On the Other Side of the Rails
A Personal Account of Transient Global Amnesia
Cheryl Cummings, MSN, RN, NPD-BC, CEN
New Hanover Regional Medical Center
Have You Met My Husband?
A classic sign of transient global amnesia (TGA) is not being able to retain recent memories, and the condition is noted by a patient repeating the same question or questions. My questions included “What is my blood sugar?” “Have I been to CT scan?” and “Why am I here?” I also introduced my husband, I am told, many times despite having already done so.
“TGA is defined by a sudden onset of an anterograde and retrograde amnesia that lasts up to 24h.” Anterograde amnesia is the inability to form new memories, and retrograde amnesia is the loss of past memories. My case started on a Wednesday afternoon. I was at work in the emergency department in my position as a Patient Assistance Center (PAC) nurse, a position created to prevent unnecessary readmissions to the emergency department by providing help with follow-up appointments and medications. This is done either with a face-to-face meeting before discharge or via a phone call after. The day started out normally; much of what I remember is looking back over my charting, phone calls, and text messages. I had 3 meetings scheduled for the afternoon. I am told that the first and second meetings went smoothly. Although, during the first, I had thought I had the wrong agenda but recovered sufficiently to participate. It was during the last meeting where it was noticed that I was not “quite right.” Although, it was not readily apparent what was “off” at the time.
At the end of the third meeting, I am told that I started repeating some of the questions I had asked earlier, which was noticed by a coworker and friend of 14 years. According to her, we had discussed that I hadn’t eaten lunch and that she would call and check on me later. I recall nothing of the 3 meetings. It was during not 1 but 2 phone calls later that this friend told me to leave my desk, go to triage, and “hand the phone to the triage nurse.” She did this because I did not remember calling her the first time or calling her again to see if we were still meeting that day. I was checked into the emergency department a little after 3 PM with a diagnosis of altered mental status. Staff were unsure whether or not to call a code stroke because I did not present with facial drooping, arm weakness or numbness, or speech difficulty (FAST exam). Miami Emergency Neurologic Deficit (MEND) scores were also negative. In fact, my PAC coworkers were surprised to see my name on the track board in the emergency department because of how normally I was acting.
I like to think that I was treated like a VIP, but at my hospital we take altered mental status and stroke very seriously. I was seen within a few minutes by an emergency provider; had a point of care glucose (84 mg/dl), blood chemistries, and an electrocardiogram; had 2 IV’s placed; and a non-contrast head CT ordered within minutes after checking in. When the CT came back normal, an MRI of the brain was ordered as well as carotid ultrasounds. The only abnormality noted was that I kept asking the same questions repetitively and could not recall the answer or even asking the questions. Per provider notes and my husband’s recollection, not only did I lose the ability to form new memories, but I could not recall recent memories—I didn’t know what I did yesterday or what upcoming trips I had planned.
Labs, imaging (CT, carotid ultrasound, and MRI), and EKG were all normal with the exception of changes on MRI that were felt to be secondary to chemotherapy received in 2000 for breast cancer. The diagnosis of TGA was based on normal labs and imaging, the episode 42 witnessed by my colleagues (repeated questioning and confusion), and an intact memory except for anterograde and some retrograde amnesia that resolved within 24 hours. I do not remember being examined by the emergency provider, the neurologist, nor the hospitalist who admitted me for overnight observation, but I knew who they were, having worked with them for years. It is important to note that other than the loss of my short-term memory and some loss of recent memory, I was behaving and acting normally. When my memory for current events started to return, they were still choppy and incomplete. I would be looking at the clock one minute and see that it was 6 PM but when viewed again the time was 11 PM; there were huge gaps in between. I remember being pre-medicated for my MRI but do not remember how I got to MRI. I remembered my coworkers and people I worked with on a day-to-day basis but could not remember having just talked to them. I remember the MRI, but I could not tell you how long the test took or when I returned to my room in the emergency department. I remember asking my nurse to get my phone charger as my battery was almost dead, and I wondered what had happened to my clothing and earrings. I am sure she told me several times, but it was hours later before I was able to process and remember these details.
