Friday, April 16, 2010

This Father's Daughter

She was 50. Prior to being transported to our ER, her only complaint had been for non-traumatic elbow pain over the past two weeks. She was on no medications and had no significant medical history.

She was at home, preparing to visit her doctor for a scheduled visit, when she collapsed. Because she didn't drive, her elderly father had planned on swinging by to pick her up. He had just called and spoken to her minutes earlier to let her know he would be there shortly.

He arrived at her front door and knocked. No answer. He rang the doorbell. Again, no answer. Panic set in. This was not like his daughter to not greet him when she was expecting him. He knocked again, harder. Nothing. He kept his finger pressed to the doorbell, hoping his daughter would hear its continuous ringing and come to the door. She didn't. He tried turning the doorknob, but it was locked. He banged his aging shoulder against the door. It didn't budge.

He remembered the spare key she had given him months ago. "I'll never need this," he had said, trying to give it back, but his daughter had insisted he put it in his glove compartment. He stepped off the concrete porch pad and ran down the sidewalk, back to his pickup truck to retrieve the key. He found it, hidden under a pile of napkins.

Returning to the door, he struggled to fit the key into the lock. As a father, he knew something was wrong, very wrong. With trembling fingers, he finally succeeded in properly jamming the key into the door's lock. He turned the doorknob, barely breathing now, his mind racing of the possibilities he would encounter.

The door opened. He stepped into the small kitchen and yelled his daughter's name. No response. He listened to hear if the shower was running, but it wasn't. He strained his ears for anything, any sound of activity that would reassure him he was overreacting.

That's when he heard the moan. It was garbled and low, guttural almost. He followed the sound into his daughter's bedroom. That's where he found her, lying on the floor, beside the telephone nightstand.

He tried to rouse her, but he couldn't. Knowing something was terribly wrong, he dialed 911. Waiting for the prehospital team to arrive, he sat down on the floor beside her, caressing her head. Talking quietly to his daughter, he filled her ear with the promises that everything would be okay. It had to be, since they were all each other had.

The ambulance team arrived. After briefly interviewing her father and performing an exam, they prepared the daughter for transport to our emergency department. They were concerned that this patient may have had a stroke. They offered the elderly father a ride in the ambulance, with his daughter, but he decided to follow them in his pickup.

In the ER, the prehospital radio went off. They reported that a 50 year-old woman with a sudden onset of right-sided weakness and garbled speech was being transported to our facility. There had been no signs of trauma. Confirming that the time frame was adequate, a stroke alert was called in preparation of this patient's arrival. She would be a perfect candidate for tPA therapy if she did indeed suffer a stroke that was not hemorrhagic.

I, with the rest of our ER team, waited for this patient's arrival in Room 26. In three short minutes, she was being wheeled through our ambulance bay doors and down our hallway. Quickly, we were able to slide the patient from the prehospital stretcher to our hospital cot, all the while listening to the medical report given by one of the paramedics.

Her vital signs revealed that her blood pressure was quite high. She had no fever, her respirations were slow and erratic, and her pulse was normal. On exam, she had a flaccid right side, was nonverbal except for her occasional moaning, and teetered between some minimal form of consciousness and being unresponsive. It appeared that this patient had suffered some catastrophic brain event.

We emergently intubated this patient, both to protect her airway as well as ensure adequate oxygenation to her ill body. After a repeated exam by the neurology team, the patient was hurried to the CT scanner to determine the extent of her stroke.

While she was out of our department, escorted to CT by our nurse, the respiratory therapist, and a neurology resident, I went to the family room to speak to this patient's father. I was accompanied by our social worker and nursing supervisor.

I knocked on the door, opening it slowly to reveal a gentleman in his mid-seventies, tearful and distraught, running his hands through thin wisps of graying hair as he sat in the corner wing-backed chair. He had the look of a hard-working, honest man, dressed in a pressed flannel shirt and brown Dickie pants. He was alone.

"Sir," I said quietly, after introducing myself and my team, "I'm so sorry about what you are going through. Can you tell me what happened or anything that might help us with your daughter's care?"

With great detail, he told me about their plans to visit her family doctor that morning regarding her elbow. He was not aware that she had any medical problems. "She's a hard worker, that one. Never had time to be sick, really." He shared how he went to pick her up, only to find her collapsed beside her bed prior to his calling the ambulance. I listened intently, watching this father struggle to be stoic in his misery.

After maybe five minutes, a faint knock on the family room door preceded one of our nurses stepping in and interrupting our conversation. "Dr. Jim," she said, "can you come here, please."

I excused myself, leaving the father with our social worker and nursing supervisor. I stepped into the hall. "What is it?" I asked the nurse, herself wearing a worried look on her face.

"The CT scan, it's bad. The radiologist wanted me to get you."

I rushed to our physician work space, pulling up the patient's head CT images on the computer panel while I dialed the radiologist's number. What I saw saddened me. This patient had a significant brain hemorrhage, one that was shifting her brain from its midline and filling her ventricles with blood. The radiologist confirmed what I was looking at--that this patient most likely had a ruptured brain aneurysm. I called neurosurgery and the OR stat, since this patient needed emergent decompression of her brain's swelling and bleeding. Her problems were life-threatening.

I went back to the family room, where I sat down opposite the father. His expectant eyes bore into me. Slowly and deliberately, I explained all of the results to him. He unabashedly cried, his shoulder's shaking. "She's all I have left," he muttered. I was affected by his emotions and, looking at the tearful social worker and nursing supervisor, I knew that I wasn't alone.

We escorted the patient's father back to Room 26, where he was able to sit with his daughter as we awaited the go-ahead from the OR. I hovered in the room with several techs, the patient's primary nurse, and a respiratory therapist, overseeing the quick preparations of getting his daughter ready for surgery. I continued to watch the father, unable to turn away from the deep grief and ache that enveloped him.

