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In early 1986 Ron Huber twice attempted to take his own life. The precipitating factors that had a role in these incidents included his diagnosed bipolar condition making an abrupt transition from a manic episode to a depressive episode, and the estrangement from his Oregon forest activist- associates brought about by the disorder. The result of the below described incident is chronic anterograde amnesia, a severely reduced ability to place new information into memory. (1) History and Physical Examination Peter Kenyon, MD 1/27/86 Good Samaritan Hospital
DATE 1/27/86 Peter Kenyon, M.D. HUBER, RONALD 753050 HISTORY and PHYSICAL EXAMINATION
History is taken 'from the patient's professed cohabitant and a close friend. To their knowledge the patient has been in good health up until the current time. They describe a number of psychosocial stresses that he has been under during the past 8 months. This included the death of his brother, apparently associated with drug use including alcohol. He has also been involved in the Earth First protest movement to preserve the environment. This involved a period of incarceration and subsequent community service. Apparently there has also been some disagreement and falling out between he and his fellow ecologists. The cohabitant states that he has been very depressed. She describes and effort at a joint suicide by the patient and herself. The plan was to funnel exhaust fumes back into the car in which they were to fall asleep. However, she was unable to stay in the car and the attempt was aborted.. On the day prior to admission the cohabitant states that the patient left the house and was gone for a period of approximately 2 hours. He then returned to the house with lacerations on the left arm which were bleeding. He was confused and aggitated. His behavior was quite bizarre. She describes that he turned on the burners of the stove and held his hands over the flames and would then try to blow out the lights as if they were candles. He finally settled down and went to sleep. She describes that he slept normally. Today he was less agitated, but remained somewhat confused. She took him to the friend's house. She describes his mental status as being coherent, but very poor in short term memory. She states that the patient was able to recall things happening 2 weeks ago, but not in the last 2 days. Because of this they finally brought him to the ER. At the house the car was apparently found turned off. Hose had been taped to the exhaust system and somehow directed back into the interior of the car. There was a window which was broken. They believe it was broken from the inside. They found no evidence of foul play. They also found no evidence of any other medications or drug use. Further denied that the patient has ever used medications or mood altering substances. PAST MEDICAL HISTORY: Otherwise unknown. Tetanus immunization is unknown.
EXAMINATION: Well developed, well nourished man whose color appears good who is in no
distress.
Pulses are present in the feet and there is no edema. There are multiple small lacerations over the left arm with no evidence of foreign objects. NEUROMUSCULAR EXAMINATION is notable in that the patient is oriented to self. He knows that this is a hospital in Corvallis, but cannot recall his name. He has no idea of the date or day. He is able to recall his parents phone number, but has difficulty naming the president. He is very slow in his answers and feels that his thinking is quite dull. The patient was not ambulated. Finger to nose is performed well. There is no tremor. Cranial nerves are normal. Strength is 4+ throughout. Sensation is grossly intact. Babinski's are downgoing bilaterally. ABGs show pH 7.36, PC02 37 and P02 186 on 3 liters nasal oxygen. Saturation is not measured. Carboxyhemoglobin level is not available at this hospital. EKG is normal. IMPRESSION;
PLAN: The patient is admitted for observation of his neurologic status and development of possible ischemic injury to other tissues. Suicide precautions will be taken. High flow oxygen will be provided, although it is now at least 30 hours after the alleged exposure and 90% of the carbon monoxide should have been exhaled by now. Psychiatrist will be consulted. 1/27/86D - 1/28/86T 1214 Peter D. Kenyon, MD/kag ========================================================== (2) Emergency Report by E.R. Mack, MD 1/27/86 Good Samaritan Hospital
DATE 1/27/86 E.R. Mack, M.D HUBER, RONALD 753050 EMERGENCY REPORT
Two weeks prior to this, both the patient and the girl friend made a suicide pact together at which time they got into the car, started the motor, and then had the exhause fumes piped into the car. After several minutes, they apparently changed their mind, so they turned off the ignition and got out of the car. According to the girl friend, the patient had been depressed for, the past several months, and this is attributed to the fact that he got in trouble with the law in Linn County last summer, when he and other environmentalists occupied some trees in a logging area. The patient's usual occupation is environmentalist and writer, but he has not worked for, some time. The friend states that last night the patient slept some, but much of the night he talked jibberish. He has been extremely confused and disoriented today. Examination reveals a 30-year old male, who appears confused. Speech is rather slow and halting and word content is rather simple and elementary. His color is good. He is oriented as far as person and place. is concerned. Also appears to be depressed. His pulse is 104 and regular, BP: 128/78. PERRLA. Fundi normal . No nystagmus. No evidence of increased intracranial pressure. Neck is supple. Lungs are clear to P&A. Heart tones normal. DIAGNOSIS: Carbon monoxide poisoning by history on 1/26/86. Depression with suicide attempts.
