John Simon was a business executive for a prominent health insurance company. During a seminar on health care management, he sneezed, then sagged out of his chair and slid to the floor. The first thing he saw was the face of the woman who’d sat beside him.
What happened? he asked, but he didn’t recognize his voice or his words as he said them. He reached up, but as he did, his hand seemed to disappear. People gathered round. All of them were talking, but as if from far away. Someone kept saying, 911, 911, 911. Maybe he kept saying it. Faces disappeared and reappeared, but that one woman was always there. He tried to think. She had told him she was once a nurse; now she was a lawyer. She looked very much a nurse now, leaning over him. They had talked about contracts during lunch. What was her name? And he saw his wife momentarily next to her, which was strange because this was a business seminar. He couldn’t remember his wife’s name either.
Two men, young men in uniforms, came to take care of him. He thought they were policemen at first but then realized they were paramedics. They got out their equipment and attached monitor leads and oxygen to him, which was ridiculous. Look at this: now they were trying to take his blood pressure.
What is it? he asked. What’s wrong with me?
Sir, I think you’re having a stroke.
This is absurd, he thought. I’m only 37. He tried to sit up but couldn’t. He felt as if he were drowning.
They set off in the ambulance, careering around corners, which he thought was funny; it wasn’t as if he were dying. Then he realized it wasn’t so funny. After a while the ambulance doors opened and he was rolled inside a hospital. People were trailing the gurney as it rolled along. All were dressed in green scrubs, except one woman in a white lab coat. She had dark hair and a stethoscope slung around her neck. She must be the doctor, he thought. Women are doctors now, men are nurses, and nurses are lawyers. For a moment he was buoyant, lifted up onto the bed by a sea of hands. Then that woman, the doctor, leaned over him and asked questions. What was his name? How old was he?
That doctor was me.
Quick check. Blood pressure 160/90, pulse 88, breathing unlabored. Spontaneous eye opening. Sir, sir! What’s his name? Mr. Simon, sir, I’m your doctor. Pupils are equal and reactive. Normal heart sounds. Sir, squeeze my hand. Squeeze with your right hand. Good. Now squeeze with your left. Squeeze your left hand. . . .
Nothing. This 37-year-old otherwise healthy male has had a sudden neurological event--probably a stroke.
The admitting clerk was there, pad and pencil in hand. Sir, when’s your birthday? Do you have your insurance card? Who’s your doctor? She stood there asking questions that are really irrelevant in the early care of a critically ill patient. But unfortunately, when someone suffers a stroke there’s not much care to interfere with, beyond the physical exam itself. Other than giving oxygen, controlling blood pressure, and correcting incidental problems, a doctor can do little more than wait and see whether the stroke symptoms get better or worse. At least that’s the way it’s been. Now there may be a new treatment, and that, for me, was even more of a problem.
I had read glowing reports that a clot-busting drug used to treat heart attacks could be used to treat certain stroke patients, dramatically reducing their risk of a catastrophic deficit. This would indeed be wonderful, but I was skeptical. I was aware of recent studies showing that in some cases clot-busting drugs could make a stroke worse. In fact, only one study had shown a clear benefit for clot-busting drugs--and even then only in patients who had been treated within three hours of the onset of symptoms. So I had doubts, and those doubts made me apprehensive about how to treat Mr. Simon.
A stroke is the brain’s version of a heart attack. There are two main kinds. One is caused by a clot in a blood vessel of the brain. The other is caused when a brain blood vessel ruptures and blood leaks into brain tissue. Both disrupt the oxygen flow in the brain, often causing permanent brain damage. A clot-busting drug can be helpful only in strokes caused by clots. If the stroke is from a bleed, the drug may make the bleed much worse, turning a stroke from mild to catastrophic.
