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Sleep Apnea, Snoring, Narcolepsy,
Insomnia and Other Sleep Disorders.

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CASE VIGNETTE - 3.


When he arrived at his office shortly after 8 a.m. on the following Monday, there already was a message on the answering machine from Mrs. Waxman, asking that Dr. Andrews call her immediately. Andrews suddenly realized that he had forgotten to reach her the preceding week. He also was surprised that she would have called him, since he couldn't imagine Waxman remembering (or bothering) to tell his wife that his doctor wanted to speak with her.

He had his receptionist place a call to her, but there was no answer.

Less than ten minutes later, the receptionist buzzed him. "There's a Dr. Jack Tyler out here who says he needs to speak with you right away. Something about Ralph Waxman."

"Are you sure? Jack works at Memorial Hospital, across town. How would he know Waxman?"
"I don't know, but he says it can't wait. I'll pull his chart."

Tyler strode into his office. "Bill, I hate to add to your morning, but things are in a mess. I need some information on a consult that I just saw at Memorial. I was coming by here anyway for a committee meeting next door. I also think you need to know what is going on. You remember your patient, Ralph Waxman?"

"Sure. I just saw him maybe a week ago. Actually, his wife just called here."
"I'm not surprised. He just killed a woman."
"Get serious, Jack. He's obnoxious, but he's not an axe murderer."
"No, I don't mean that. He was driving one of his company's trucks, went left of center, ran one car off the road and then hit the car behind it head-on, at full speed. The woman driving it was killed instantly. Her six-year old daughter is alive but in pretty bad shape at Childrens', from what I'm told. Did Waxman have a history of cardiac conduction problems?"
"Not at all. His heart seemed fine. I think we even did a stress test on him last year. How come?"
"It's pretty strange, Bill. Waxman was brought in by squad. His right kneecap was shattered in the crash. The ER couldn't find much else physically wrong with him--so sign at all of any head injury, even though they said he acted spaced out and not quite with the program. Actually, he should have been having a good amount of pain, but the ER doc said that he seemed lethargic, nonetheless."
"So what does all that have to do with his heart?"
"The ER doc did give him something for pain. Ten minutes later, a nurse who walking past his stretcher glanced at the monitor they'd put on him. Waxman was in the middle of a long asystole. Before she could react, he started having a convulsion. They got that under control, but he kept dozing off and having asystoles."
"Didn't they they reverse the narcotic?"
"Sure they did. Trouble was that it didn't change anything. He kept dozing off and having more asystoles. They put a temporary pacemaker in yesterday and are planning on a permanent one later this morning, unless you can provide some information that would get him out of it."
"No--not really. I didn't have him on much medication, I don't think. No indication that he'd had an MI?"
"Not at all."
"So that was why he hit and killed the woman, I guess. He blacked out at the wheel?"
"Sorry, Bill. It isn't that simple. The cops came in right after the squad arrived. There was a good witness: the driver of the car in front of the woman; the guy that Waxman ran off the road. His head was up."
"What?"
"Just what I said. Waxman wasn't slumped over or anything. He was sitting up behind the wheel of his truck and his head was up. There was still enough daylight for the driver of that first car to get a good look at him. Said he looked like a zombie that was looking straight through him, rather than at him. No attempt to brake at all. Waxman just kept barreling along at full speed."
"So they did a tox screen?"
"Sure. Part of the reason that the police came was to make sure they didn't forget to do it. Blood alcohol negative. No drugs of abuse detected. The lab at Memorial sends out to a reference lab for more thorough assays. Results won't be back for a bit. So I need to find out what on earth you might have given him."

 

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COLUMBUS COMMUNITY HEALTH
REGIONAL SLEEP DISORDERS CENTER
Accredited by the American Academy of Sleep Medicine.

Robert W. Clark, M.D., Medical Director
1430 South High Street
Columbus OH 43207

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