The mediation was scheduled for noon. When the attorney in charge of the mediation was an hour late, his assistant began earnestly to find him. This was not typical behavior at all. A phone call to the condominium where the attorney lived sent security guards to his residence and then to the parking garage, where they found him slumped behind the wheel, seat belt securely fastened, and his keys in his hand. Emergency services were immediately called. The security guards rapped loudly on the car window, causing the attorney to regain consciousness and open the car door. Emergency services transported the attorney to a nearby hospital for evaluation, even though the security guards described the attorney as having fallen asleep behind the wheel of his car.
Upon arrival at the emergency room, the attorney’s speech was slurred and virtually incomprehensible. He was unsure of his location or the reason for his being there. Hospital emergency personnel were informed that he had apparently fallen asleep behind the wheel of his car in the parking lot adjoining the senior living condominiums where he lived.
When the attorney’s assistant arrived at the emergency room, the ER physician informed him that several tests had been conducted, and all results were normal. The physician believed the patient was simply dehydrated and was going to send him home.
For reasons that aren’t clear to me, the attorney called me from the emergency room. His speech was almost incomprehensible, so his assistant took the phone from him and explained to me what had transpired. When he told me that the ER physician said he was just dehydrated and was going to be discharged home, I simply couldn’t believe what I was hearing. I vigorously told the assistant that the ER doctor’s conclusion was “garbage”… that I had spoken with the attorney just 36 hours earlier, and he was alert, oriented, and his speech was perfectly clear. This was not dehydration! This was a brilliant attorney, a brilliant practicing attorney who clearly had some type of neurologic or cardiac event, and there was no way in the world he should be sent home! The attorney’s assistant immediately found the ER doctor and relayed this information to him. Fortunately, the ER doctor had the good sense to change his mind and admit the attorney to the hospital.
Over the next 72 hours, the attorney’s speech cleared, and he was once again oriented to time and place. His pacemaker was interrogated, and no events were found. There were no persistent neurologic deficits. After three days, he was discharged home.
In considering these events, one has to ask how a supposedly highly trained ER doctor could come to the conclusion that this man was dehydrated. According to the attorney’s assistant, the physician said that all the laboratory tests were “normal.” Was his urine concentrated? Was serum osmolality high? Were his electrolytes abnormal? Was his hemoglobin and hematocrit high? Was his skin turgor abnormal? If any of these tests were done and were “normal,” how does a physician conclude that there was sufficient dehydration to cause slurred speech and disorientation? Or did the ER doctor simply see an “elderly” man who likely had some stage of dementia? After all, he was apparently told that the patient fell asleep behind the wheel of his car in a parking lot. At least, that was what the emergency personnel said, who were given this information by the security guards. No doubt the security guards had sufficient expertise in medicine to reach this conclusion.
I am profoundly glad that the attorney’s assistant was there, and I am profoundly glad that the attorney himself called me from the emergency room, although he has no memory of doing so. Medically, a definitive cause of the loss of consciousness followed by slurred speech and disorientation has not been found. And while ER physicians are frequently stretched far too thin, it still appears to me that the diagnosis of “dehydration” was what I initially said it was … garbage. A convenient diagnosis, perhaps, to camouflage a bias against someone who appears elderly to you or perhaps to camouflage a lack of medical knowledge? What does seem clear to me is that family members or friends who once accompanied an individual to the hospital for emotional support should now accompany the individual to protect them as well.
Sydney Lou Bonnick is an internal medicine physician.
