“Hey Doc,” said Darrel, one of the nurses, with a smile, “you should probably come see this psych patient EMS just brought in a little while ago. She’s bat shit crazy. I can’t get anywhere near her to place a line.”
“Yeah?” I closed out of a patient chart and looked up, “What’s she up to?”
“Man, she’s drooling and moaning and screaming, and shaking her head at me,” he said moving his head side to side. “But her vitals are pretty good.”
I pushed away from the desk and walked briskly to the room. This one sounded interesting. “Ma’am,” I said loudly from the foot of the bed. “I’m doctor…”
“Brrrr!” she spat. “You stay away from me!” I stood back and observed. “No, No, NO you don’t!” she swung wildly in the air.
I stood back and watched for a little while, glancing at the monitor displaying her vital signs. Everything seemed reasonably normal and stable, so we had some time. “I’m just going to listen to your lungs and heart to make sure everything’s fine. Is that OK?” I asked. She didn’t respond, as she was pointing to something to the opposite side of me, and finally said “you’re a good fluffy girl, aren’t you?” I wasn’t offended.
Her heart was a little on the slow side, and her lungs were perhaps a bit wheezy and gunky, but it was hard to say with all of the upper airway drool sounds that were reverberating from her throat to her chest. Her shirt was damp from all of the thrashing and sweating she had been doing, but now seemed a bit less agitated. Whatever fluffy was doing, she was calming her. “Ma’am,” I said out loud again. She looked at me suddenly as if noticing me for the first time, drool foaming at her mouth and dribbling down. “When did you start, uh, feeling strange?” No response, but she heaved into a blue vomit bag. When she recovered, I shined a penlight in her eyes and her pupils were smaller than normal and less reactive to light. That is often seen with opiate overdose, but she was not acting sedated like we would expect with opiates. She was acting agitated and hallucinating. She was acting nuts.
I stepped back again, and ordered some tests for her Altered Mental status–urinalysis and chest xray to make sure there were no common infections, complete blood count to see if her infection-fighting cells are elevated. Electrolytes to check if her calcium, sodium, or other electrolytes are off due to overexertion or hormonal issues. Excess calcium in the blood is known for “bones, moans, and psychiatric overtones” I recounted to myself, meaning joint pains and odd behaviors. I continued…looking for toxic substances, so I ordered a urine tox screen, aspirin/acertaminophen drug levels. Liver failure can cause confusion, so I ordered a liver panel. CT head to rule out brain mass or bleeding. While I was inputting my orders, a middle aged lady entered the room and sat in the chair next to the patient.
“Hi, I’m Dr. Nagavi, the Emergency Physician here today. Are you related to Ms. Smith?” I asked. I thought she looked a lot like Ms. Smith.
“Yes, she’s my sister.”
“OK, great. Thanks for being here. Does she have any history of psychiatric disorder, or any drug use that you know of?”
“No, not at all. Um, she’s usually really meticulous and usually acts…normal,” she said widening her eyes and motioning with her hand to the patient.
“Any recent stress at home or work that you know of?” I asked.
“Um, gosh,” she thought out loud, “No, in fact she just went on a cruise with some friends and said she had a blast. She did say she had some bug bites on her neck and arms and was a bit upset that she may have brought back some bed bugs…but she’s been back a few days and acting normally since.”
“Uh, huh,” I remarked.
“She did say she was going to buy some bug spray and spray her sheets and bedding down tonight, but I don’t think she’s laid down since.”
I walked over to the patient who was still drooling and now beginning to cry. “Ms. Smith.” She was moaning and crying but looked up at me. “Did you spray any bug spray today?”
She nodded affirmative through her tears and drools.
“Where?” I asked, believing we were on to something.
“Everywhere!…,” she managed to moan through the drool. “Onnn da suitcase, sheets, da caapet….”
I pulled the sheets off her feet, and indeed, she was barefoot. She was already slightly less confused, but clearly exhibiting signs of organophosphate or cholinergic toxicity. This is when too much acetylcholine–the basic nerve transmitter of the body–builds up at the nerve ends due to inhibition of the normal enzymes that degrade it. When this happens, the effects on the peripheral nervous system–that is the nerves in the skin, muscles, and lungs and NOT in the brain or spinal cord–are typically most pronounced. The acetycholine directly stimulates these nerves, causing basic bodily functions to go into over-drive. Excess tears, saliva, throat and lung secretions, urination, sweating and the like. Also, when the the vagus nerve–the nerve that ordinarily acts like the “brakes” on the heart–is overstimulated, it could slow the heart down dangerously.
Additionally, there are central neurologic effects on the brain including confusion, coma, and even death sometimes. She had many of these symptoms and the history supported it. I had read about this condition and its treatment many times in residency, but it is not a common condition seen in the US. I had never seen or treated it. It is often seen in agrarian societies where pesticides are used in an unsafe manner–overspray etc. It’s also a symptom of war chemicals weapons such as sarin. Victims of sarin and other nerve gases will literally drown in their own drool and bronchial secretions.
I stepped out of the room and grabbed Darrel. “Do we have any atropine in the Pyxis?”
“I don’t know…”
“Well if we do, give her 1mg IV stat. She’s got cholinergic toxicity from bug killer. And if we don’t have any, grab a vial of benadryl or benztropine or something and please find me,” I ran off to see the backlog of patients that were awaiting my emergency evaluation and treatment. Let’s see, runny nose; skin rash; ankle sprain…
I returned to the room after seeing several other patients, and Ms. Smith looked up at me and smiled. “How are you feeling?” I asked and remarked how much she appeared improved.
“Oh, much better,” she smiled.
“So how much bug killer did you spray on your carpet?” I inquired.
“I sprayed until the carpet was soaked and the can was empty…I didn’t want no bed bugs in my house.”
–DrMedicineMan
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