This patient was taken to the OR. Thankfully, she made it through her emergent neurosurgery. She remained far from a successful outcome, however, since her following few days after surgery would be fragile and tenuous.

Usually, I follow-up with these types of emergent cases, the types that pull at my heartstrings. But, for this case, I didn't. I couldn't. I thought of this patient and her father frequently, yes, but I couldn't bear to think of this father losing his adult-daughter. I was willing to risk not learning of a possible successful outcome if it meant I also didn't learn of a sad, heartbreaking one.

I recognize what I am doing. I am protecting myself, adding another cement block to that protective shell that surrounds my heart. Building it up. Tearing it down. It is a constant but necessary struggle for each of us in the medical field.

I hope and pray, though, that this patient did well. After all, this father's daughter was all he had left.

As always, big thanks for reading. Next post will be Monday, April 19. I hope you have a great weekend...


Chrysalis said...

I can't blame you. Just reading this, I could feel how awful that would be.

Medical Mojave said...

What a great father-daughter relationship. I hope she made it. They deserved a happy ending.


rlbates said...

Ditto, CA and PAP. Take care, Dr Jim.

Gia's Spot said...

Once again, you have pulled my heartstrings and I am shedding tears. Please don't ever lose your compassion and caring for those that walk through your ER doors, it is a miracle in itself!
Have a splendid day!

The Hopeful Elephant said...

Way to start Friday on a high note! ;)

Patients/Families like that eat me up too. I resort to jelly beans in my time of need. Jelly beans make me happy. You can't eat Jelly beans and be sad.

Prayers for all.

Katie Axelson said...
This comment has been removed by the author.
Katie Axelson said...

Wow! I don't know what to say other than, "Great job on another touching post, Jim."
<>< Katie

Unknown said...

My daughters are 6 and 9, and I can't imagine going through this at any time in their lives.

I'll give them a few extra hugs tonight...

Anonymous said...

Been there done that, only it was this daughter's father. I only wish we had an ER doc 1/10th as compassionate. They failed to call neurosurgery and instead calling a covering internist. Dad had to be airlifted to a major university hospital. The 6+ hr delay caused by the ER staff failing to call the neurosugery specialist right away was grossly detrimental to my father's suffering (as evidenced by his initial MRI vs. the MRI obtained upon arrival at the neuro ICU).

At minimum you gave this father's daughter a fighting chance. I only wish this daughter's father was given the same. Thank you on their behalf.

Cal said...

What a sad recounting of a sad event, I would spend my days crying if I had to do what you do! Very nicely told, you really manage to capture the emotions of the people in your stories. I enjoyed reading it, even though it made teary.

Anonymous said...

How terribly sad. You did all you could, and now you can only hope. I understand completely your reluctance to look into the final outcome. ER docs are as human as the rest of us. Be comforted that you, and everyone else at your hospital, did all you could do in the face of something so catastrophic.

Have a peaceful, gentle weekend, Dr. Jim.

peace-sue said...

This was a particularly personal post to me right now, because this week I made an appointment with my primary care doc because of some weird, potentially serious recurring symptoms I've been having. My own thoughts combined with this post has got me thinking about a question different from would you rather dies quietly at home or otherwise....

I've been thinking about whether I'd rather live life fully until something took me down unexpectedly, or have early symptoms that would lead me to a doctor and a diagnosis that was frightening and required many more trips to a doctor. Some very wimpy part of me would rather not know....

Em said...

That story hit really close to home. I hope the lady was okay. My uncle lived another 6 years but no without permanent damage.

coulrophobic agnostic said...

Well, you never know. My grandmother was at least 70 (don't remember how old she was exactly) when she had a massive cerebral hemorrhage that was supposed to kill her. Not only was she fine, she had NO lasting damage and lived another fifteen months before dying in her sleep at home. (She had a ton of health issues, was obese and didn't take care of herself, so this was considered a victory as far as I'm concerned.)

I hope this woman bounced back too.

Rositta said...

A very sad story and hoping for a good outcome doesn't make it so. I understand that in your place some detachment is necessary in order to prevent your own burnout. I have know some ER docs here (not as a patient), who have told it that it's one of the most stressful places to work. Hopefully the outcome was good for this father-daughter...ciao

Smalltown RN said...

OH Doc....I hear you. As health care practioners we have to do something to protect ourselves and emotions, if we didn't I don't know how long we would last in our field of practise.

It's never easy caring for a critically ill patients knowing that the outcomes might not be what we hope for. We have a tendency to get somewhat attached to some families and patients, just by the shear nature of our work.

When I worked as a Palliative care nurse people often asked me how I could do that kind of response was simple...I loved it....I loved being given the opportunity to enter someones life if only for a short time and to do whatever I could for them and their families to make this time of transition for them as emotionally & physically painless as possible.

You did what you had to doc...the fact that you recognize these emotions and the impact these events have on you speaks volumes...stay strong....we need docs like you in the ER!

WWWebb said...

Thanks again, Jim for another touching post.

One of the good things about being an EMT Is that you almost never learn about patient outcomes.

One of the bad things about being am EMT is that you almost never learn about patient outcomes.

I think you understand what I mean.

Anonymous said...

sometimes it just stabs at your heart doesnt it? I hope she is able to recover to have a quality of life...

Jabulani said...

Jim, thank you for writing this. That's all I can say.

SeaSpray said...

I cried with this one.

"I recognize what I am doing. I am protecting myself, adding another cement block to that protective shell that surrounds my heart. Building it up. Tearing it down."

I understand exactly what you mean.

I hope they had their happy ending too.