How can you tell if a stroke is from a bleed or a clot? By doing a ct scan, the radiographic test that has revolutionized brain imaging. The biggest problem is time. In some institutions a brain ct scan can be obtained in 15 to 20 minutes. In others it may take up to two hours. But studies show that if the clot-busting drug is to work, it has to be given early. And many patients with strokes don’t get to the hospital until their symptoms are hours old, too late to begin administering the drug. Mr. Simon was lucky. He arrived minutes after the onset of his symptoms. If anyone could be helped by the drug, it would be him--that is, if he had a clot.
Mr. Simon’s exam showed a left facial droop, complete paralysis of the left hand, and marked weakness of the left leg. As I was running the reflex hammer along the bottom of his foot, I looked up and saw two nurses wheeling a bed containing an elderly woman. I had ordered a ct scan on her an hour before.
Stop! I called. He goes first.
I rode shotgun on the cart, pushing the iv pole along with the nurses in the parade down to the scanner. I sat behind the ct technician watching images from the core of the brain crystallizing and dissolving on the screen. There were the lovely patterns of nature--the sulci, the cerebrum, the thalamus, the falx. All of the structures I had sweated to memorize in school were now laid out effortlessly before me.
It was a matter of moments. I could see that John Simon’s ct scan was normal.
This, obviously, did not mean his brain was normal. Patients with strokes from clots typically have ct scans in which the abnormality appears only after several hours. Bleeds, however, usually show up right away. John Simon appeared to have had a stroke caused by a clot.
I left a message for the attending neurologist; I was sure he would advise me to give a clot-busting drug. But I was still worried that in this case we might make things worse. Time ticked by. At last Dr. Zimmer returned my call.
Normal guy, I said. No history of medical problems. He was at a conference and he sneezed. . . .
I think he may have a dissection.
That made sense. A dissection is a tiny tear within the lining of the blood vessel; it can impair blood flow disastrously without causing bleeding outside the blood vessel. Dissections are rare, but the sneeze could have caused one by momentarily increasing the pressure in Mr. Simon’s brain. Treating a dissection with a clot-busting drug might indeed do more harm than good.
On the other hand, he added, it could be a clot. The only way to tell for sure is to do an angiogram.
An angiogram is performed by injecting dye into a brain artery; the dye allows us to trace blood flow and actually see whether a clot or dissection exists. It is much more difficult to do than a ct scan, and since it is invasive, somewhat more dangerous. But my hospital didn’t have the sophisticated facilities and experienced staff to do angiograms.
Try University Hospital, Dr. Zimmer said. The brain attack team.
University Hospital was one of two local medical centers that advertised the newest treatments for stroke.
I hung up, dialed University’s paging operator, and asked to speak to the brain attack team. A Dr. Dash came on the line right away. She took the case after I had spoken only a few sentences.
We’ll get the angiography suite set up now. Send him over--fast. Time is critical. She turned away from the phone, and I could hear her say, Where’s the helicopter?
It’s out, I heard someone shout.
Our hospital has a critical-care transport team, Lifeline. It was my turn to lean over to our clerk.
Lifeline? I asked Mary.
They’re out, she said. And there’s only one truck today.
She raised a finger, though. Let me see what I can do.
Doctor. Lynn, the head er nurse, came up to the desk. Why don’t you come and take another look at this guy.
I ran to Mr. Simon’s room. If anything, he looked worse. Now he couldn’t move his left leg at all. I flicked my pen up the bottom of his foot and his toes fanned out, the big toe arching away from my pen. The not a good sign sign. He was losing more motor control.
His wife had arrived. I tried to explain to her what was happening, but she was nearly hysterical. Please, doctor, she said, please help him.
I said I wanted to transfer him to University Hospital. They have a team of specialists that may be able to treat him with things we can’t. Maybe, I told myself, maybe, maybe. They can do an angiogram. . . . I balked at trying to explain an angiogram to this frantic woman.
Someone tapped my arm. It was my patient nudging me with his right hand. Even that hand seemed weak now. He tried to speak but gave up; his speech was slurred. He raised his hand into a recognizable okay sign-- okay to transfer.
