Brain cramp: The emergency physician's worst nightmare☆

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• Abstract
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Abstract 

Yee P. Brain cramp: the emergency physician's worst nightmare. Ann Emerg Med. March 2002;39:329-330.

See related articles, p. 287 and p. 344.

As emergency physicians, we all have, at one time or another, suffered from it: the much dreaded brain cramp. What is it, you ask? Let me explain. During the dying days of my emergency residency training, I recall attending an interesting resident education round, during which we discussed various case presentations of patients who suffered bad outcomes. These cases highlighted the fact that, often, disastrous outcomes resulted from very bad clinical judgment made by normally competent and conscientious physicians. We were asked to ponder why this happens and whether it will eventually happen to all of us. The chief of our department, a soft-spoken, articulate, and brilliant sort of guy with knowledge and experience that will always dwarf mine, summed it up with 2 words: brain cramp. We all chuckled a little at this colloquialism, although admittedly, it really is no laughing matter. Similar to muscles, our brains are susceptible to fatigue and cramping when overstimulated. In more technical terms, it should probably be referred to as intermittent neuronal dysfunction, temporary cortical blackout, or transient grey matter meltdown. There are many plausible reasons for this entity. The hectic and confusing environment of the emergency department, the continuous interruptions and demands for our immediate attention, attempting to manage multiple patients simultaneously, determining whether to admit or discharge borderline ill patients, dealing with any array of unpleasant and reluctant consultants, and trying to cater to the unrealistic demands of some patients can, at the best of times, be exasperating. At worst, it can unexpectedly overwhelm our ability to concentrate and to remain focused. The result is a fragmentation and breakdown of our usual logical thought processes, that is, the brain cramp. Even our most focused colleagues can fall victim to this phenomenon and become completely frazzled on any given bad day. In the midst of a brain cramp, any decision is hard to come by, let alone a sound one. Working in the ED, it seems necessary and essential that we become masters of multitasking. Yet, operating at this hyperacute and overdriven state, day in and day out, is precisely what predisposes us to falter at times with these brain cramps.

Having just completed my residency 4 months ago, working full time in a high-volume ED can be very daunting. Being a neophyte emergency physician, I quickly realized that perhaps I was in over my head. I will not soon forget my first major brain cramp. I had just come on shift that morning and was already up to my eyeballs with a couple of chest pains and abdominal pains, a few weak and dizzies, and plenty of walking wounded with various fractures and lacerations crowding the triage hallway. While irritable, febrile children wailed in the background, I was already wondering whether I would make it to the end of the shift. Double coverage was still 3 hours away, and my department was sinking fast. As I was pondering what to do with the annoyingly vague gentleman with the atypical chest pain, a nurse informed me that Mr. X, a leftover patient from the night shift, had a low blood pressure. Mr. X, who was never signed over to me, was an elderly man who presented with severe back pain that was diagnosed by the previous emergency physician as muscular in origin. He was given several doses of narcotic medication and held overnight for pain control and observation. Someone else had already written discharge orders, so I did not feel compelled to intervene. This pleasant nurse stated that she wanted to hold him in the observation unit for a little longer until the meperidine wore off. Tragically, I did not give it any further consideration.

In residency training, certain red flag symptoms were repeatedly drummed into our tired, oversaturated brains. For instance, febrile neonate equals rule out sepsis; sudden-onset, worst-ever headache equals rule out subarachnoid hemorrhage; syncope and melena stools equal rule out massive gastrointestinal bleed; pelvic pain and hypotension in a woman equal rule out ectopic pregnancy; and so the list goes on.

Yet, on that particular morning, I failed to realize what severe back pain and hypotension in an elderly man equaled. Without even realizing it, I was in the throes of a brain cramp. I mistakenly assumed that the nurse was correct in concluding that his low blood pressure was the result of the narcotics he had received. As I ploughed through the never-ending pile of charts in the triage box, preoccupied with keeping the ED afloat, I never gave that patient a second thought.

A few hours later, very pleased that 2 weak and dizzy elderly patients had been discharged and that the 3 “rule out” fractures were just soft tissue strains, I bumped into that same nurse as she was helping an older, pale-looking man to the washroom. As I passed her, she casually mentioned to me that his blood pressure had come up slightly and that she was planning to send him home. Still, unknown to me, my brain remained in a tetanic state, as I nodded my approval to her, while secretly rejoicing that the ED was finally quieting down to a more manageable state. As my shift came to an end, my exhaustion was outweighed only by my relief to see the next attending arriving for duty. Change of shift and handover are always a risky business, so I was glad that none of my patients needed to be passed on. Just as I was preparing to leave the ED, I overheard that a vital signs absent (VSA) was being wheeled in. On my way out, that same nurse, now looking quite upset, peered out of the resuscitation room to inform me that the VSA was the same man with the back pain who I had discharged a few hours earlier. In an instantaneous moment, my brain cramp disengaged, only to be replaced by the frightening realization of the tragic consequences resulting from my transient, but ill-timed brain failure. What was I thinking earlier? Or worse yet, why was I not thinking at all? What a truly awful and numbing feeling it was. As I drove home that evening, I paid little attention to the road. My mind was busy ruminating about that poor old man and the sobbing wife he had left behind, all the while kicking myself for not seeing the waving red flag and praying that this unfortunate brain cramp, although my first, would also be my very last.