The Tick of Time

By Tony Dajer|Saturday, April 01, 1995
RELATED TAGS: MENTAL HEALTH
Trauma, it’s a trauma!

I looked up from the squalling two-year-old I was examining for an ear infection. The paramedics were wheeling in an elderly Chinese woman on a stretcher. Velma, a tall Jamaican nurse with a stiff British accent, stood in their way.

Trauma? That’s for me to decide, she said crisply. The patient in question lay as inert as a wax statue. Mama? said Velma, bending over the woman and prodding her gently. Mama? How are you?

No response. More shaking. The old lady’s head sagged onto her shoulder. Mama was definitely not waking up. I walked over.

Gentlemen. I nodded at the medics. What happened?

Well, this poor lady was pushing her cans into the recycling bin at the supermarket. Suddenly a crowd rushes in and knocks her off her feet. After that she doesn’t get up, doesn’t budge. The daughter was with her and says she was pushed pretty hard, but we didn’t see any bruises or lacerations. Been out cold for about 30 minutes now.

See? Velma interrupted. No bruises. It could be a stroke. She won’t be needing surgery--she should go to the medical side.

It was Velma’s job to size up new patients and decide if they needed surgical or medical treatment. Normally a trauma patient would be handled on the surgical side, in case she had suffered injuries that needed bandages or stitches.

One of the medics pulled a face. You mean she had the stroke at precisely the same second they knocked her over? Come on.

I shrugged. Well, at the moment I’m the only attending physician here anyway. Why don’t we put her on surgery? It’s less crowded.

Sure thing, chorused the medics, glad to be moving again.

I turned to Velma. Let’s assume she is a trauma. She needs to be stripped, vital signs repeated, labs drawn, and an IV line started. I’ll be right in to see her.

I finished up with the two-year-old and hurried over to our newest patient.

Her daughter stood at the bedside, holding her mother’s hand. Mrs. Wu, she indicated protectively, intent on rescuing her mother from anonymity in an ER where the doctor spoke not a syllable of their language. Then she leaned over and breathed a gentle susurration of Chinese into her mother’s ear. But Mrs. Wu, impervious as ever, betrayed no response. In fact, her placid face struck me as too unperturbed. Suddenly the stampede at the recycling bin story smelled like a red herring.

But if Velma’s stroke theory was on target, what kind of stroke could it be?

A stroke is what happens when an artery in the brain bursts or is blocked long enough to deprive the brain of oxygen and alter brain function. When an artery is plugged or extremely narrowed, it causes thrombotic stroke. When an artery bursts, it causes a hemorrhage, or bleeding, in the brain. Hemorrhages are much more devastating than thrombotic strokes, but they are far less common in the elderly. On the other hand, thrombotic strokes don’t usually send patients into a sudden coma.

The word coma, taken from the Greek word for deep sleep, refers to the deepest sleep imaginable. Not even the loudest noise or the most piercing pain will wake the patient. It is the picture of a brain utterly incapable of interacting with its surroundings, of a window turned suddenly into a mirror.

In a healthy brain most of the functions that allow us to perceive and interact with the world are handled by the cerebral hemispheres. These structures, which sit like halves of a crinkled, elongated orange atop the rest of the brain, are the site of sensations, thoughts, and commands. To the rear--in the rumble seat of the skull--lies the cerebellum, which coordinates movements ordered by the hemispheres. Below the hemispheres and in front of the cerebellum is the brain stem. One of the brain’s oldest and most primitive parts, the brain stem is the trunk line that carries nerve signals between the brain and the body.

Most strokes occur in one of the hemispheres, and in these cases, the patient usually remains somewhat responsive. That responsiveness requires at least one functioning hemisphere and, above all, an intact reticular activating system, or RAS. The RAS is a dime-size collection of neurons in the upper brain stem, and it’s the brain’s on-off switch. Knock it out and the sublime machine inside our skulls becomes as easily aroused as a bowl of Jell-O. Because it is located at roughly the same level as the eyes, the RAS is also intimately entwined with the nerves that control eye movement. For the physician, that link can provide an important clue to the integrity of the brain stem. If a clot or bleeding damages the RAS, it usually disturbs eye function too.

