Firestorm

By Tony Dajer|Saturday, June 01, 1996
It was 7 A.M. when I arrived at the hospital. The soft blue dawn surrendered to the emergency room’s fluorescent, round-the-clock glare. Reuben, the night-shift attending physician, smiled blearily.

How’d it go? I asked.

Oh, the usual. And nothing to sign out.

My turn to be thankful. But now another emergency: coffee. I was heading back to the doctors’ offices when a faint mewling began outside. Ambulance backing up. I gulped a mouthful of coffee and headed out. The ambulance bay doors hissed open. A young woman’s voice came howling in: Leave me alone! Ow . . . oh. Damn you! Leave me alone!

Bleed, I thought, though drug overdose would have been the better bet. I was working in an emergency room serving a small northeastern city. The city’s economy had crashed with the Atlantic fish stocks, and drug abuse and psychiatric problems abounded. But the worst mistake in medicine is to label patients wacky before you label them sick. And nothing makes someone delirious as shockingly fast as a hemorrhage in the brain.

Four stout paramedics pinned the girl down. Ann, the head nurse, and I converged on the stretcher. The nearest medic filled us in.

Virginia Carlson, 22-year-old, horrendous headache at 4 A.M. Vomited twice. Then, the parents say, she got like this. Been fighting the flu for a couple of days.

No! Go away, the girl hollered. Ow . . . ow. I hate you!

The medics hung on so we could tie soft restraints around her wrists and ankles. A brain hemorrhage was still possible, but the flulike symptoms described by her parents suggested a new contender: meningitis, inflammation of the membranes enveloping the brain and spinal cord that is usually caused by a bacterial infection. While Ann, two more nurses, the four paramedics, and Bob, our 250-pound nurse’s aide, wrestled Virginia into restraints, I found her parents.

Mrs. Carlson was astonishingly calm, given that her daughter was being restrained by an ER crew. Mr. Carlson, a thin, quiet man, took his cues from his wife.

What do you think is wrong, Doctor? Mrs. Carlson asked.

I can’t say yet, but I need to ask some personal questions very quickly.

Please.

Does your daughter use any kind of drugs or drink alcohol?

No, never, came the firm reply. I know she’s used marijuana now and then, but she’s a sweet, responsible, wonderful kid.

Medications? Even over-the-counter?

No.

She hasn’t been under more stress lately, she’s never taken pills or tried to hurt herself?

No.

And no penicillin allergy? She’s taken it before?

No allergy and yes, she’s taken it.

Just then, Ann called out: Rectal temp 101.

Be right back, I said. The crew at the stretcher had thinned. In her delirium, Virginia struggled against her restraints, desperate to flee the demons she was imagining had bound her hand and foot.

Ann came over.

You thinking what I’m thinking? she asked.

Meningitis--although there’s still a small chance of a bleed, even with the fever, I answered. But what she needs right now is penicillin--lots and fast. Four million units. Repeat in four hours.

A single dose of 1.2 million units of penicillin will cure strep throat. Virginia needed 20 times that much per day every day until she cleared the infection.

And after the penicillin?

CT scan first, then spinal tap.

Sedation?

Tons. She needs to lie still for both. We can’t just pin her down.

In treating first and diagnosing second, I was gutting medical dogma, but meningitis demands a shoot-first-ask-questions-later approach.

The meninges make up the protective wrapping of the brain and spinal cord. There are three layers of meninges, running from forebrain to spinal cord, which is why there is no such thing as exclusively spinal meningitis. The innermost membrane--the meshlike pia mater--hugs the surface of the brain and spinal cord like shrink-wrap. The outermost membrane is the dense dura mater. Sandwiched between is the arachnoid, a loose-fitting membrane that holds the cerebrospinal fluid, or CSF. This fluid-filled compartment insulates the fragile brain from damaging jolts, and it is here, in the warm CSF, rich in glucose and proteins, that meningitis-causing bacteria can flourish.

