Case of the Month
March 2007

57-year-old male, bizarre behavior

Dispatch
"Aid 1, 57-year-old male, bizarre behavior at the transit center”

En route your crew discusses the following considerations:

• Scene safety
• Reasons for alter level of consciousness

While en route the dispatcher advises that the patient is on Bus #3442 and that transit police are on scene.

Scene Size-up
You arrive at the transit center and are waved down by a transit officer. She leads you onto the bus where you find a gentleman in a seat towards the rear of the bus. You note a smell of urine and body odor. He appears to be homeless and poorly groomed, however he seems to be happy, with a broad smile on his face that is flushed.

Initial Assessment
As you near the patient he greets you with a slurred, but energetic, “Hello.” He has a radial pulse of 114 which is regular, and his skin is cool, dry and somewhat flush. He reaches out in a friendly gesture and states he is grateful to see you again; however, you have never met this man before. You ask him if he feels okay and he replies “Swell!” You see no obvious trauma at this time.

Initial Treatment
Due to his level of consciousness, respiratory status, radial pulse and skin signs, you decide the patient is NOT SICK. Your partner initiates oxygen via a nasal cannula and his blood sugar level is checked. His oxygen saturation is 98% with the cannula.

Event and Recent History
You ask the patient what is going on today and he proceeds to tell you about his recent return from crab fishing in the waters off of Alaska. He states “I particularly enjoyed the time you and I spent together in Alaska.” He describes in detail a dinner engagement you and had at an unnamed bar. (You’ve never seen this man before, yet alone had dinner with him.)

You decide to question the bus driver and you find out that he boarded the bus about an hour ago. He was staggering when he got on and seemed to be grabbing at something in the air, but he did not disrupt the other passengers so the driver let him be. The driver became concerned when the man would not wake up and it appeared that he had been incontinent of urine. 

Further Evaluation and Treatment
The patient’s blood sugar is 103 mg/dl. His blood pressure is 118/P and his skin is cool. You see no respiratory difficulties. You smell an odor of alcohol on his breath and he seems to have difficulty keeping his focus as his eyes drift off frequently during your interview. The rest of his exam is unremarkable. As you continue your exam, he rambles on about travels to Alaska and the Far East.

With the assistance of the transit officer you and your crew remove the patient from the bus. He has a great difficulty keeping his balance as he walks. He is docile and entertaining during the transport the local ED.

After a short neurological evaluation and some blood tests it is determined that he is suffering from Wernicke-Korsakoff syndrome as a result of a thiamine deficiency. His care plan is to increase his thiamine level, re-hydrate him, and to continually to evaluate him for alcohol withdrawal. He is hospitalized for several days to treat the Wernicke-Korsakoff Syndrome and then he was discharged to a detoxification facility. Even after thiamine levels are corrected, he may have lasting affects.

Wernicke-Korsakoff Syndrome
Wernicke-Korsakoff syndrome strikes up to 12.5% of alcoholics. It occurs because heavy alcohol use interferes with the body’s absorption of thiamine (Vitamin B-1). This deficiency leads to the damage of many of the nerves of both the central and peripheral nervous systems. In the early stages it is referred to as Wenicke encephalopathy. As the damage progresses and become more permanent it becomes Korsakoff syndrome. Symptoms may include vision changes, hallucinations, loss of muscle coordination, memory loss, confabulation (making up stories), and hallucinations. It can be a true medical emergency and can lead to coma and death.