I’m combing through my brain of what the actual fuck is wrong with Dustin.
I have to put aside that he’s my husband. The pesky fact remains that he’s the love of my life and I’m terrified. So I have to turn off wife mode and turn on provider mode.
I start with the facts and start building the HPI (history of present illness) in my head. Note, this is my HPI, not the physician on his case.
Dustin is a 34 year old caucasian male who presents to the emergency department via EMS s/p report of syncopal episode and seizure. Patient has with a past medical history of alcohol use disorder with reports of sobriety for 4 years, current marijuana user, hearing loss in left ear s/p recurrent cholesteatoma, depression, and ADHD. His past surgical history includes a rhinoplasty for deviated septum in high school, and several surgeries on left ear for cholesteatoma removal, tympanoplasty, and reconstruction of hearing bones.
Nicole’s provider mode HPI
In layman’s terms: 34 year old white dude had a seizure and lost consciousness. He is a recovering alcoholic and claims to be sober for 4 years. He smokes pot. He doesn’t hear well out of his left ear. He had a benign tumor in his left ear that came back a few times after removal and had reconstructive surgery to improve his hearing. He also had a nose surgery. Depression and attention deficit hyperactivity disorder.
I continue to interrogate Dustin and his colleague Quinn to get more information. Turns out that Quinn being with Dustin was a huge advantage. His wife has epilepsy so he’s not unfamiliar with it and can help me tease out some more relevant facts. From Quinn I gather a little more relevant facts/timeline:
- Yes Dustin had lunch. (Dustin often forgets to eat)
- They entered a conference room for a meeting.
- Dustin was trying to talk and started stuttering.
- They tried to get him to sit down when he passed out and started convulsing
- Seizure was described as “grand Mal” where he was convulsing, turned blueish purple.
- Seizure lasted approximately 5 minutes.
- (Not relevant but hysterical) Someone yells out into the hallway “is anyone a doctor?” and calls 911. (Please recall my description of Dustin and his colleagues, a bunch of super smart computer security nerds. They work for a financial firm – fat chance of a random doctor just roaming around).
- When Dustin regained consciousness, he started swinging punches at the security guard.
- EMS came and rolled over to the hospital
Dustin recalls the story as:
“I wanted to say something REALLY REALLY inappropriate but I couldn’t get it out which pissed me off. I was stuck on words and they wouldn’t come out. Then I woke up on the ground with some big ass dude on top of me so I punched him.”
Paraphrased from memory
Back in wife mode, I’m totally amused and super curious. I was dying to know what he wanted to say that was so inappropriate but he couldn’t remember. Alas…
Back in provider mode, I start fleshing out the HPI a little more.
Dustin is a 34 year old caucasian male who presents to the emergency department via EMS s/p report of syncopal episode and seizure. Upon arrival patient is A&Ox3 but lethargic, pale, and diaphoretic. Vital signs stable. Friend accompanying patient reports seizure “described by friend present as “grand Mal seizure” with patient being unconscious and convulsions lasting approximately 5 minutes in duration. He reports patient being confused and combative upon regaining consciousness. Upon arrival to ED patient is alert but lethargic, pale, and diaphoretic. Vital signs stable.
Patient has no past history of seizures. Past medical history includes of alcohol use disorder with reports of sobriety for 4 years, current daily marijuana user, hearing loss in left ear s/p recurrent cholesteatoma, depression on SSRI and receives CBT, and ADHD on stimulant.
His past surgical history includes a rhinoplasty for deviated septum in high school, and several surgeries on left ear for cholestoma removal, tympanoplasty, and reconstruction of hearing bones.
Family history: Mother is still alive, in her 60’s, with history of obesity, HTN, smoking, ulcerative colitis. Father is deceased died of ruptured aortic aneurism in mid 40s. Four siblings all alive, sister with no significant medical history, oldest brother with type 1 DM and substance use disorder, second brother with significant substance use disorder and significant mental illness diagnosis unknown. Paternal grandfather died in mid 30s for unknown reason. Significant substance use disorder present on maternal side of family.
Nicole’s HPI
Still not totally clear what’s going on here. He had a seizure. Family history has significant substance use disorder, mental illness, and other historical facts that don’t really contribute to why he had a seizure.
