The patient was a 38 year old male brought in by his mother for two days of subjective fever and myalgia, with one day of confusion, bizarre behavior, and word-finding difficulty. According to his mother, patient started behaving strangely the morning of presentation: was putting multiple socks on one foot, tried to put a sock on his head, was attempting to speak but could only get some words out, scrawled the word ‘help’ messily on a sheet of paper. Mother reported patient came home from work early two days ago because he was feeling ill and having body aches.
The combination of fever and altered mental status raised suspicion for meningitis; thus, lumbar puncture (LP) to detect pathogens in the cerebrospinal fluid (CSF) was attempted in the emergency department. A second year emergency medicine resident attempted the LP first, but was unsuccessful. The ED attending then attempted and was also unsuccessful. Broad spectrum IV antibiotics were started in case he had meningitis. The patient was then admitted to the internal medicine service and sent upstairs.
When I entered the patient’s room in my gloves, yellow gown, and face mask, the patient’s mother was at bedside, crying. I introduced myself in broken Spanish. She asked me what was wrong with her son, why he was acting so strangely, why they had stabbed him in the back so many times in the ED. The patient was only loosely oriented, and was also extremely hard of hearing. Pretty soon we were shouting, trying to get the patient to answer some basic questions. After a few more minutes, I had to rush off to rounds. I told them I’d be back later.
After hearing my presentation of this patient on rounds, the attending felt that she should re-attempt the LP. It would have to be done quickly though, as she was rounding with multiple teams that day. The attending, senior resident, intern, and I marched over to the patient’s room and suited up in protective gear. None of us could speak Spanish. We whipped out a translator phone and started obtaining consent for the procedure from the patient’s mother. Then we asked her to go to the waiting area. We put the translator speaker phone on its loudest setting, and asked the translator to yell through the phone. The attending opened her LP kit and started positioning the patient. Via the yelling translator phone, she said to him, “Ok, I need you to get on your side and curl into a ball. Bend your knees all the way into your chest. Now stay very still. No matter how much it hurts, do not move. That’s the most important thing. Do not move.”
She motioned to me to come to the side of the bed, and told me to hold the patient’s arms and legs down, squishing him into a ball. She told me not to let him move.
At the first insertion of the needle into his back, the patient groaned and squirmed.
“Don’t move!” she said. The translator yelled it.
She kept removing and inserting the needle, changing the angle and entry point slightly each time. Over and over. Maybe 12 times.
The patient was crying, trembling. Sweat and tears rolled off his face, soaking his bed. He was begging us to stop, but he could barely get the words out because he was sobbing so hard. And there I was, using my weight and strength to pin him to the table, forcing his knees into his chest. Every so often the attending would make eye contact with me when he jolted, willing me to keep him still.
I have no other way to describe this than torture. I have never seen a human being in so much agony in my entire life. Yes, there was lidocaine injected with a smaller needle before the puncture was performed with a thicker needle, but I will never forget the image and sound of this terrified and confused man curled up on this table, clearly in the worst pain of his life.
At some point, a senior neurology resident appeared in the room, ready to give the LP his own try. The attending moved over and the neurologist descended, shouting his own choruses of, “Don’t move, stay still.”
Eventually, the neurologist gave up too. He had not succeeded. The doctors ripped off their masks and gloves and threw them away, storming out of the room.
I was directed to go find his family, explain what had happened, and explain that he would be needing yet another LP today, this time CT-guided to ensure success. Because it is expensive and requires a radiologist, the CT-guided procedure is reserved for patients in whom standard bedside LP is unsuccessful. I fetched his family from the waiting room and brought them to a slightly more secluded section of the hallway. And there we stood, in a random hallway at County, talking via a translator phone that kept beeping due to calls waiting about other patients. I told them that he had been through a lot, that he was in a lot of pain, that he still needed the procedure to diagnose his possible brain infection. I was unsure of whether I believed it myself at that point.
They asked me why none of the doctors could do his LP. They asked me what I thought was wrong with him.
Later in the day he went down to the CT suite and his LP was finally successful. I wonder how much more he suffered there.
Within two days, his mental status returned to baseline. His fever resolved one day after presentation. His antibiotics were discontinued, and he was discharged home without follow up. All CSF studies from the LP were negative. When he and his mother asked what his diagnosis was, we all just shrugged our shoulders.
Meningitis? Who knows. Because the antibiotics were started before the LP was successful, the negative CSF results could reflect meningitis that was cured by the antibiotics before the sample was taken. No one can say for sure.
One of the residents half-joked, “Maybe he was just drunk and had a cold.”
I’m not sure what my $200 of medical education bought me today. Perhaps it bought me the realization that in the process of becoming a doctor you don’t lose your humanity all at once. It happens so slowly you might not even notice.