Crozet Annals of Medicine: What’s Normal?


The holidays are upon us, time to take some time off, slow down and connect with friends and family. Time to celebrate with good food and drink.

And a time to put on some weight. Most holiday weight-gain stories in the popular press assert that the average American puts on five pounds between Thanksgiving and New Year’s Eve each year.  Well, the good news is the National Institutes of Health studied it rigorously in 2000 and found that the actual weight gain on average was one pound. Still, that one-pound gain continues every year and pretty soon you realize that 20 or 30 holiday seasons have come and gone and your waistline reflects that.

Holidays in the ER are not really time to slow down and take some time off. While clinics and doctors’ offices close, the ER stays open and fully staffed and far from slowing down, we remain busy. Instead of time off, my colleagues and I will work at least a portion of the traditional holiday breaks.

While we see the routine things that would normally be taken care of in the closed primary care practices, the holidays also bring a special kind of challenge that comes when far flung families re-connect once a year; the “pop drop.”

Families that haven’t seen old dad for a year or more are shocked at his greatly diminished condition and rush him to the ER to be rejuvenated. His bewildered wife comes along, asserting that nothing really has changed. His doctor, who could clear this up, cannot be reached of course, because it is the holidays.

So we are tasked with sorting out the effects of the inevitable march of time from reversible illness. We are pretty good at this, less so at conveying to the kids that mom is right, this is dad’s new normal.

A related puzzle happened to me last holiday season. The medics brought in a middle-aged man who was comatose. He had arrived in Charlottesville just the day before from Arizona where he lived. His family had not seen him in two years. They noticed that he seemed sluggish when he arrived, but did not give it much thought.

The next morning they could not get him out of bed but still they did not give it much thought.  When afternoon turned into evening and he could not be aroused, they called the medics to come and get him. The family members did not accompany him to the ER and could not provide the medics with any medical history or any medications he might have been on.

Coma is a spectrum and we have a scale to measure it on, the Glascow Coma Scale (GCS). A GCS of 15 is wide awake and a GCS of 3 is about as bad as it gets, absolutely no response of any kind to deeply painful stimuli. It may seem strange but ER doctors are trained experts in inflicting fiendishly deep pain, when appropriate, without causing any lasting damage. Our knowledge of anatomy and pressure points means we can arouse all but the most deeply comatose patients into movement of some kind.

My patient woke up a little to deep pain but lapsed back into coma when not stimulated, giving him a GCS of 10, which is a fairly deep coma. All he could tell us before he slipped back into coma was that he thought he was in Tucson.

There were some clues to the problem imbedded in his exam. First we rolled him and discovered a Fentanyl patch on his lower back, which we removed. Fentanyl is a powerful opioid (narcotic) pain medicine. Under the skin of his buttock an implanted device could be felt, either a spinal nerve stimulator or a pain pump that pumps medicine directly into his spinal cord. So we knew he had chronic pain of some sort. With chronic pain comes a whole host of medicines that in combination or in over-dosage can precipitate a coma. He did not have any alcohol on his breath and had only a slight improvement in his GCS when administered Narcan, an antidote to opioids. So he had more than just opioids on board, but probably not alcohol. His reflexes were somewhat brisk, indicating a possibility of anti-depressants as well.

We ran a few more tests and admitted him to the ICU. He woke up two days later and gave us a list of his medicines, most of which we had suspected. He told us, and the family confirmed, that this was the third time this had happened to him, and that it was accidental. He couldn’t really account for exactly why this had happened. He and the family were unconcerned and showed no insight into the seriousness of his overdose. Nothing we said seemed to reach them. Our reality was not their reality.

So this holiday season take some time to really connect with your family and friends. Be thankful for close family who know you well and won’t mistake your illness for normal or your normal for illness. Celebrate each other and join together over good food. You can easily shed a pound as your New Year’s resolution. Happy Holidays!


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