As noted previously, I was admitted overnight for observation. My memory had started returning, but there were still gaps. I had been on a low carbohydrate diet for months, but I didn’t remember this until I had eaten 3 packages of graham crackers. My thoughts also included my mother, whom I had not been to see in a while, only realizing later that she had died at hospice 6 months prior. With each passing hour, my memory gradually returned. After my phone battery was charged, I could speak to my husband, who tested my memory further by asking me what trips I had planned and when. After I could tell him about the upcoming trips and dates, he knew I was back to normal. He had already received assurances from providers that this would occur–usually within 24 hours of diagnosis. He later had our 2 sons call and quiz me on upcoming dates and events to ensure that it was not a fluke and my memory had returned.
I was cleared by both the hospitalist and the neurologist to return to work, which I did after taking the weekend off. There were no lasting effects other than the missing hours of the TGA that I would not regain. I could piece together part of this time by reviewing my medical chart, phone records, and text messages, and by interviewing staff, coworkers, and my husband. The incidence of TGA is “between 3 and 8 per 100,000 per year.” Cases of reoccurrence are rare and usually associated with an ischemic event.8 Most of the case studies I reviewed were “one and done” episodes, and I am happy to report as of this writing post, mine has been a one and done episode. After this experience, I wanted to learn more about TGA, so I began reviewing the literature. I found no clear cause of TGA. One source indicated that it could be caused by vagal maneuvers; the same paper stated that it could also be caused by “migraine-related mechanisms.” However, I do not recall a vagal episode, and I do not have a history of migraines and did not experience any pain during the episode or recall a vagal episode. As for a possible adverse drug effect, I was not on any daily medications at the time and seldom take anything other than an occasional ibuprofen. I have remarked since the episode that it felt like having anesthesia with propofol or midazolam—you remember who you are but tend to repeat the same questions. Other causes were quickly ruled out. My blood glucose and HbA1c were within normal ranges, and I did not have a traumatic brain injury. I did not have alcohol-induced amnesia, nor was I overly tired or stressed. In my research, I was unable to find anything on thyroid disease causing TGA—I was sure it factored into it as I had recently been diagnosed with a hyperthyroid and was pending surgery for removal of an 8 cm by 6 cm thyroid nodule.
As a nurse and as a patient, I truly appreciated the presence and value of a “whiteboard”; this was my lifeline to what was going on around me. My nurse updated it often, but it was never truly enough to keep me from pestering staff about what was going on and why. One aide had the patience of a saint, taking time to answer all my repeated questions. If only she had updated the board to reflect those questions, it probably would have saved her some time repeating the answers. My husband left me a note that I would look at often: “Mike gone home to walk and feed the dogs, can be reached at…,” which helped me tremendously, because even though I introduced him often, I could not remember him being there. That note provided reassurance that not only had he been there but he was leaving a number where I or staff could contact him if needed.
I am grateful for the staff that cared for me during this episode that may have been frightening, but I was reassured by their presence and by their insistence that everything was going to be okay. I learned firsthand the power of the whiteboard and how important it is for communication, not only for the patient but for the family and staff as well. To this day, I can’t go by a whiteboard without thinking about my experience. To those that cared for me during this experience, we share a private joke asking, “Have you met my husband?” or “What was my blood sugar?” and smile.
Cheryl Cummings, MSN, RN, NPD-BC, CEN
Cheryl has over 30 years nursing experience in critical care, transport and emergency nursing – and worked several years in educating emergency staff on electronic documentation. She is an active member of her local ENA chapter, Sigma Theta Tau and is part of nursing shared governance at her organization. She has presented various topics (CHF, ED Discharge, etc) both regionally and nationally. Understanding that emergency nursing is not static, Cheryl continues to seek opportunities to not only learn but to educate others in this dynamic and fluid environment.
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