I haven't been trained...

...to read radiological studies.  I'm not a doctor.  I might be able to look at a chest x-ray and tell that something is wrong, but I couldn't tell you what.  CT scans and MRIs are mysteries to me, interpreted and translated into written language that I can then interpret and translate into language that my patients can understand.

But when I watched the images flicker by on the computer screen in the CT scan room... the snapshots of slices of brain tissue... I saw the bleed, and I knew it was bad.  My heart sank.

This 71 year old woman came into one of my rooms by ambulance.  That morning she woke up as she normally did, took her pills, and upon exiting the bathroom said to her family, "I don't feel very good," and suddenly developed right sided paralysis, facial droop, and slurred speech.

As I cared for her, she deteriorated at a rapid rate.  She was bleeding into her brain, and she was bleeding fast.

By the time the family arrived (15 minutes or so behind the ambulance's arrival), we'd already done much of what needs to be done when a patient having a stroke comes into the ER.  EKG, lab studies, CT of the head/brain, IV access, NIH Stroke Scale neurological assessment... things happen really, really fast when we all know that time = brain tissue.  Minutes after their arrival, it became apparent that this woman, who only an hour before had been walking and talking, and only 20 minutes ago could tell me her name, was not going to be able to maintain her own airway safely.  She was vomiting uncontrollably, and I'd rolled her to lie on her side to try to keep her from aspirating her own emesis.

The physician asks the family if they want us to put in an endotracheal tube.  They're crying, holding on to each other, and lost.  "We don't want her to suffer!" they say.  The physician says, "I can't speak to that, but I can tell you that either way, I don't believe this is going to be a good outcome.  She may die.  If we don't put the breathing tube in now, she will almost certainly die from being unable to breathe.  You need to tell us what you want us to do."

I was manually ventilating the patient with an ambu-bag, my gloves covered in vomit and blood from where her IV pulled as we rolled her onto her side.  I watched this family's anguish and grief, their terror and indecision... and had to make the conscious choice to shut down my emotional self entirely.  It was the only way I could continue to do my job.

We intubated her and connected her to a ventilator.  We sedated her with Valium and Propofol.  We bathed her and put a clean gown on her.  We maintained IV fluids and soft wrist restraints and frequent neurological checks.  We put in a gastric tube to empty her stomach so she wouldn't vomit, and a temperature foley catheter to empty her bladder and monitor her core temperature.  We gave her a unit of platelets to try to get her blood to clot to control the bleeding within her skull.  We secured a bed for her in the intensive care unit.  We had stabilized her as best we could. We offered the family water and coffee.

I went through the motions, trying to absorb and learn what I could about the procedures we were performing.  I answered the family's questions as clearly and honestly as I could.  My brain was telling me that this woman was not going to long survive this event, and my heart was trying to tell me something I couldn't deal with right then.

Honeybunch stopped by a little later in my shift to bring me my spare car key (I'd locked the car with the keys inside when I got to work that morning).  We'd just transported the woman to the ICU.  When I hugged him and thanked him, I nearly broke down right there in the waiting room.  Sometimes a kind word, a concerned look, an embrace from someone who cares is like being given permission to cry.

I fought the tears for nearly 11 hours, until I started my drive home. 

I got through my first massive hemorrhagic stroke case.  I'm better prepared for the next time it happens in regards to what needs to be done to try to save a life.  But I don't know if I'll ever be any more prepared for the emotional assault of seeing a family trying to make that kind of decision...in a small room with about a dozen strangers in it, with their mother/wife/grandmother covered in vomit and blood, with a physician nearly shouting at them to decide what to do.

I'm going to write an advanced directive this weekend.  I don't ever want my family to struggle with that choice on my behalf.