Shahar Madjar, MD, Journal columnist

At approximately 4:30 in the afternoon when everyone was going about their business, a shout for help was heard from the mail room.

Josh, the office manager, and other office employees, rushed over to the scene. They found Jennifer standing next to the copy machine, holding the outgoing mail basket, her face pale. Speechless, Jennifer pointed at Elizabeth who was lying on the floor, unconscious.

Minutes later, when EMS arrived, they found Elizabeth to be confused and unable to communicate. All she could say was only “yes” and “no.” Bob, from Accounts Payable, who usually keeps to himself, told the medical team that he saw Elizabeth earlier, at lunchtime, and that she appeared “unwell.”

At the ER at a nearby hospital, Elizabeth seemed a bit better. There were moments in which she could mumble quietly in response to simple questions, but in other moments, she sank back into unconsciousness.

Family members who were contacted by phone and colleagues from the office told the medical team that the 49-year-old Elizabeth had always been in good health except for mild hypertension and that there was no history of neurological disease in the family.

A finger-stick test showed that Elizabeth’s glucose level was normal. A Covid test was negative. There was no fever. Elizabeth’s heart rate, blood pressure, and respiratory rates were all normal. And yet, on neurological examination, when she was asked to perform simple tasks, such as touching her nose, she wasn’t able to perform even the simplest of coordinated movements.

When a person falls down and loses consciousness, the doctors are faced with two important questions: why did the patient fall and lose consciousness, and did the patient sustain any injuries from the event?

In Elizabeth’s case, the second question was easier to answer: she didn’t fall from a great height, only from a standing position to the floor; there were no signs of external trauma or injury, and no furniture, at the mail room, with hard, sharp edges; and a CT angiography indicated no head or neck injury, and no damage to the blood vessels supplying the brain.

Why did Elizabeth fall and lose consciousness? In order to answer this question, perhaps another question should be asked: What keeps a person upright and what allows a person to be fully conscious? To put it simply: to remain upright and conscious, a person needs a functioning brain. And for the brain to function, a good blood supply to the brain is an absolute necessity.

What can go wrong in that regard? An injury or an insult to the neurons in the brain is called a neurologic event, while a disturbance to the blood supply to the brain, leading to loss of copiousness and a fall is called a syncopal event (or, more commonly termed, fainting).

What went wrong in Elizabeth’s case? If a neurologic event is the culprit, her inability to speak (aphasia) may indicate that she had a stroke or a transient ischemic attack (a mini-stroke). But other neurologic events should also be considered: seizures (the result of a burst of uncontrolled electrical activity between brain cells); multiple sclerosis (in which the immune system turns against the protective sheath around nerve fibers); a brain tumor, or a brain abscess; inflammation or infection of the brain (encephalitis) or of the envelopes around the brain (meningitis).

What went wrong in Elizabeth’s case? It could also have been a syncopal event: she could have had a vasovagal response, a sudden drop in heart rate and blood pressure in reaction to a stressful trigger; or a heart disease or an arrhythmia in which the heart rate became irregular resulting in insufficient blood supply to the brain.

Often, medical sleuths rely on a process of differential diagnosis. Like I did in the prior paragraphs, they first make a list of possible diagnoses. They then consider each diagnosis, and, by process of elimination, exclude some diagnoses and focus on others until they narrow down the field to a single diagnosis that is most likely to cause the patient’s disease. This process is the equivalent to the work of a detective who is trying to find a serial killer by methodically and meticulously ruling out all of the suspects, but one.

Sometimes, though, the work of a detective, or that of a doctor, becomes miraculously simple. It happens when a piece of evidence, call it a smoking gun, points to one particular criminal, or to a single disease.

When the lab technicians analyzed Elizabeth’s peripheral blood, they found numerous schistocytes. These were fragments of red blood cells–irregular and torn–a smoking gun that calls for prompt investigation and intervention.

What caused Elizabeth’s collapse and loss of consciousness? Will the doctors make the diagnosis in time? Will they save her life? I will tell you more in my next article.

EDITOR’S NOTE: Dr. Shahar Madjar is a urologist working in several locations in the Upper Peninsula. Contact him at smadjar@yahoo.com or at DrMadjar.com.