wiggly line that goes boop-boop-boop in the ER shows).

And platelets, which we'll be looking into later, are critical to making your blood clot. I've forgotten by now what a normal platelet count is, since I haven't seen one in a year or more (Dr. Google says it's 150,000 to 450,000; thanks!), but the important thing to remember is this: Sunnydale has a policy that says, due to the general shortage of platelets for transfusion, ain't nobody getting a platelet bag unless their plates are under 10 grand.

So I get this patient. Brilliant, funny, cynical, hilarious: the sort of person you would want to drink your gin with the very second the sun crosses the yardarm. He showed up at Sunnydale's clinic that morning--wearing, and here I shit you not, an ascot--for his usual platelet transfusion (because he has a bevy of weird clotting disorders that I won't go into here) and mentioned casually that his left leg just went dead the night before.

They ran him over to the ED, where it was discovered that he did not have a brain bleed, he was not any more sick than usual according to the bloodwork, and that he was having an NSTEMI right there in the ED.

Whereupon they transferred him to me.

Now, the interesting thing about this case is this: the MRIs we did showed no stroke. Neither did the CTs of the brain that he had over at the ED. I imagine they've gotten a CT of his spine by now; I certainly hope so, since it's likely that he had a clot or some sort of weirdness going on in his spine.

Except for that whole platelet thing. People who develop clots normally have a risk factor that's incredibly common: a normal platelet count. His was not normal. In fact, it was the worst I've ever seen: less than a thousand. Why he wasn't just sort of seeping blood out from every orifice is beyond me; his platelet count was so low that our lab just sort of shrugged, ran the test a couple more times, and said, "Walp, here 'tis, have fun."

I suppose he could've had a spontaneous spinal hematoma, which would explain his symptoms, but he had no pain. Pain is the hallmark symptom of a spinal hematoma. Of course, he had no pain with the heart attack, either, so maybe that's not the best thing to go on (hence my hope they've done a spinal CT by now).

In short, this is how his exam by Dr. Heron, the neurologist who reminds me of a wading bird, went:

Dr. Heron: "So, how did you feel just before your leg went dead?"

Patient: "It was the best day I'd had in years! I felt just fine. No worries, no pain; just got up from the couch and fell over."

Dr. Heron (while doing complex neurologist-stuff with pokey things and feathers and such): "Okay, do you feel this? This? How about this? Oh, you feel that?"

Patient: "Yes, I feel that. It's sharp."

Dr. Heron, standing back and gazing adoringly at the patient, as though he's a new form of insect never before described by science: "Fascinating!"

When Dr. Heron says "Fascinating!" in that tone of voice, and with that charming smile, I expect two things: a bevy of the most obscure lab tests I've ever seen, and a very strange diagnosis at the end.

My conversation with him later went something like this:

Me: "Um....did they tell you that this patient was in the middle of an MI when he came in?"

Dr. Heron, busily looking up obscure tests to order: "Yes, they mentioned that."

Me: "Do we want to do anything about it?"

Dr. Heron, distractedly: "Do we? I mean, can we do anything about it?"

Me, totally out of my depth with anything below the neck: "Er....well, we can't stop it, if that's what you mean. But it might be a good idea to, you know, try to prevent any more damage to the myocardium. With medication. Er."

Dr. Heron, still more distractedly: "This is why we hired that physician's assistant with the specialty in cardiology. What was his name again? Call him. Oh, and how long will it take to get a beta-three gronkorcium scan with trilateral snorfle screening back from the lab?"

I called the PA and let him handle it.


Andrea said...

Bwah ha ha ha ha!

How'd he do? You can't stop here! What was the Rx? (I'm a CCU nurse, I'm DYING to know!)

It seems lately there have been a lot of Catch-22s with regard to MI and bleeding. MI + GI bleed (LOTS of these lately), MI + subdural hematoma, MI + new dx cancer that needs to be resected. WTF?

bobbie said...

Cool!!! Please keep us posted as to eventual Dx and Tx ~

Ya sure as hell can't put him on Plavix/ASA!!!!!!!!

KAK said...

This is awesome. I work at a teaching hospital and I really enjoy when the interns look at me and say, 'well, what should i do?'...I really want to tell them to go back to an accreditied medical school.
Does this dude have DIC? I hate when you have awesome patients and they are super sick.
I'm a RN on a nephrology unit, so I usually only get the cranky patients, so an awesome patient is a rare commodity indeed. Keep us updated!

messymimi said...

Just when you thought you had seen everything.

As to the no pain, he may just be one of those with such a high threshold that nothing phases them.

Zane said...

I love it when they start ordering labs from the Dr Seus Lab Reference Manual.

Anonymous said...

Snork...I too have forgotten what a normal CBC looks like. If it ain't 5/18 I'm a happy camper. And even then, well, pretty happy! That and BUN/Cr, I know what it should be but nearly everyone one of our patients is nowhere near that.

Dr. Heron almost sounds like our new interns, but at least he knows the neuro thing...