To the Editor,
In the fourth year of medical school, some of us get posted in rural hospitals to understand the working of such hospitals. A few of us were posted in a hospital in central India. We reached there, full of exuberance.
On the third day at 6 am, rushed into the ER; a son with his elderly father who was unresponsive for the last half an hour. We rushed to see the patient. He was mute, unresponsive, had a babinski and was moving only the right side. Full of enthusiasm, we made our spot diagnosis "if this is not a stroke, then what else can it be?" Somebody mentioned about checking his sugars but then we felt no need. There were no imaging facilities and we took the son aside to explain; trying to fit into the consultant’s shoes. He needed to be referred and we informed the consultant that it was probably a right middle cerebral artery (MCA) territory infarct. We talked to the son about clots and hemorrhages and the need to image his father to decide the best course of action. We could see he was shell shocked! Anyways, he gathered himself to wake up the lone taxi driver in the village to drive to the city hospital.
On returning back, we started hearing heated arguments in the ER. Lo! Our right MCA infarct was up and throwing a temper tantrum at our consultant for not letting him go back to his home. Apparently our consultant had checked in on the patient and had ordered a random blood sugar, (it was 20 mg/dl!). Over a course of100 ml of 50% dextrose later, the infarct man was now superman.
We had overlooked the history (he had been a diabetic for years on Oral hypoglycemic agents) and closed our eyes to the common reversible causes of unresponsiveness (seizures and stroke-like symptoms). The consultant had systematically approached the patient and had avoided the huge costs which were unnecessary. He also politely educated us after settling the gentleman. This was a humbling experience.
"From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us."1
Hypoglycemia is a frequent side effect of diabetes treatment and needs to be constantly monitored and the patient has to be educated about the symptoms and treatment. One of the leading causes of misdiagnoses has been earlier identified as the lack of ordering appropriate tests.2 Hypoglycemia is a great masqueradeand has been commonly associated with stroke like signs.3 It only needs a rational approach with judicious application of evidence based medicine to clinical problem solving, which can pick such common diagnoses.4
1. Hutchison SR. BMJ 1953;1:671.
2. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006 Oct;145(7):488-496.
3. Fowler MJ. Hypoglycemia. Clin Diabetes 2008;26:170-173 .
4. Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ2009;338:b1860.