E.R. Mack, M.D
========================================================== (3) Report of Consultation by John Schenkel, MD 1/28/86 Good Samaritan Hospital
DATE 1/28/86 John Schenkel, M.D REPORT OF CONSULTATION HUBER, RONALD 753050 Ronald Huber is a 30 year old single white male who tried to commit suicide by gassing himself with carbon monoxide. He apparently was sitting in a car recycling the exhaust and was apparently in the car approximately 2 hours before being taken out by friends. He had attempted this about 2 weeks previously when both he and his girlfriend were going to kill themselves, however she changed her mind, so he has apparently been contemplating suicide for some time. Ron himself does not remember much of any of this and does not remember yesterday or his suicide attempt at all. When asked why he might have done that he said "must have been in dispair over not having any work" and then he became somewhat disorganized and then asked what was the question. Then he said the future does not look particularly bright. Additional history obtained from his girlfriend Samizu Matsuki and Charles E. Trauth include the fact that Ron has been very depressed after his failure to save some old growth trees. He and someother people had formed an organization to save the trees and apparently he had been thrown cut of this organization this last fall. He and his girlfriend had been living literally hand to mouth with nothing but stamps, borrowing 1 or 2 dollars from friends here and there. According to Charles Trauth Ron had suffered "character assassination" by this group and was accused of stealing and committing violent acts. He also was convicted of a felony by a judge in Albany because of his attempts to stop the logging in these old growth trees so he is now on probation. According to his girlfriend, his appetite has been intact and he has been eating. He has been sleeping well, but has been very despondent. According to his friend, Charles Trauth, he had concealed his depression rather well and Charles had no idea that Ron was this depressed. According to Samizu and Charles Ron was not a drinker and did not use drugs. He had used marijuana only a very occasional basis. He had no known medical problems. Another issue which had troubled Ron was that his brother who had been 2 years older died last March from an overdose of either alcohol and/or heroin. On mental status examination Ron was oriented to person and place, but not at all to time. He could not even guess at the month and thought the year was 1985. He could remember none of 3 words after 5 minutes and even though he could calculate somewhat that is he could subtract 7 from 100 and obtain 93 he could not perform serial 7's because he could not remember what he was doing. He could spell the world backwards and recite 6 digits forward. His general fund of information is intact and could name the presidents back through Kennedy. He had more difficulty with abstractions and was not able to abstract on an intermittent proverb, did have some abstract concept with regard to a complex proverb but was not able to complete his answer. I suspect he is able to abstract, but is somewhat disorganized. ASSESSMENT: At this time Ron Huber is obviously substantially impaired from an organic point of view. Most remarkably with regard to his recent memory. Since he cannot remember much of what was going on prior to the suicide attempt it is difficult to discuss his depression with him. He talks about things only in the most vague and generalized terms almost as if it must have been this way or as if it were this way. As if he were figuring out what must have happened from the consequences of what happened. PLAN AND SUGGESTIONS:
Thank you for referring this most interesting client. John Schenkel, M.D./tt 78FR140 Rev: 141-85 ================================================ (4) Report of Consultation, Cecelia Keller, MD 1/28/86 Good Samaritan Hospital
