holiday heart.

It's Christmas week in a sleepy town wedged between the North and South Carolina border. A 5 o'clock drive to work is marked by the monotone of traffic; a sea of red lights swimming home under a remarkably pink-purple sky. As the last rays of sun disappeared under a dark velvet shroud, I pulled in under a crisp, newly-installed sign in glowing red: EMERGENCY. I was at a new, state-of-the-art facility in a quaint border town that had never known this luxury. After a tumultuous process over the last several years, filled with the finest local politics, the facility had finally opened to great fanfare and was serving the community. The emergency department was a massive, smoothly polished space of gleaming white floors and polished hardwood surfaces. Every patient room was a large, white sanctuary surrounded with walls of clean aluminum and glass. The rooms were replete with the most advanced digital monitors and the brightest multi-colored LED displays I’d ever seen. The overhead lights swiveled smoothly and cast an almost holy glow. The beds were all fitted with smooth, ergonomic adjustments. This was the kind of space that made you believe that ordinary mortals could manufacture miracles; all for a small copay in the span of a two-hour visit to the ER...

As we had recently opened, the volumes were volatile. However, we were fortunate to serve a hard-working, independent community that fought hard to create a place for us. My first week was filled with earaches, over-turned ankles, and allergic reactions. The convenience of having us in the community brought out several who remarked, "Well, I wouldn't have normally gone to a doctor for this, but since you're here..." While holiday weeks promised a predictable lull as people made preparations with their closest family, you never knew what would come in. As I was carefully putting a rambunctious 2 year old's lip back together, I noticed a new patient on the board; a young man checked in with the potpourri triage category "Other Complaint". As I completed the 2 year old's discharge papers, I opened up the young man's chart and browsed the nurse's notes:

"42 year old male presenting with jerking of his right leg earlier today. Symptoms resolved. Probable sinus infection. No active complaints".

As I walked in and pulled the curtain behind me, I found a nondescript man in a navy blue workjacket sitting at the edge of the bed. He was peacefully staring up at the television watching something in Spanish. As we started talking, I noticed his speech had a slow, forced quality; I sat there imagining that I could see him concentrating hard on pressing each word to his lips, carefully explaining what brought him to the ER. He had been walking around that morning when his right leg began to shake uncontrollably. He couldn't control it and for a few minutes had trouble standing. Finally, as he sat down, the symptoms resolved. Here he paused. He also reported feeling sick with a mild headache and a lot of sinus pressure and congestion. He wanted something for a sinus infection…

As I launched into an explanation of how sinus disease couldn't possibly be linked to a tremor in his legs, I asked if he had any other medical issues or medical history. "Nope, that's it doc. Perfectly healthy". It turned out that he was from the Midwest and was only in town for Christmas visiting his brother's family. "I normally wouldn't come in for this doc but you guys have such a nice place...” After hearing this line all week, I asked, "Something must’ve really bothered you to bring you to us while on vacation. What was it?" Again, he seemed to carefully consider his answer, "a few months ago, I was sitting on the toilet and I was reaching for the toilet paper. As I reached across with my right hand, my whole arm just flung itself to the wall and I couldn't control it...it was only for a few seconds...but I had trouble holding the toilet paper. Now it happened to my leg. It may just be a bad sinus infection, but I just thought I should get it knocked out..." I started his neurologic exam and everything appeared to check out. He had no deficits. He had no pain, and he had normal strength with a complete range-of-motion in his arms and legs. As I jerked his Right ankle upwards, I noticed that he had sustained clonus, a steady, rhythmic jerking of the ankle when rapidly flexed. Sometimes this means something, sometimes it doesn’t. As I left the room I heard the nurse come in, look up at the television and ask, “I didn’t know you speak Spanish?” He looked at her and said flatly, “I don’t… Is this Spanish?”

And there it was. The devil was always in the history. A few odd occurrences in an otherwise harmless story that leaves you with a bewildered, sinking feeling. His CT scan revealed an angry golf ball sized mass lodged along the left brain. It had began to press on the surrounding tissue causing swelling of the brain. The tremor in his leg was likely a focal motor seizure. The headache was likely caused by the buildup of pressure in his skull. As I came in and sat down to deliver the news, he just stared at me in silence. He blinked a few times and said nothing. I couldn’t tell if he understood. He asked for his brother. As I called his brother into the room, they looked at each other, and tears began streaming. I explained what we had found, and the brother’s face softened as he wept. It all began to make sense; months of odd behavior, slow speech, the occasional tremor; and the sinus headaches. I got him admitted. I spoke to Neurosurgery. I gave him medicines to make him more comfortable. And silently, I prayed for him.

The drive home that morning was cold. Christmas week in a border town. I called my wife and told her that I loved her; Then I asked her if my speech sounded funny…

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