Mary, leaning into the room, announced that she had a transport team--a paramedic who knew how to drive the truck, and the head nurse, Lynn. It was now an hour and 35 minutes since Mr. Simon’s collapse. I could only pray for an uneventful ambulance ride and a quick response on the other side.
Just as they were heading out of the room, there was a phone call for me.
It’s Dr. Dash, Mary told me.
I grabbed the phone. We’re just loading him, I said. He’ll be there shortly.
No, you have to stop.
Our clinical coordinator contacted your registration clerk. You can’t transfer him here. This man has the wrong insurance.
The wrong insurance. You never checked his insurance status. We don’t take his insurance. You never checked.
That’s the last thing in the world I’m worried about.
Look. Take him to the Foundation Hospital. They have a brain attack team, and I think they’re accepting patients.
But that will put us another hour behind. Look, you accepted him, and you’ve got everything set up. I was furious, helplessly watching all the time we saved go down the drain. The Foundation Hospital may not even accept him.
They’ll accept him, she said. I’m pretty sure.
But I just told him and his wife that University Hospital is the best place in the city for strokes. Now you want me to tell them I’m sending him to the other best place in the city for strokes.
Is his wife there? I’ll explain it.
The team came wheeling out into the hallway, the patient in a tangle of wires from the portable monitors, oxygen tubing, and iv lines. Stop! I shouted, hands up in the air.
What’s going on? Lynn asked. Everyone floundered to a halt and looked at me. What? What?
I waved the wife over. She looked even worse than the patient, if that was possible. I handed her the phone receiver and told her to talk to the doctor. I went over to Lynn. He’s got the wrong insurance, I whispered. They want us to send him to the Foundation Hospital.
We looked at each other, stunned.
I looked over at the wife. Her hand was drooping so that the receiver was nowhere near her ear. She was clearly in no shape to make a decision. I stood there for a moment thinking, This cannot be real. Then I ran over to her and grabbed the phone away.
We’ve wasted precious time already. You’ve accepted him. He’s coming to you! End of discussion.
Dr. Dash sounded almost relieved. Okay, okay. Send him here. We’ll deal with all that later.
I slammed down the phone and waved to Lynn. University! I shouted, and they were off.
I sat down and stared at my hands. In medicine we have grown so accustomed to the splendid luxury of cost being no object that any financial restraint seems intrusive. This financial concern, however, was more like appalling.
I sat there with my head in my hands.
It occurred to me that I might be liable for the cost of this man’s stay. After all, I had just knowingly sent him to a hospital not covered by his insurance. I never obtained his permission. Maybe I would have to pay the bill. Then I shook myself. We all, the nurses and the techs and I, had gotten this patient seen, scanned, and transferred in about an hour. If this man had any chance to recover, it would be because of this. We did what was best for him.
I thought about what strokes of this magnitude can mean: paralysis, feeding tubes, indwelling urine catheters, bedsores so erosive they take on a life of their own. You can’t walk without assistance; you can’t bathe; you can’t dress. You can’t sing; you can’t dance.
But you can still cry.
An hour later Dr. Dash called me. There was something wrong with her voice. It took me a moment to realize she was crying.
What happened? I shouted. Was it a dissection or a clot or what?
He had a clot, she sobbed back. A big clot right in the middle cerebral artery. We went in. You could see it beautifully on the screen. We gave him the drug and the clot just vanished. His leg strength has completely returned, and he’s moving his arm much better. Nearly full recovery!
I felt for a moment how a saint must feel when attendant at a miracle, simultaneously very big and very small.
He wants to go home, Dr. Dash said. He wants to go back to his business conference. He wants to know why he is here.
Tell him. . . I started to say but stopped. I was going to say, Tell him he’s there because I sent him to the wrong hospital to get a medication that I didn’t think would work.
I hung up the phone and covered my face with my hands. There I was, humbled again. This, I thought, must be the art of medicine.