A SICK DAUGHTER
The young woman lay on the stretcher, her eyes closed, her armsand legs in constant, purposeless motion. At the doorway, the patient's mother stood motionless, petrified by the image of her healthy, exuberant 20-year-old daughter, now pale and unresponsive. She went to the bedside and stroked her daughter's sweaty cheek. ''What have you done, my little girl?'' she whispered in the young woman's ear.
THE KNOWN UNKNOWNS AND THE UNKNOWN UNKNOWNS
The young woman appeared not to hear, not even to know her mother was there in the emergency room of the Upstate University Hospital in Syracuse. All that the emergency-room doctors could tell her was that her daughter was dropped off that morning by a young man. The triage nurse spoke to the man, who reported that the woman had gone to a concert with him the night before. They had been separated, and when they met up at the end of the evening, she had seemed happy — euphoric even. She slept on his couch, and that morning when he tried to wake her, she wouldn't even open her eyes. That was worrisome, but he let her sleep, he told the nurse. Later she became incontinent and began vomiting. That's when he finally took her to the emergency room. Then he left.
A LONG NIGHT
Waves of guilt and anger swept over the mother. She had waited up all night for her daughter. The girl always came home when she said she would, but the night before she hadn't. At 6 that morning, the mother drove to the apartment of the friends her daughter had gone out with. Yes, her daughter was there, a sleepy, hungover-looking young man told her. She was asleep. Worn out with worry and fear, the mother's relief turned to anger. How could her daughter have forgotten to call and let her mother worry all night? Tell her she's in big trouble, she told the young man, and then she left. Now she asked herself, Why hadn't she gone into the house and tried to bring her home? How could she have left her there? And what kind of friend would bring a sick girl to the E.R. and then just disappear?
THE EXAM
The young woman was unable to respond to her name, answer any questions or follow even the simplest commands when she was examined by the E.R. doctor, Lauren Pipas. Only when the doctor rubbed her knuckles against the woman's chest — a maneuver used to check a patient's ability to respond to pain — did the woman seem to have any awareness of the world around her. She moved, trying to elude the knuckle pressure, and moaned, but even then didn't open her eyes. She had no fever, and her heart was beating normally.
POSSIBLE DIAGNOSIS
In a patient this age who comes in unresponsive and with no obvious illness, drug intoxication or overdose is the most likely cause. Pipas ordered a urine drug screen, which would pick up the most commonly abused drugs. She also tested her blood for acetaminophen and salicylates, the active ingredient in aspirin. An overdose of either common over-the-counter medicine can kill if not diagnosed and treated quickly. And though an overdose seemed most likely, Pipas needed to make certain there was nothing else going on. The urinary incontinence reported by the young man suggested a possible seizure. So she also ordered an EKG, a chest X-ray, a head CT and routine labs, including a blood count and chemistry test. She would also test for thyroid disease and pregnancy, both common in young women who came to the emergency room.
SURPRISING RESULTS
The test results came back quickly. The EKG and CT were normal. She had none of the most commonly abused drugs in her system; there was no alcohol, no marijuana, no opiates. The urine test was positive for amphetamines, but that seemed an unlikely cause of her unresponsiveness. Her serum sodium — a key blood chemical that is central to most body functions — was dangerously low. Low sodium, or hyponatremia, can cause a loss of consciousness and seizures. If not corrected, it can cause permanent brain damage, even death. This remarkably low level of sodium would clearly explain why the young woman was unconscious. But why was her sodium so very low? It was an important question but one that would have to wait until the woman was stabilized.
TREAT FIRST, EXPLAIN LATER
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