Things aren't always what they seem.

I swear some nights I'm getting a message. Clear as day. Tonight it was to look a little deeper. I was trauma nurse, and it was altered mental status party 2010. First patient I got was a pretty simple low blood sugar. I'm getting her all fixed up when another patient rolls in- a guy in his 40s from a halfway house, again, altered mental status, cutting up, trying to jump off the stretcher to walk to the bathroom. EMS has zero history, and trying to collect it from the patient is about as effective as trying to collect history from the damn blanket warmer. Dude insists on peeing before getting in the bed, spills about half the pee on the bed, then proceeds to try and pull a cigar out of his pocket and light up in the room. Fabulous. I'm crabby because it irritates the shit out of me to take care of drunk and high people. The guy denies taking anything but has this weird acetone/boozy odor about him so I just assume he's probably drunk or huffing something and lying about it. He finally falls asleep and is pretty peaceful other than sitting up on the side of the bed to urinate every 30 minutes or so. I go about my day and am working on getting my low blood sugar lady upstairs to a bed when another nurse on my team brings me a critical lab value- sodium of 115- pretty low-on my "drunk" man. I finish up all my paperwork and look over in the room to seeing going pee again. That's when it dawns on me-shit, this guy isn't drunk at all, he's Diabetes Insipidus. I talk to the admitting doctor and we keep him down in the ER for another hour while he writes orders- the guy has made 4 liters of urine by the time I bring him upstairs. And his alcohol and drug screens are all negative. Shows me.

While we're holding him, I get another lady next door-called in EMS as an overdose. She is screaming and kicking the EMTs- we have to put on limb restraints before we can even move her from the stretcher to the bed. No medical history they're aware of other than some unidentified chronic pain that she's seeing a pain management specialist for. Her husband gets there and tells us it's happened before-she tends to take too much of her pain meds. He gives us her meds and she's taking 40 mgs of Oxymorphone a day and then Dilaudid for breakthrough pain. Holy shit. That pretty well explains it. We do an EKG and I bring the chart to the doctors- we've started a catheter and sent blood, but kind of as an afterthought I think, "Oh, well, we know what this is but I better do a blood sugar." Yeah, It's 37. WOW. I ask her husband- "Does she have Diabetes?" Yeah? Great. I run and grab some D50- as soon as I give it, the lady sits up, looks at me, smiles and says hi, as if this is the first time we have met. I guess for her, it was. She was pretty much totally normal after that. I got the whole story as I took care of her- apparently, she passed out about 5 hours before her husband called EMS. She had just taken her Dilaudid and Insulin and hadn't eaten. Her husband thought it was just the pain pills and planned on letting her sleep it off- when she didn't come around after several hours he decided to call EMS. Luckily, she did great and we discharged her- after a long talk about taking your pain medicine and Insulin with food.

I'm hoping this stuff will start making me think in terms of diagnostics a little differently. It's won't assume it's either this or that, but that it's all of the above until completely proven otherwise.