Status Dramaticus

I had five minutes left in my shift in ambulance triage last night when they brought her in.

Stiff as a board on the stretcher, with her arms curled up in a familiar posture, shaking (more like tremors than tonic-clonic action). Nonrebreather in place. Wearing light blue scrubs.

I looked at the paramedics. "What the heck is this?"

"Status dramaticus," one of them responds, rolling his eyes. "Freaking out at home, her young son called us. We found her on the floor like this. Gave thiamine, glucose, narcan with no response. She's been like this off and on nearly the entire time. Apparently her boyfriend broke up with her, and she went out for a few cocktails. Her ex-husband was there too."

The patient smelled like sake. Her pupils were responsive--when I could get her tightly clenched eyelids open--and then she would roll her eyes up in her head. Almost no response to sternal rubs, pinches, or anything else. Pseudo seizure? It didn't look real. Unfortunately, I couldn't get a good O2 sat on her, so into a monitored bed she went, as I called to the doctors for assistance.

On the monitor, she was tachycardic (at about 120); 02 sat was 97 on a room air. Blood glucose 169. Blood pressure 140/80. And the shaking and eye-rolling continued. We called her name: "Mary! Mary! We are trying to help you! Please open your eyes and look over here!" She would stop for two seconds, moan and flop around, and then start with the clenching again. One milligram of ativan later, the clenching stopped, and the moaning and rolling started. Having determined that she was in no immediate danger, the docs went back to seeing the zillion other sick patients in our packed ED.

Our charge nurse stayed at the bedside for a few more minutes while I went to finish entering the triage and get ready to leave for the night. I was chatting with the paramedics as they were finishing their paperwork when their eyes widened. I looked behind me: Mary was walking down the hall, weaving slightly, toward us and the exit. "You have gotta be kidding me, " I said.

"Mary. Where are you going? Mary. MARY! Stop right now." I put my hands on her as she passed by and she shoved me hard enough to make me stagger.

"I'm OUT OF HERE!" she shrieks, yanking out her 18 gauge IV. Blood spatters on the floor.

Everyone grabs gloves, and the paramedics (two large guys) make a wall in front of her and restrain her as I get a stretcher. She starts struggling mightily and we almost lose our grip--she nearly avoids slamming her head on the railing of the stretcher. The doctor and I make eye contact and nod, and I give her the other milligram of ativan and five milligrams of haldol in her thigh. She is screaming and struggling, "LET GO OF ME!!!!! LET GOOOOOOO!!!!! Tell these MEN TO LET GO!!!"

I tell her we will let go if she stops struggling, and if she starts fighting or screaming again, we will tie her down. I tell her she cannot leave, that I've given her some strong medicines, that she's intoxicated, and that she needs to stay here so that she will be safe. We start wheeling her into our psych seclusion room. As we're pausing to take the other stretcher out of the room, she tries again to get off the bed. "I'm leaving this mickey mouse hospital."

"No, Mary, you are not. Get your butt back on the bed. This is not an option for you." As she sees that we're rolling her into the seclusion room, her eyes widen.

"No WAY. I am NOT staying in here." I assure her that she is; that she was brought in "unresponsive" and that she has to stay for her safety.

"Yeah?" she says. "Obviously your staff has NO CLUE how to handle an emergency. YOU LEFT AN UNCONSCIOUS PATIENT just LYING on a stretcher!"

I blinked.

"Mary, you were NOT unconscious."

"YES I WAS!"

I realize the futility of this conversation. "I'm not even discussing this with you. You are staying in this room, and this young lady is going to make sure that happens." With the one-to-one in place, I left for the night. Almost forty-five minutes late.