When I performed a quick test of Mrs. Wu’s reflexes, she showed no response. Not a twitch of her arms or legs--nothing. It was extremely unlikely that a stroke in one of the hemispheres would cause such profound unresponsiveness. The trouble, I was sure, lay in her brain stem. To check my hunch, I gently pulled Mrs. Wu’s upper eyelids back with my right thumb and forefinger, then rotated her head as if she were resolutely signaling no. This technique, called the doll’s eyes maneuver, stimulates the balance mechanism of the inner ear to signal the eye-coordinating center in the brain stem that the head is moving. If the center is intact, the eyes will then compensate for the head’s rotation by moving in the opposite direction. That movement enables the eyes to retain their original focus. Thus, just as when a doll’s head is turned to the side, the eyes keep looking straight ahead.

Just as I feared, Mrs. Wu’s eyes lacked the doll’s eyes reflex. When I turned her head, her eyes followed. This failure, coupled with her complete paralysis, was very bad news.

Although a patient can often survive and even recover when damage occurs in other parts of the brain, surviving damage to the brain stem is extremely rare. Because the brain stem regulates breathing and heart rate, hemorrhages there are almost uniformly fatal.

Mrs. Wu’s daughter locked her eyes on mine. What are you doing to my mother? they asked, smoldering.

I made a circling motion around my head, in the ridiculous hope that she would guess that it meant Your mother needs a CT scan. Then I said, Very bad, your mother is very bad. The smooth planes of the daughter’s face fractured into sobs. I might have paused to console her, but any hope for Mrs. Wu, I rationalized, lay in headlong speed.

Velma, I half shouted, let’s get her up to CT scan.

Immediately we bundled Mrs. Wu up, kicked off the stretcher brakes, and sped upstairs.

When I returned, my next patient was waiting, an elderly gentleman who had fallen and smashed his forehead. Mending the gash would take at least 45 minutes. Halfway through the job, though, I pulled off my gloves and called the CT scan technician.

Ben, I said hurriedly, what do you see?

Well, I haven’t printed out all the images yet, but it’s bad news--it looks to me like there’s blood at the level of the brain stem.

Poor Mrs. Wu. I would check the scan myself as soon as I was done suturing but, I was sure, to no use. When the brain stem is damaged, there is scant hope of repair or recovery. I would wait until an interpreter arrived to help me break the news to Mrs. Wu’s daughter.

Sobered by Ben’s report, I resumed stitching up my elderly patient’s forehead. After I had finished, I met Velma in the hallway. She was beaming.

Oh, Dr. Dajer, Mrs. Wu is back from CT scan. And, you might be interested to know, she’s awake.

Huh?! I grunted.

Yes, she’s talking, Velma continued, all nonchalance.

No way, I stammered. She had no doll’s eyes. Ben said he saw blood.

Well, according to the interpreter, she’s perfectly lucid and would like a sip of water. She says she just feels a little dizzy, that’s all.

I glanced over toward Mrs. Wu’s bed. Sure enough, there she was, chatting quietly with her daughter and the interpreter. All my hypotheses suddenly tangled like spool on a fishing rod: maybe the stampede at the recycling bin had knocked her out and now she was coming around. Maybe my doll’s eyes test had been too quick to be accurate. Maybe Ben had mistaken old calcifications in her brain for blood.

Just then, Ann, the head nurse, wheeled in a middle-aged man drenched in cold sweat.

I think we have a heart attack here. Let’s move, people, she said loudly.

The ECG agreed with Ann. While the nurses started IV lines and mixed medications, I prepared the clot-busting drug that we hoped would dissolve the clot in our patient’s coronary artery. Amid this hubbub, Mark, the second attending physician in the ER, walked in.

He took the medicine side; I would go back to surgery. I explained the new patient’s condition and then was off, finally, to consult with the radiologist about Mrs. Wu’s CT scan.

I extracted Mrs. Wu’s scans from a stack of images and handed them to the radiologist. Here, what do you think?

He shoved the film under the metal edge of the view box, then slowly ran his finger along the last set of panels. Hmm. Interesting case, he said. A cerebellar hemorrhage, two to three centimeters across . . .

Cerebellar! I cried. Oh, damn, damn!

He looked up, concerned. You okay?

Me? Sure. But Mrs. Wu would be a lot more okay if her doctor had jumped on this 45 minutes ago.

If a hemorrhage in the brain stem is a virtual death sentence, a cerebellar hemorrhage can yield a governor’s pardon. It is the only kind of stroke for which surgery is recommended. A surgeon can cut into the cerebellum and remove the clotting mass of blood, thus relieving any harmful pressure on the nearby brain stem. But the surgery has to happen very fast. If the mounting pressure damages the brain stem, the patient will stop breathing.

