Case 17: Different Strokes.

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It’s Sunday afternoon, and I’ve been called in almost four hours before my shift is supposed to start.  Black coffee feels good the second it hits my tongue. It makes no sense, but as I swallow, I can feel the stimulant at the base of my brain. The darker the brew, the faster my step.

Seconds after arrive, I’m called to the Acute area to see an elderly woman who can’t breathe. She’s ninety-four, and she’s gurgling for air. As I approach the resuscitation room, I pass two middle aged-women. They are hovering outside a neighbouring room, like vendors at a fair, trying to get me to stop. But they don’t have food, or vinyl records from the eighties; they have a loved one who they want me to see. Immediately. One freezes, her hand gesturing like a traffic guard as she tries to wave me into the room. The other throws up her hands as I pass, saliva punctuating her sigh: “puh!” They can see the elderly woman fighting for her life, and I can see their sister – sitting comfortably, a blanket pulled up to her waist.

“I’ll see her just after this,” I say. I enter the resuscitation room and whip the curtain closed.

The elderly woman is scared. Her heart is a broken pump, and fluid is gathering in her lungs. Congestive heart failure – she is drowning in her own body. I order medication as a respiratory therapist straps a mask over her nose and mouth. “It feels like sticking your head out the window on the highway,” she’s told. I scribble on the chart, and ask them to call me if she doesn’t settle. “If this doesn’t help you,” I say, yelling over the machine, “I may have to put a breathing tube into your lungs, and put you on life support.”

She closes her eyes, shakes no, and points to her daughter.  “No,” the woman at the bedside says. “She doesn’t want that. She’s signed a D.N.R.” Do Not Resuscitate. I put a hand on her shoulder and nod. I appreciate her foresight. I’ve never been sick, and have never had anyone close to me become severely ill. I’ve never had to be this brave.

I open the curtain and leave. The unit clerk sees me and I point to the room I’ve just left: “Stat portable chest x-ray, please.” As I walk, footsteps are behind me. I feel the woman’s hand before it taps my shoulder.

“You said you’d see my sister next.”

I speak without slowing – without turning to look at her. “Let me get her chart first.” She follows me to the nursing desk where the nurse gives me a look and hands me the chart. I point the woman away: “Please just wait in the room, I’ll be there in two seconds.”

The patient is forty-six. She lives twenty miles away; there are at least four hospitals between her home and here. Her vital signs are perfect, and her presenting complaint is “other.” This can mean anything. It can mean ‘pain all over for months.’ It can mean ‘fear of contracting hookworm.’ It can mean ‘Christmas lights in my bum.’ I flip the chart to the triage note.

“They want a carotid doppler,” the nurse whispers.

“What?”

She flips to a page with the letterhead of another hospital.

“There’s no way,” I say. “It’s Sunday.”

“I told them already.”

“Finally,” one of the women says, as I enter the room. I ignore this, and go to the bedside. I introduce myself as the patient smiles. I ask what brings her in.

“I had another mini-stroke,” the patient – Danielle –  says, at the same time that her sister says, “it keeps happening, and we need answers.”

“Mount Sinai should have never discharged her,” the other sister says. “We’re not taking her home this time.”

“Hold on,” I tell the sisters, “can you let her speak?” I really want to ask them to leave, or remind them of our ‘one visitor per patient’ policy, but this won’t go over well, and I’ve learned to pick my battles.

A day earlier, at a restaurant, Danielle’s sister had noticed that she was slurring her words. Danielle said not to worry, that a chicken bone had scratched her throat, but when she stumbled on her way to the restroom, 9-1-1 was called. The paramedics had taken her to Sinai, the closest hospital. By the time she was seen, four hours later, her symptoms were resolving. The doctor ordered blood work and a CT scan of her head.

“Did it show anything?”

“All normal,” a sister says.

“You’re speaking fairly clearly now,” I say to the patient.

At the foot of the bed, there is another sigh. “You’re not sending her home. Same thing happened last time.”

“Are you feeling better?”

She nods yes. I take her history. She denies previous medical issues. She’s only had one surgery – her gallbladder. She has a clerical job in a chiropractor’s office and smokes half-a-pack a day. She doesn’t drink. She denies pain, and has no other symptoms, but her tongue still feels sluggish on longer words.

“What happened today?”

A sister jumps in. “What are we supposed to do? I’m afraid to leave her alone. They said she had a mini-stroke. What if she has a bigger one? What if it happens while she’s driving? She drove to my house today and was ten times worse when she rang the doorbell.”

“Wait,” I tell the sister. “Tell me exactly what happened today.”

“Same thing!” she says, throwing up her hands, before telling me the story. “She came to my house for a visit. When she got there, she was unsteady, and wasn’t acting normal. I called 9-1-1 but when the paramedics came, she refused to go with them. She isn’t thinking clearly.”

I look to Danielle. “Then how did you end up here?”

The sister answers: “I called our other sister and we dragged her here. She isn’t herself.”

“How is she now,” I ask, as I begin to examine her.

“We were asking for a doctor to see her earlier! She’s better now but we’ve been waiting forever.” I check the chart. She was right – they’d been waiting long – almost two hours.

The other sister jumps in: “Can we do the ultrasound of the neck?”

“There’s no way to get a carotid doppler right now. Even if we could, and if it showed a blockage in the arteries of the neck that feed the brain, nothing would happen until after the weekend.”

“Well then we’re wasting our time.”

Her physical exam is normal. There is no facial asymmetry. She smiles, speaks, and gestures well. Heart, lungs, and abdomen are normal. Power is equal and strong in her upper and lower limbs. An ECG is also perfect. I order blood work, although attached blood tests from two days ago are normal.

Before I leave, a sister steps in front of me. “Wait, what about another CT scan?”

