Thursday, June 25, 2009

So, yeah. It was a bad day the other day.

She'd been fine when I saw her at 0730. A little groggy, yeah, but that was because she was on tremendous amounts of Neurontin and various painkillers, a result of her having had a spontaneous epidural hematoma. (Note to Googlers: spontaneous epidural hematomas are extremely rare; two of my patients on the same day had had them. Such is life at Sunnydale General.) At any rate, she was moving all the limbs that she had been moving before, and could speak fluently, if sleepily, in response to questions.

Then, at ten past eight, her daughter called. She was concerned because Mom wasn't picking up the phone. Daughter is the sort of thorn-in-the-side, pain-in-the-ass advocate for a patient that we simultaneously dread and admire: she'd enlisted the help of a couple of family friends who were nurses, and she called regularly for updates. 

Anyway, Mom wasn't answering the phone. This wasn't unusual, as Mom tended to sleep in. Plus, as I'd said before, she was groggy that morning anyhow. But, because my Spidey-Sense started to tingle, I went into her room anyhow, to see if she needed help ordering breakfast.

I found an obtunded patient who couldn't move her right side and couldn't speak. She'd stroked out at some point in the last forty minutes.

After the usual stat CT scans, administration of Narcan and a bolus of normal saline in the vain hope that this was merely dehydration, rushing around notifying family members (thank God I didn't have to do that), and transferring her to the ICU, I sat down with the intensivist for a post-mortem of what might've happened.

Turns out she'd had an episode the day before of having one arm go dead. Her legs were already gone, thanks to that spontaneous epidural hematoma, and we couldn't feed her coumadin or heparin or any of the usual anti-clotting drugs, thanks to that spontaneous epidural hematoma. Although she'd recovered her arms in a matter of seconds the day before, the fact that she'd lost one at all (and by "lost one" I mean "lost all motion and sensation") led us to believe that she had some sort of clotting disorder besides the original one.

And, sure enough, she had a previously-undiagnosed bit of atrial fibrillation. A-fib, as we call it in the biz, is a condition in which the top chambers of the heart don't squeeze regularly. Instead, they sort of shiver. This doesn't affect how you feel, much, but it allows small clots to form in the backed-up blood that isn't cleared from the atria. When the heart muscle finally gets its shit together and manages to actually contract the atria, clots can shoot into the brain.

Which is what happened in this case.

The bitch of it is, the utter, total, black-furred bitch dog of it is, there was nothing at all we could've done. Some part of her clot cascade was impaired to the point that she had an eleven-inch long hematoma in her spine with no rational cause, so it's not like we could anticoagulate her. Doing so would've caused the hematoma to restart, and would've certainly killed her.

So, instead, she gets to live with only one (partially) working arm, no speech, and no ability to recognize her daughter.

The daughter was on the way to the hospital later that afternoon. I am not looking forward to seeing her. Even though there was nothing I could've done differently, and nothing would've changed even if I had witnessed the stroke, I still feel responsible.


Deana said...

Please let us know how it goes. I'm so sorry this happened to you. It sounds difficult.

Karen said...

I'm sorry. I want to tell you to not feel responsible (you shouldn't) but I too am a 'black hole of guilt.' The pull is so strong that no guilt shall escape me.

So here's a cyber-hug and an internet head pat.


woolywoman said...

Sorry. It sucks when that happens.

gorochan said...

I think even if the a fib had been seen/found, they wouldn't have done anything except maybe a low dose of beta blocker, she sounds too unstable to do the dilt drip or cardioversion. No way to know how long she'd been in a fib or predict when she'd throw the clot. Sucks a lot. I guess figure out what the clotting disorder is and see if it's genetic?

shrimplate said...

I am deeply sorrowful for the patient and her family. And you too, HN.

I've been there and done that. More than once. And I'm not looking forward to the inevitable next time.

LivingDeadNurse said...

wow thats a rough situation. I hope things get better and the daughter doesn't give you a hard time

hughmon said...

My wife called me at work - perhaps the 5th time in 30 years she called my work phone - told me "I think I had a stroke".
I beat the ambulance to our (rural) home.
She got wonderful treatment (Navy Hospital Bremerton WA).
I sure wish she could still remember who I am....

Anonymous said...

wow...all that comes to mind is...that sucks HUGE, what a crap situation. I'm sorry