DATE 1/28/86 Dr. Cecelia Keller. M.D. CHIEF COMPLAINT: Loss of recent memory CLINICAL HISTORY: 30 year old right-handed white male with psycosocial stresses in the last 8 months has been quite depressed over recent death of brother and general dissatisfaction with life. He and his cohabitant had a joint suicide effort consisting of carbon monoxide poisoning attempted. HIs partner was not able to comply with their deal and the suicide gesture was aborted. Shortly thereafter, the patient was noted by his companion to be disoriented, confused and had problems with memory. Over the ensuing week his behavior changed and the patient was then brought to the ER for further evaluation. This information was obtained from the chart. The patient had no recollection of any of the major events. The patient and I had a brief conversation at which time he stated that he had been under psychological stresses and depression. He had no recollection of any of the events that happened since his suicide gesture of two weeks ago. Aside from this the patient stated he has never had any neurologic disease, has not had meningitis or encephalitis as a child. He was quite non-conversant and was not able to give an adequate family history. REVIEW OF SYSTEMS states that the patient is in good physical health aside from his psychological problems. Other medical history essentially is noncontributory. The patient stated he had no allergies. EXAMINATION: This is a well developed, well nourished white male who was in bed and quite quiet and reserved. HEAD: Normocephalic without evidence of trauma
The patient is alert to name and place, disoriented to time. Is 1 out of 3 object immediate--the patient on repeated trials could not remember that this was 1/28/86. However, when told that it was January, the patient was appropriate in his response that this was a part of winter and that the weather should be cold out because it is winter. His mathematics was poor and he could not calculate. He was quite frustrated by the fact that he could not recall the date and the year. Several times during the examination he asked me again what was the year and date. Even after repeated trials, he still could not recall these events. VISUAL FIELDS: Full by confrontation: EOMs full without nystagmus, corneal reflexes brisk bilaterally. NO facial asymmetry could be appreciated. Facial sensation is intact. Tongue and uvula midline. MOTOR EXAM shows no fasciculations, tremors or atrophy. All muscle groups tested were 5-/5. DTRS 2+ and symmetric, negative Babinski's. SENSORY EXAM: Intact to pin, temperature, vibratory sense. CEREBELLAR EXAM intact to finger nose, rapid alternating movements, heel shin activity. Romberg is negative. Patient was not ambulated. ASSESSMENT: This is a 30 year old right-handed white male with carbon monoxide poisoning presently presenting with Wernicke encephalopathy secondary to anoxic episode. Otherwise his neurologic examination at this time is essentially without any other focal deficits. Usual course for carbon monoxide poisoning is that of gradual improvement. However, mental confusion, loss of memory may become a permanent composite as the reflection of some neuronal cell loss. Parkinson's disease may develop at a later date. In addition multiple neuritic problems such as peripheral neuropathy or mononeuropathy may develop at a later course time. RECOMMENDATIONS: At this point the patient has severe problems with immediate memory of the Wernicke type. These people tend to respond to high dose Thiamin-Folate therapy. Unfortunately this therapy is not always as dramatic as it is in alcoholics. If this becomes a permanent aspect of his memory, the patient will not be capable of functioning within our society After a few weeks, if the patient's memory does not improve, formal psycometrics should be done. His other possible problems of neuritis or Parkinson's disease will only need followup at a later time. No treatment for the present will be necessary. The patient is under psychiatric evaluation at this time for his mental health. Thank you for the referral of this interesting patient. 1/28/86D 1/29/86T Cecelia Keller, MD/kag
=========================================================== (5) Discharge Summary. Peter Kenyon, MD. 2/4/86 Good Samaritan Hospital
DATE 2/4/86 Peter Kenyon, M.D. DISCHARGE SUMMARY HUBER, RONALD 753050