For an ER doctor, it is uncomfortably easy to mistake meningitis for drug-induced dementia. Thankfully, meningitis can be confirmed by performing a spinal tap, in which some CSF is drawn out through a long needle inserted into the lower back and is then examined for bacteria and infection-fighting white cells. But before performing a spinal tap, a doctor must rule out the possibility of a tumor or broken blood vessel in the brain. Both conditions can create dementia--as well as dangerously high pressure within the brain. When pressure is greatly increased inside the skull, drawing CSF out of the spinal canal can force the brain through the foramen magnum, the opening in the skull where the brain meets the spinal cord. The soft, gelatinous brain tissue is then crushed against unyielding bone. Fortunately, a CT scan, which can detect tumors or brain hemorrhages, can head off such a disaster. But CT scans take time. And meningitis won’t wait.

If a patient is battling an infection as life-threatening as meningitis, antibiotics should be given immediately. Unfortunately, doctors are often reluctant to fire such heavy antibiotic artillery without having lab results that prove infection. So some doctors wait for a cell count before starting life-saving antibiotics. In addition, doctors want to make an accurate diagnosis, and if they give antibiotics before they do a spinal tap, the lab culture will turn up negative.

The way around this is to give antibiotics promptly and then use tests that detect antibodies to bacteria rather than the bacteria themselves. In a healthy young woman like Virginia, I knew there could be only two major contenders, and both bacteria, the pneumococcus and the meningococcus, are vulnerable to penicillin.

The drug dripped into Virginia’s IV line. Fifty minutes had passed since Virginia arrived, and it had taken that long to get her restrained and prepared for treatment.

I prayed the delay wouldn’t make a difference.

Ann brought Virginia’s parents over. Mrs. Carlson began to stroke her daughter’s forehead.

Did you see the faint rash on her chest, Doctor? she asked. Yesterday she was taking a warm bath for the muscle aches and said, ‘Mom, what do you think these red spots are?’

At that point, all my alarm bells went off. In all the uproar, we hadn’t yet stripped Virginia down and done a skin exam. Ann pulled back the sheet. Virginia’s chest and abdomen were speckled with little red bumps. Even more deadly than meningitis is meningococcemia, a condition in which meningococcal bacteria spread through the bloodstream. Meningococcemia is one of the fastest infectious killers around, and it’s known for its peculiar rash. Outpacing even the latest made-for-TV horror virus, it can dispatch its victims within a few hours of symptom onset. I suddenly wanted those 50 minutes back very, very badly.

The meningococcus bacterium, technically known as Neisseria meningitidis, is not some rare imported microbe that catches an immune system off guard. Rather these bacteria are so common that many of us harbor them in our noses and other mucous membranes. Fortunately, antibodies that stand sentry like saguaro cacti on our mucous membranes usually snag any invaders.

But in rare cases a virulent strain of N. meningitidis manages to overwhelm the sentinel antibodies and penetrate mucosal cells in our respiratory tract. In a feat of Machiavellian biochemistry, they somehow masquerade as a familiar cellular import, duping the cells into swallowing them up in membrane-bound capsules and ferrying them to capillaries beneath the mucosal barrier. Once in the bloodstream, they deceive the immune system by displaying the same molecular ornamentation as red blood cells. Thus disguised, they slip through the blood-brain barrier, which normally protects the brain against infection, and run riot in the defenseless CSF. The result is meningitis. Of the estimated 20,000 cases of bacterial meningitis in the United States each year, roughly 2,500 will be meningococcal infections.

In meningococcemia, N. meningitidis multiplies in the blood, causing so much infection that the immune response can swerve out of control. In a normal immune response, the walls of the blood vessels become more porous to permit immune cells into infected tissue. But in overwhelming infections, the blood vessels leak so much that blood pressure plummets. Blood pours into the skin and the internal organs, causing massive hemorrhaging.