I should note that historically I’m usually not so quick to put out there that I’m a nurse practitioner because that can sometimes be off putting. Sometimes people see it as braggadocious, know it all, annoying, or even “I’m watching you.” But the reality of it is, I also don’t want to muddy the waters. I respect the provider’s role and expertise. I also don’t want to mislead a provider and send them down an unnecessary rabbit hole. I want their genuine and unadulterated assessment of what is going on. I also want people to treat me and my loved ones as they would anyone else. I don’t want or need special treatment. Additionally, I work in cardiology and specialize in advanced heart failure. I’m not an expert on everything. I don’t want providers to skimp on information they assume I should know. Frankly, I’ve always hated neurology so this isn’t my wheelhouse at all.
However, this time was different. I didn’t want to pussyfoot around. I wanted answers. I didn’t want to lallygag around. I wanted to be helpful where I could be and figure out what the fuck was wrong.
A kind woman walks into the room and identifies herself as one of the residents taking care of Dustin. I quickly tell her I’m his wife and I’m also a nurse practitioner. I fill her in on his past medical and surgical history. I cut straight to the chase, “Dustin has a significant history of alcoholism but completely stopped drinking 4 years ago. He also is a daily pot user. Do you think it’s worth getting a tox screen?”
In my mind, I was terrified he had secretly started drinking again and perhaps he was in withdrawal which caused the seizure. So she asked Dustin if he had been drinking and he denied any alcohol use. I replied, “I trust him. There have been no signs of alcohol use but it is part of his history.” She said that it would not have been helpful since he has since been given a benzodiazepine. The next step was the head CT. In my professional opinion, that was totally reasonable.
I was still concerned maybe it was related to alcohol. However, looking back I think I was hoping it was alcohol related because that we can deal with. Of course it would be hard, but he has been sober for so long so I know he could do it again if he had to. The unknown scared me and I didn’t want it to be anything unknown. I wanted it to be a reasonable straightforward fix.
Transporters come and Dustin rolls off to get his head CT. Head CT scans are quick even with contrast. So Dustin isn’t gone long and the doctor comes back shortly after with an update. She says,
“So we found something on the CT scan. Looks like he’s had a pretty big stroke at some point.”
Paraphrased from my memory
I look at her incredulously. I reply,
“A stroke? In a 34 year old with little to no risk factors? A pretty big stroke at some point? Like in the past? And nobody noticed a pretty big stroke in the past? He has no deficits or residuals. How big is this stroke? Is this a final read, has an attending read it? Can you show me the images?”
Paraphrased from my memory
While I am talking she logs into the computer and starts to pull up his imaging. She notes it’s about 3 cm and shows me the scan noting that there isn’t a final read by an attending yet.
I’m looking at the screen and there is this giant blob in my husband’s beautiful brain. A giant blob in his left frontal lobe.
I reply to her,
“I’m sorry but this isn’t a stroke. That’s a mass and I’d like to wait for a final read from an attending before jumping to the stroke conclusion.”
Paraphrased from my memory
It’s July, she’s an intern. I wanted someone other than a brand new, week old doctor reading his scan.
She tells me they are going to start him on Keppra, an anticonvulsant, get a neurology consult, and admit him. Okay, that seems reasonable to me. Neurology comes and sees him and does a quick Neuro exam. The ED doc comes back and tells me the final read is back and it is a mass.
I fucking knew it.
A stroke made NO sense to me. She tells me that they will be moving him to another part of the emergency department to free up his current room for incoming patients while he waits for his hospital room. He will be admitted under the neurology service. Okay, no big deal. I know how emergency departments work and that it’s not uncommon for it to take fucking forever to get into an actual room.
Quinn stays with Dustin for a bit so I can step outside to think. Shannon is here with her bag full of goodies and we go find a table outside of Beatrix. Everything is fucked. Some of my work colleagues call me and offer support. Some of my work colleagues call me as nosey ass bitches wanting to be lookyloos. I say this because like literally everyone in the world, you have some colleagues you like and some you don’t.