FINAL DIAGNOSIS: Acute organic brain syndrome compatible with carbon monoxide poisoning. Multiple superficial lacerations. Alleged history of depression and suicidal ideation. Please see the admission history and physical for details leading up to the hospitalization. History is taken entirely from the acquaintances of the patient who brought him to the emergency room. It is stated that Mr. Huber was in good health but had been quite depressed over the past 6 months. This had been attributed by his friends to his involvement in a protest movement with an environmental activist group, incarceration and subsequent probation following those protests, falling out with members of the environmental group and the recent death of his brother after a prolonged coma, said to be due to drug and/or alcohol. It is stated that he and a female acquaintance had made a suicide pact and 2 weeks prior to admission had locked themselves in a car with the exhaust rechanneled back into the interior. After a short period of time, the female had decided not to proceed further. One day prior to admission the patient is said to have left the home for a period of 2 hours. He returned and was markedly agitated and disoriented. He had multiple lacerations over his forearms. She allowed him to rest that night but when he was still confused on the morning of admission she brought him to a friend's house. This friend then convinced the two of them to come to the emergency room. The description is that a vehicle had a hose inserted in the exhaust which was rechanneled into the interior. A window was broken out from the inside of the car. In the emergency room patient was found to be confused. His speech was slow and halting with a very restricted vocabulary. His color was described as good. His vital signs were normal. General exam was normal. Laboratory Studies: Hemoglobin of 15.1, WBC 10,400 with 65% PNM and 1% bands. Urinalysis was normal with no evidence of hemoglobinuria. Chemistry profile was normal. Arterial blood gases on 3 liters of 02 showed a pH of 7.36, PC02 37 and P02 185. Carbon monoxide level was less than 2 (24 hours after the alleged exposure). Urine toxicology screen showed nicotine and 1 other unidentified substance. Chest x-ray was normal. EKG was normal. EEG was normal. HOSPITAL COURSE: The patient was initially treated with 100% 02 through a non-rebreathing mask for 4 hours. He also received Thiamine, folate and a multiple vitamin. He was given a tetanus booster on 1-27-86. Patient was seen in consultation by Dr. Keller for neurologic evaluation. She found him to be disoriented to time and found it impossible to learn the current date. Neurologic exam was otherwise normal. She interpreted this as Wernicke type encephalopathy secondary to anoxic episode, compatible with the alleged carbon monoxide poisoning. She thought that gradual improvement would be likely. However she noted that mental confusion, loss of memory, Parkinson's disease and multiple neuritic problems may be long term complications. Patient was seen in consultation by Dr. Schenkel for psychiatric evaluation. He found him to be substantially impaired with little recall of his prior depression and suicide attempt. He did not feel that there is any significant depression or psychiatric evaluation indicated at the current time. The patient is placed on low Amitriptyline by the neurologist. This is being discontinued at the time of discharge. Formal psychometric testing has been advised in approximately 1 month's time. The patient has been seen in the hospital daily by occupational therapy to work on his memory skills. Patient has complained intermittently of global dull headaches for which he has been given aspirin. The patient's probation officer from Linn County, Mr. Brent Adams was contacted and has okayed the patient's travel out of the state to stay with his parents. No other activity has been approved. Any other changes in his address must be discussed with the state of Oregon correction division. Possibility of psychiatric committment was discussed as the patient is clearly a danger to himself and others from his past behavior and clearly needs a supervised environment in view of his marked decrease in short term memory and judgement. However, supervision by responsible family members appears to be a reasonable alternative. Patient is being discharged at this time into the custody of his mother who will return him to their home in Maryland. Neurologic follow up is to be arranged by them. Good nutrition has been advised. Peter Kenyon, M.D./tt Date 2-4-86 Time: 2214 ======================================================== |