When there is severe internal bleeding, a blotchy, purplish rash sometimes covers the skin. Fortunately, Virginia’s rash didn’t look like that. But the Carlsons needed to prepare for the worst.

She has meningitis, I told them. It is also possible the infection has spread through her bloodstream.

Could she die? Mrs. Carlson asked, without a quaver in her voice.

Yes. The critical period will be the next 24 hours. Her blood pressure is stable now. If it holds like this till evening, we’ll be miles ahead.

If she survives, could she have problems? Brain damage? Mrs. Carlson looked me right in the eye. She wanted the truth.

There’s a chance, I answered hesitantly. Yes.

Fortunately, Virginia’s CT scan was negative. No tumor or hemorrhage in the brain. With Bob’s bulk blanketing Virginia, and Ann hugging her into a C shape that would expose the spaces between her vertebrae, I performed the spinal tap. I slipped the needle between two vertebrae and extracted the spinal fluid. It was cloudy, as I expected, but the pressure I detected added to my fears. In a normal patient, the pressure in the spinal canal will not force the CSF above 180 millimeters on the spinal tap manometer. In Virginia’s case, the pressure exceeded 550- -the instrument’s highest measure.

That astronomical pressure meant Virginia was fighting an enormous brain infection. When the body fights infection, immune cells gather at the infection site, causing swelling. Virginia’s brain was so swollen that she needed to be managed by a neurosurgeon, which our hospital didn’t have.

The lab called. Virginia was infected with meningococcus. Unlike pneumococcal bacteria, which tend to cause only isolated cases of meningitis, a virulent strain of meningococcus can cause outbreaks of meningitis in otherwise healthy young people. The bacteria are spread by close contact or through a sneeze or a cough; outbreaks tend to crop up in the close quarters of schools or military camps. For unknown reasons, some people suffer invasive infection, while others remain healthy carriers.

Who had had close contact with Virginia? I ticked off all the possibilities: her family, the medics who had wrestled her down, the ER staff, and friends who had spent the night at her house two days before. They would all need a two-day regimen of the drug rifampin, which kills meningococcus in the nose and throat and eliminates any risk of disease. Then there were the casual contacts. Because of their limited exposure, they wouldn’t need--but would understandably clamor for--the antibiotic treatment.

We arranged Virginia’s transfer to a nearby hospital. By the time she left she was unconscious--an effect, I hoped, of the sedatives we had given. Ann took along a bag of penicillin to give her en route.

Virginia’s blood pressure hasn’t moved a millimeter, I told the Carlsons as they prepared to accompany their daughter. That was good news. When Virginia came in, her blood pressure had been normal. If it was holding steady, the infection was probably not spreading through her bloodstream.

The next morning, Ann greeted me with a rueful look.

They just took Virginia’s brother into the emergency room. Headache and chills.

Oh no, I thought. We covered him with rifampin, didn’t we?

You bet, Ann replied.

Whew. Is the town going nuts?

What do you think?

And how’s Virginia?

She’s still unresponsive. The doctors at the other hospital don’t sound too optimistic.

My heart sank. Fifty minutes. What had taken us so long?

Still, it was too early to tell.

That afternoon came the verdict on Virginia’s brother: his spinal tap was negative. It was just the flu.

Two days later the clouds parted a bit.

Virginia opened her eyes this morning, Ann told me. She would live. But what about residual brain damage? It can take months for brain injury to show up.

Four weeks later, I called Virginia’s mother.

Oh, Virginia’s back at work now and doing pretty well, Dr. Dajer. The worst thing is the headaches--they make her think the meningitis is coming back. They scare her.

I knew Virginia was probably out of the woods. She wasn’t showing any signs of brain damage, and reinfection with the bacteria was pretty unlikely. But I also knew what Virginia was feeling. Meningitis is a terrible foe, and no matter how fast a doctor acts, it can act faster. Virginia had been lucky.
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