“You just told me it was normal two days ago.”

“But they told us it might be a brain-bleed, and sometimes they can only be seen within the first six hours.”

“If they can’t see it on a scan, and it’s a suspicion, then usually they do a lumbar puncture to look for blood.”

“Yes!” she says. “A spinal tap. They wanted to do that.”

“And?”

“Danielle didn’t want it. They made us sign out against medical advice. We left because everything was taking so long. They were basically ignoring us.”

“I’m not worried about a bleed,” I say. “She has no headache.”

A sister turns to Danielle. “You do have a headache, don’t you? Tell him. You have a headache.”

The other jumps in: “You said this started with a headache. Out of the blue. Eight out of ten. We told the nurse before you came.”

I review the nursing note, and it’s documented – headache, light sensitivity. I ask Danielle if she still has these symptoms, and she looks to her sisters and says ‘a little.’ I mention that I’d just asked her if she was in pain and she’d said no. I also explain that I flashed a bright light an inch from her eyes and she didn’t flinch. In fact, she smiled.

“She has all the symptoms of an aneurysm,” a sister says. “We’re not taking her home.”

A nurse pops out of the resuscitation room and calls for me. “Ok,” I say, as I order the scan and head out.

I check on the ninety-four year old. The mask that is helping her breathe covers her entire face. I ask how she’s doing, and she manages a tired nod.

Over the next two hours, I see a seventy year old with profuse rectal bleeding, a twenty-year old who’s fallen off a ladder (albeit two steps), two elderly people who’d swallowed food down the wrong pipe, and a seven year old with a badly broken wrist.

When I return to the Acute Room, Danielle is being wheeled back from CT, as one of her sisters complains to the porter: “I don’t see why we both couldn’t go with her.” The porter apologizes gently, and leaves. Just as I pass the room, a unit clerk calls out: “There’s a tech on the phone for Acute Nine.” My heart sinks. Danielle. The techs do this – when they see something that needs attention, they call over to the ER and let us know right away. Danielle’s nurse takes the phone, pen in hand, and scribbles on a loose page.

I pull a chair up to a screen and look for her name. I click on it and pull up her scan, flipping slowly through slices of brain. I sharpen the contrast and scroll through again. I still don’t see what I’m looking for – areas of white – signs of blood.

The nurse hangs up and shows me what she’s scribbled. I’m confused. “That’s strange,” I say. “Do you see any signs of this?”

“No,” she says.

I stop in to see the seven-year old. He’s hungry, but I tell him he can’t eat or drink. “We’re going to put you to sleep in about ten minutes so I can straighten out your wrist. You can have anything you want when you wake up.” I stop in on the rectal bleed. His blood pressure is stable, and he’s waiting for blood to be matched for transfusion. Just before I head to Danielle’s room, I see a three-month-old in respiratory distress. As I’m assessing the infant, one of Danielle’s sisters is pacing outside the room. It’s as if she can’t see the child, or the worried mother, or the respiratory therapist holding a mask to the screaming child’s face. I look up quickly, and in a voice that comes out louder and harsher than intended, I tell her to go back to Danielle’s room. “I’ll be there in just a couple of minutes.”

It’s eight-thirty now, and Danielle’s symptoms have resolved completely. She’s been up to the bathroom twice, and is anxious to leave. “What did the scan show?” a sister says. “The nurse said something was off with one of the tests and that you’d talk to us.”

The nurse is taking Danielle’s blood pressure. She records the numbers, then asks quietly. “Will she be discharged? We need the bed.”

“Yes,” I say.

“What?” one of her sister says.

“Wait,” I say. “Maybe the two of you should leave the room while I talk to Dan -”

“Absolutely not! We’re her sisters, if it wasn’t for us, she’d still be at home.”

I speak directly to Danielle. “It’s your choice. Do you want them in the room?”

“Yes,” the sister says. “She does.” The other sister wags a finger at me. “How can you even ask her, something isn’t right. She can’t make an informed decision.”

“Yes she can,” I say. I ask Danielle again. “Do you want them in the room?”

“It’s fine,” she says.

“First of all. The CT scan is totally normal, just like the one you had yesterday.”

“Then what’s wrong?”

I turn to the sister. “What’s wrong is that she’s drunk, or at least she was drunk when she got to your house, and maybe a little less drunk when we took her blood. Her alcohol level was through the roof.”

A nurse pops in. “Can you come re-assess the baby? I think she needs another mask.”

I step out. “She’s drunk. She was slurring and stumbling because she’s been drinking. A lot. She drove to your house drunk, and seemed altered because she was drunk.”

“I didn’t have anything to drink,” Danielle says.

“That’s absurd,” a sister says. “It’s the middle of the day. And my sister doesn’t drink.”

“I’ll let you talk about it,” I say, leaving the room.

Ten minutes later, a sister approaches as I’m finishing a chart. “Okay, she admitted it, she’s been drinking. Heavily. What do we do now. How can you help her?”

“Well,” I say, “the first thing that concerns me is that she’s hiding her drinking, and driving while drunk. I should inform the Ministry of Transportation.”

“Okay,” she says.

“And I can have a crisis worker bring you some resources on alcoholism.”

She nods.

A few minutes later, I overhear her discussing this with Danielle. Danielle is suddenly angry, and snapping at her sisters for bringing her to the hospital. Seconds later, she’s walking swiftly toward an exit, cursing.

I return to see the ninety-four year old, who is much improved, as is the infant. Seconds later, I’m called overhead; the seven year old is asleep and needs his wrist straightened.

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One comment

  1. Ah, the pushy family who know it all. I remember this scenario well from my days as a criminal lawyer. I had to get instructions from the client, not their “support” so I would just boot the mouthy relatives out of the room without hesitation.

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