Stroking and choking: Dying and crying.

No time to think about science, collect data, or postulate. Flying by the seat of the pants and holding onto life as a practical matter.

I was studying for the oral board exam in emergency medicine (EM) about the difference between two of the many types of types of stroke when (1) the unhappy victim is weak on one side of the face but weak on the opposite (contralateral) side of the body, versus (2) when the weakness is on the same (ipsilateral) side of the face and the body. Crossed hemiplegia (one sided weakness) is when the cranial nerves will be affected on one side, while the extremity motor deficits are on the other side ride. This lesion or ding in the brainstem (most rudimentary part of the noodle just north of the spinal chord) will affect the infranuclear cranial nerves ipsilaterally, and the motor tract contralaterally, because the motor tract decussates (crosses) just above the spinal cord. (http://www.ferne.org/Lectures/ssneuroexam%200501.htm)

This while I wait to hear from my brother whether or not now is the time to travel 4,000 miles to be with my elderly, demented Da who seems to have had a stroke and may have aspirated. If true, the prognosis would be bleak. My brother flew to Scotland today. I called to get my shifts covered and get a rush put on the new passport I was waiting for. Now I am waiting for the word that it is time to come. I do not know what kind of stroke Dad might have had.

So with that on my mind, I worked a 12 hour, pretty busy shift in the community ED (Emergency Department) and here are just a few of the first time, nearly first time, dreadful and less so things I was witness to today at work:

A 106 year-old woman who fell down the stairs, got a thoracic vertebral compression fracture, and demanded (in Greek) to be sent home. Hospitals scare her. She did not get to be 106 by enjoying being in hospitals.

A true traumatic hyphema befell a middle aged woman when a bungee chord snapped back in her face and hit her open eye. It seems like it is always mentioned in textbooks, but I have hardly ever (maybe once before) seen red blood layer out horizontally in the anterior chamber of the eye. You see a line of blood over the bottom of the pupil. Weird looking. You can see it with the naked eye, but it makes you want to wear safety glasses.

A 27 year old healthy woman on Depo-Provera (birth control shot) came in with a chief complaint of “whole right side of her body hurts” per triage. She had a right sided PE (blood clot in the lung)! The closer history was of a right scapular pain radiating down the right arm, pleuritic (worse with breathing in) with mild headache and nausea. She was anxious, and overweight. Most frightening, on reflection, for the EP (emergency physician) was that she had normal vital signs and oximetry, AND a borderline negative D-dimer. Why send a d-dimer (blood test) if I am getting the CT (CAT scan) anyway? You are right. I should not have, it was a waste. But, I can actually get my CT and have it read often faster than I can get the result of the d-dimer.

I wrote a prescription for aphthasol for the first time for aphthous ulcers. See how easy medicine can be when they pick decent names for things!

Saw the worst case of shingles I have ever seen today. I think the dermatomal distribution was about L3 or so from low back to upper thigh. Painful blisters that were red and angry and itchy. Valium seemed to help more than opiates. The woman was on the transplant list for a new liver as hers had hepatitis C. Interestingly, her granddaughter had chicken pox a couple of weeks ago.

For the first time in one shift I had two people that spoke only Greek. Sadly, timing and dementia prevented me from getting them and their families all together. I guess that would have been a HIPA violation. My Greek is limited. I could not even determine what sorority she was in (Class of 1922!).

I had a status epilepticus 45 year old person seizing like crazy, and the elderly mother remembered at the last minute to tell us that her son was allergic to both phenytoin and phenobarbital. That was a first for me. I am used to the amazing coincidence that people would be allergic to all the non-narcotic types of pain relievers, but not both of those antiseizure meds. They are the second and third line agents to use. Good thing the first line benzodiazepam did work.

Another first was when the surgical subspecialist who did the operation six days before the healthy young man got a DVT (blood clot in an extremity) actually admitted the patient back onto his service for anticoagulation. Just kidding. Of course he did not. The patient got the on call Doc.

I had the radiologist look at a chest and abdominal film from man with epigastric pain. I have seen a lot of x-rays by now, and every day I see something for the first time. Today I was especially perplexed. Dozens of scattered radioopaque formations across the anterior and posterior chest wall (can tell from the lateral picture): some were spiral, others squares and rhombi, diamonds and stars. They looked like doodles or shells. Just calcified rib cartilage he says. I still think they are metallic robot worms.

I have a beloved daughter baby girl. I get emotional thinking doing things with my child that my Dad did with me. Things he showed me or said or taught me come spilling out into my life with my sweet daughter. It is as though he loves her through me and across time. If that makes any sense.

You see, this is really a sad blog entry. Perhaps a cathartic one. I hope so anyway, because I had to pronounce dead a very small, very beloved child today. It was the first time I had to do that when I really could not tell the family what had happened. He was found lying there, unresponsive. Just a small child, too old for diapers but too young for school. EMS (emergency medical services) arrived and found no heartbeat, no breathing. They did everything. We tried and tried. Tried everything and then everything and again. The ME (medical examiner) will find out, but I would have to guess he choked.

There is some science now that supports the idea of having the family bedside during the resuscitation (Crit Care Nurs Clin North Am. 2002 Jun;14(2):177-85.
Family presence during resuscitation. Tucker TL.). I think that once it is practical or possible to have someone else in the trauma room it is our responsibility to give the family that option.

My Dad was clear about his DNR (do not resuscitate). I expect that my brother will call in the next few hours to say get on a plane, or not.

My baby is sleeping in her bed, in a snuggly sleeper. She looks snug and safe and well. I’ll keep checking on her.

P.S. – I originally tried posting this to my blog on July 25th. I got some message back saying that I was getting screened for being potential SPAM (The cheek!), and that I would hear latter. I never heard back. I am trying to post it today 8/6/6.

Dad died on the morning after I finished writing this. We flew out to Scotland as soon as we could, but arrived at the Edinburgh airport about two hours after his last breath. We stayed for the funeral and flew back to the U.S. in time for me to work on Friday morning.

Dad had a vascular dementia for years. He had small strokes that devastated his mind cumulatively over time. It was no surprise that he eventually had a bigger stroke. So, reconstructing what the assorted Scottish docs told my surgeon brother – who in turn told me. Either Dad got left weakness and fell, or just fell and hit his head giving him a subdural hematoma. Either way, (and with surgery not being considered anyway it does not really matter) he seemed to be recovering from the sudden onset of left extremity weakness for a day or so. Mentally he was returning to his baseline mental status which was confused but alert. Next day, he starts with some mild respiratory symptoms. What happens next is all too familiar to doctors: worsening breath sounds, tachypnea (rapid breathing), then fever, tachycardia, hypoxia, eventually coma, acidosis, arrest, death. Sepsis is an overwhelming infection. Almost certainly he aspirated a little bit or oral or gastric secretions into his lungs on the day of the initial event. The aspirate then festered into a fatal pneumonia.

Like I said, he knew from long ago, and documented in a living will, what he wanted at the end of life. A plastic cigar in the throat (i.e. an ET tube – i.e. being on a ventilator) and someone drilling a hole in his skull was not part of that.

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