Now it all made sense: when a hemorrhage occurs in the cerebellum, it may temporarily stun the nearby brain stem and RAS, inducing coma. Mrs. Wu’s doll’s eyes reflex had been absent, but only temporarily; Ben had seen blood, but around the brain stem, not in it. I had fit the facts to my first-impression diagnosis. I had heard only what I’d expected to hear and let 45 precious, possibly life-saving minutes dribble away.

Move! a voice hollered inside my head. But that was more easily shouted than done. Our hospital has no neurosurgeon, so we first had to arrange for another hospital to accept Mrs. Wu. Second, Ben needed to transmit Mrs. Wu’s scan over a computer hookup, a sophisticated but time- consuming process that would delay other urgent cases. Third, an ambulance would have to elbow its way through midday traffic, pick up Mrs. Wu, and dash to the other hospital.

I stormed out of the radiologist’s office and poked my head into the CT scan suite.

Ben, Mrs. Wu has a very fixable cerebellar bleed. Can you beam her scan uptown? I’m going to call neurosurgery right now.

Soon as I can, Ben said, his eyes fixed on the orange-lit console in front of him.

I ran downstairs. How’s Mrs. Wu? I asked Velma.

Not so good. Her daughter says now she has a headache. And she’s getting sleepy.

Would she slip away before we could get her to surgery? Cursing the delay, I dialed the neurosurgeon at the other hospital.

When I finally got through, he listened noncommittally.

Well, send the scan up and we’ll see, was all he said.

I walked over to Mrs. Wu. She pressed a hand against the back of her head: hurts.

Tell her daughter, I said to the interpreter, we must send her mother to another hospital immediately. She needs an operation or she will die.

The daughter’s eyes flared again. Why should she trust me? they seemed to ask. I’d already cried wolf once by announcing her mother was very bad, but then she had woken up. And now here I was acting as if her mother was in danger again. I put my hand on Mrs. Wu’s forehead and stroked her hair.

You’re going to be all right, I said, silently apologizing for the minutes I’d wasted.

I ran back up to the CT scan suite.

Ben, how did that transmission go?

Haven’t got around to it yet. Lots of cases today.

Ben, that scan really needs to go up now.

Ben swiveled on his stool.

You mean now now, huh?

Yeah, I said, nodding.

Fifteen minutes later I called the surgeon back.

Did you get the scan? I asked, hoping to hear the magic words: Send her up.

Instead he said, Okay, let me take a look at it. I’ll call you back.

Another visit to Mrs. Wu’s bedside. She was fading. Now her daughter had to shake her to rouse her enough to answer questions. What else could I do to move things along? I knew the ambulance usually took 30 to 40 minutes to arrive. If I called now, even before transfer was certain, I might earn back some time.

The ambulance crew got there in 20 minutes. And then had to cool their heels.

I sat vigil by the phone. Mrs. Wu grew quieter and quieter. I pictured the seeping blood expanding within her cerebellum like a red mushroom cloud. Finally, I couldn’t help myself.

Hi again, I said to the surgeon. I don’t mean to lean on you, but my patient’s mental status is deteriorating and . . .

Oh, you can send her up, he said. His tone suggested that any time this week would be fine. Surgeons.

I jumped up. Go!

The ambulance crew headed for the door.

The rest of the day I felt like an expectant father pacing a linoleum corridor. But Mrs. Wu’s surgery would take many hours. There was no point calling till morning.

So how is she? I asked early the next day.

Well, she was pretty out of it when she got here, the surgeon replied. Still is, but she should do well. That was a good call, by the way.

Thanks, I answered, then thought, Could have been quicker.

What if she didn’t wake up? What if the delay had allowed so much blood to accumulate that the pressure in her brain had mounted beyond all hope of recovery?

But doctors aren’t supposed to act like nail-biting fathers-to- be. I would wait to find out how well she recovered. A week slipped by. Finally, during a call to the surgeon about another case, I dared the question.

So, did Mrs. Wu--the cerebellar bleed--come through all right?

The surgeon paused. Oh no. Throat clearing before bad news. I braced myself. Then came the nerveless voice.

Oh, she did fine. Wobbles a bit when she walks. But we got it in time.

In time. Words sweeter even than It’s a girl.
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