The colleagues I did not like were very condescending and dismissive prior to his seizure and continue to be that way to this day. It felt like they were calling just to get the drama so they could be the one with the current info. One of them was probably the most thunderous cunt I’ve ever encountered in my life. So fake. So manipulative. Her face looks like a trailer trash mrs potato head put together all wrong. She is pure evil, strangely similar to Lord Voldemort in Harry Potter – except she was kind of stupid and annoying like Delores Umbridge. The other woman is like Bellatrix Lestrange, an absurdly fanatic and lunatic follower of Lord Voldemort. No actual mind of her own, just does what she is told so she receive praise from Lord Voldemort. They both get satisfaction out of torturing others and gaslighting. These two wretched thunder cunts shall be referred to as Lord Voldemort and Bellatrix Lestrange. While I’d love to use their real names it’s just not worth it. They are so wicked and loyal to their delusions much like remaining lunatics of NXIVM who still are loyal to their pedophile cult leader despite the reality. I don’t want to welcome that level of unhealthy trash back into my life. No thanks.
I remember Bellatrix telling me, “Calm down. You don’t have all the information. You don’t know what this is. Don’t be so pessimistic, it could be nothing. You just have to stay positive.”
I. WANTED. TO. PUNCH. HER. IN. THE. FACE. AND. THROW. MY. FUCKING. PHONE.
Thankfully, Shannon was there to ground me. She’s always been a calming presence. The look on her face told me what I needed – do not go all DollarTreeTM right now just get off the phone. I’ll explain the whole DollarTreeTM part another time. It’s irrelevant to this story. But that’s what I needed – next steps. Shan knows me and gets me to my core. So I abruptly got off that call and was so fucking mad.
Shannon let me vent. She knows the whole back story behind my work colleagues and how some are good and some are fucking monsters. The good versus monster colleagues is a whole other complicating factor in all of this but is it’s own story to be told at another time.
My whole body is vibrating with pure rage over this phone call. How fucking dare this bitch tell me what to feel and what to do! Don’t tell me how to live my life you sanctimonious bitch. If this were Bellatrix’s husband, she wouldn’t be so calm and worry free. She’d be losing her mind. I fucking guarantee it.
Bellatrix is definitely one of the colleagues I’d classify as a monster. To clarify and define what a monster colleague is let’s just look at what it is to me. My monster colleagues think that I am “emotionally unstable” and “irrational” which is a whole other story for a different time. But these people who think I am “emotionally unstable and irrational” love to put me in my place when they think I’m being “too sensitive”or “emotional” which is exactly what Bellatrix was doing. It was horribly dismissive and condescending.
You might be thinking that Bellatrix was trying to be nice, supportive, and grounding. But she wasn’t. That’s not who she is. She likes to be involved in all the drama, likes to follow the leader and play games at other people’s expense. She likes to be right and for you to be wrong. She loved using my sensitivity against me and had made claims that was I unhinged.
Let me be very clear. Telling someone to “calm down” is condescending and rude. Not to mention, telling someone who is “not currently experiencing peace but rather wild upheaval” to “calm down” is foolish because IT DOES NOT WORK. It usually just winds them up more making it much worse.
You think I want to be “unhinged” right now? Of course not.
Telling someone to calm down when their world is literally crashing down around them is not helpful. People should be allowed to feel their feelings and have them validated. They don’t want to be told that what they are feeling or experiencing is incorrect or unwarranted.
A better response would be something like this: Of course you’re upset that your husband has a big ass blob in his beautiful brain, that’s really fucking scary.
To suggest that having a big ass blob in a beautiful brain is anything less than really fucking scary is idiotic and hurtful.
The whole “just stay positive” is grossly inappropriate, utterly toxic, and woefully unhelpful. Staying positive will not make this giant blob in my husband’s beautiful brain go away. Nor does it make it any less serious or less worrisome.
I know people mean well by their “stay positive” and “prayers” but I don’t find it helpful. I acknowledge it can be both well intended and hurtful to someone. To me, it’s hurtful. It tells me that my fears are unwarranted and unnecessary. It tells me that it’s my fault this is so bad because I’m scared…if I weren’t scared, this wouldn’t be a problem. It tells me that my troubles are too much for you to handle so you’re just going to shut me up right now.
However, Bellatrix was correct in the sense that I didn’t know what this was yet. But lets be really fucking frank…NONE of the differentials on the list were good things to have. In fact, all of them were really awful and life limiting. So it’s really trite to push off any worries because all the possibilities are awful. In fact, I’d argue that now is the perfect time to freak the fuck out because it’s super scary no matter what it is.
I mean, I love my husband and I should be scared to death of whatever this is. If wasn’t scared to death, what does that say about me? Oh yeah, that would mean I’m a shitty terrible wife who doesn’t love their husband.
This is when I start saying a certain phrase over and over again.
