Well, I feel like a big damn hero today.
So our team has a patient, 64 years old and admitted to the hospital for alcoholic pancreatitis. He also has Wernicke’s encephalopathy - in short, he drank enough alcohol to give himself thiamine deficiency which eventually fried his brain, so he has confusion, memory problems, unusual eye movements (lateral nystagmus, if you care), and trouble coordinating his movements at baseline.
So this morning, we hear a Rapid Response ring through the intercoms with this patient’s room number being called while we’re rounding. After the entire team had a nice jog up several flights of stairs, we find him back in the bed with the nurses explaining that he got out of bed and fell.
When asked about why he got out of bed and fell, he just told us “What are you talking about? I’ve been in bed the whole time.” Given his chronic memory problems from alcohol, this was sadly a normal response from him. He didn’t seem any different and resisted a quick physical examination from my fellow intern taking care of him, saying his stomach still hurts (remember he’s here for an angry pancreas). But everyone in the room can see the bump on the side of his head.
Naturally, we get a stat head CT to make sure he didn’t have a brain bleed or fractured his skull.
When the head CT was finished, the whole team was taking a look at it. The scalp hematoma was obvious, this nasty blood-filled bump outside of the skull, but it was clear there wasn’t any blood within the brain nor any fractures.
At this point, the attending looks at the team - me, my fellow intern, the senior, and the two medical students - and begins pointing at structures in the brain and asks us what they are - a good old pimping session.
But as the attending was going up and down through the image, my eyes kept getting drawn to this subtle asymmetry in the mid brain. Right next to the right putamen, there was this blurriness where the gray and white matter met that didn’t quite match to the nice distinction of gray and white on the left. I must’ve looked really focused or confused or something, because the attending asks me what’s going on, and I just pointed at the spot that caught my attention and blurted my thoughts.
“I think this guy just had a stroke. I'm seeing loss of the insular ribbon.”
My attending does a double take at the image, squints his eyes, and dials the number for the Radiology department.
“Hey. Can you take a look at the recent CT for this patient, medical record number xxxxxxx? My intern found something lateral to the right putamen. I want to know: is this a stroke?”
I wait nervously for the verdict as the radiologist downstairs brought up the image, regretting a bit for sticking my head out there - but knowing that I’d regret it more if I didn’t say anything and this guy did have a stroke.
After a minute or two, my attending hangs up the phone, looks at me with something akin to pride and amazement, and then nods his head with a smile.
“Good job.”