“I will not apologize for passionately loving my husband. I will not apologize for loving my husband more than my job. I will not apologize for loving my husband more than other people love their spouse. I am unapologetically in love with my husband. I’m unapologetically terrified for my husband. I will always unapologetically support, defend, and advocate for my husband. I will always unapologetically choose Dustin first.”
My mantra
Shannon is a wholesome person who sees me, listens to me, and understands me. She helped ground me. She validated me. She helped me reassemble myself in the moment so I could be ready for the next steps in whatever journey this was going to be. She allowed me to be me. It’s a gift I’m forever thankful for and the mark of a superior friend.
There are only a few “monster colleagues” that I do not care for and find them to be shitty people. Many of my immediate colleagues were immensely supportive and kind. My department chief was one of those supportive people. He was in Japan giving a talk during all of this. I sent him a text, apologizing to bother him while he’s away but I needed some help. I sent a photo of Dustin’s giant blob in his beautiful brain and asked for help. He called me once he woke up.
“First don’t apologize for bothering me. You’re not bothering me. The scan doesn’t look good. Let’s pray that it isn’t what we think it is and come up with a plan. Tell me what happened and how I can help.”
Paraphrased from my memory
He quickly helped get me in touch with the chief of neurosurgery at our hospital. I’d be gathering more information over the next several days. I’d gather all his scans and have them uploaded into my hospital’s system for review. My chief was kind and supportive – a gesture I will never forget.
Time keeps ticking away. Quinn and Shannon leave. I touch base with a few other friends and colleagues. But now it’s just the dreadful process of hurry up and wait.
Hurry up and wait to be moved to a room. Hurry up and wait to be seen by the team. Hurry up and wait to come up with a plan. Hurry up and wait for tests, scans, and labs to be ordered. Hurry up and wait for the tests, scans, and labs to be completed. Hurry up and wait for the tests, scans, and labs to be analyzed. Hurry up and wait for the results to be communicated. It’s a form of torture really.
Dustin was finally moved to a regular room on the neurology floor late that night. Nothing else was going to be done today other than nurses doing the floor admission, taking vitals, sending off morning labs, giving meds, doing q4h Neuro checks. Thankfully the room had a pullout sofa that turns into a bed. I sure as hell wasn’t going anywhere. I parked my ass on the sofa and tried to get some rest which was of course impossible.
Once admitted to the floor, the primary service (neurology) now has to do all the admission stuff and write an H&P (history and physical). Things are starting to be come a little more clear now but there still is a lot of unknowns.
“Dustin is a 34 year old caucasian male with no PMH of seizures presents to the emergency department on 7/11/2018 via EMS s/p grand Mal seizure approximately 5 minutes in duration. Upon arrival patient is A&Ox3 but lethargic, pale, and diaphoretic. Vital signs stable. Upon arrival to ED patient is alert but lethargic, pale, and diaphoretic. Further workup reveals 3 cm lesion in left frontal lobe on head CT. Patient admitted to neurology service for further workup of brain lesion and seizure monitoring.
PMH obtained from patient and wife. Patient has no past history of seizures. Past medical history includes of alcohol use disorder with reports of sobriety for 4 years, current daily marijuanna user, hearing loss in left ear s/p recurrent cholestotoma, depression on SSRI and receives CBT, and ADHD on stimulant.
His past surgical history includes a rhinoplasty for deviated septum in high school, and several surgeries on left ear for cholestoma removal, tympanoplasty, and reconstruction of hearing bones.
Patient is A&Ox3. Vital signs WNL. Neuro exam WNL. Patient denies headache, light sensitivity, and any further seizure activity. Patient endorses nausea, fatigue, and intermittent confusion.
Assessment and Plan:
Admit to neurology, q4h Neuro exam, continue keppra for seizure control, admission labs and further scans pending.
Left frontal lobe mass
- 3cm left frontal lobe mass
- Head CTA w/wo ordered
- will need head MRI
- q4hr neuro exam by nursing
Seizure
My shitty admission note trying to make sense of wtf is going on. I am definitely not a Neuro expert.
- Likely 2/2 left frontal lobe mass. No new seizure activity noted
- Continue Keppra 1000 mg PO BID
- No EEG done at this time since no further seizures noted
- If additional seizures, will order EEG”
July 11th, 2018 a chaotic and shitty day indeed.
Beside you in time 