The Littlest Stroke

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Dr. Abanses speaks about his experiences with his young stroke patient.

Case: The Littlest Stroke

A six-year old boy is brought into the E.R. with paralysis on one side, unable to talk. An MRI confirms that he’s had a rare massive stroke. Dr. Abanses must make some fast and unprecedented decisions in order to save the boy from severe brain damage. However, the cure could be as dangerous as the ailment.

Q: What was your initial reaction to this case?

Dr. Abanses: My first reaction was boy, this child is in trouble, and we have to work fast. My next biggest impression was how brave he was being. This 6-year-old who could not talk to me would still follow my every command. Being taken to an E.R. is a scary enough event, but to not even be able to communicate with the people around you had to be terrifying. Yet, through it all, he did everything we needed him to do and would try it with all his might. In my eyes, that took a lot of courage by a young man.

Q: What was the trickiest part of the case?

Dr. Abanses: There were two very distinct tricky parts for me in the care of this child. The first tricky part was explaining to a mother whose husband had just died that I wanted to give her child a medication not tested on kids to see if it would work in helping her child. Explaining the complications of this medication and risk for profuse bleeding and possible death was not an easy thing.

The second part was after I gave the TPA (Tissue Plasminogen Activator), the child, who had a heart race around 110, suddenly dropped his heart race to 44. That was scary. Was he herniating his brain from massive internal bleeding, or was his heart going to stop and go into cardiac arrest? I had to choose to give him atropine to treat his heart, which could potentially decrease the blood flow to his brain, or I could choose to not give it, which could also decrease blood flow to the brain and the rest of his body.

Q: How is the patient doing now?

Dr. Abanses: I was thrilled to hear that this young man now plays basketball. My favorite picture of him on the show was seeing him climbing the rock wall - such an accomplishment. To see him using all those muscles on both sides of his body getting up that wall contrasted to that memory I have of him raising his right arm and tears flowing down from his eyes - such a sharp contrast and an end to an amazing story.

Case: A naked man is covered in cactus needles when he arrives at the E.R. after a night of partying. Dr. Cesar A. Aristeiguieta must find a way to remove thousands of tiny needles quickly, before the patient goes into shock.

Q: Were you shocked when you saw this case?

Dr. Aristeiguieta: I was certainly a little surprised to see so many cactus needles on a patient. It looked like he had rolled around on the cactus bushes!

Q: Have you seen other cases like this?

Dr. Aristeiguieta: Working in the desert, we see a lot of people that have been “bitten” by cacti. This one was certainly the most extensive, probably because he was intoxicated and not really feeling the injuries.

Q: How did you decide your course of treatment?

Dr. Aristeiguieta: Removing large cactus needles is not much of a problem when they are intact. The little, hair-like needles are the problem. Trying to tweeze them or scrape them out would not be efficient or complete. We had to figure out a way to “wax” the needles out of the patient’s skin. When no bikini wax was available, white glue proved to be a great substitute.

Q: What was the trickiest part of the procedure?

Dr. Aristeiguieta: First, we had to treat the patient’s pain, but we also had to be careful not to overdo it because he was so intoxicated. Next, we had to figure out how to get him to at least sit down and eventually lay down. That required a lot of plucking of needles off his legs, buttocks and back. For the patient, the worse part was the waxing since we were pulling out cactus needles and hair at the same time.

Q: What is the strangest case you've encountered?

Dr. Aristeiguieta: As they say, life is stranger than fiction. Recently, I had a patient that came in with an eyeball hanging out of the socket. This just happened as she was in bed sleeping. The poor patient looked like a cartoon character that had been hit in the back of the head and the eyes popped out. For me, the strangest part was placing the eyeball back in the socket. Not something you are trained to do or see everyday as an emergency physician!

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A child's mysterious broken leg causes concern in the E.R.

Case: A 4-year-old boy breaks his leg, and his mother has no idea how it happened. When Dr. Bob Slay looks at the x-rays, he notices evidence of other earlier bone breaks that the mother can’t explain. Suddenly, a case of a broken leg begins to look more like child abuse.

Q: Were you shocked when you saw this case?

Dr. Slay: Yes, because the mother seemed to really care about the child, and it was hard to think that she, or someone, was abusing the little boy, breaking multiple bones.

Q: What was your first reaction when you saw the patient?

Dr. Slay: I, of course, wanted to protect the child and made the assumption that it was abuse by the parent and wanted the parents prosecuted.

Q: What was the trickiest part of the procedure?

Dr. Slay: It is really hard to confront the parents with your suspicions. They are really “guilty until proven innocent”. There are many such cases of O.I. (Osteogenesis Imperfecta - a condition making bones grow fragile and brittle) where the parents were criminally prosecuted and lost their child for years before the diagnosis exonerated them.

Q: Have you seen other cases like this one?

Dr. Slay: No, I have not seen another case of O.I., though unfortunately, I have seen real cases of child abuse and neglect too often.

Q: What's the most difficult case you've ever encountered?

Dr. Slay: There was one with a traumatic injury to a small child, consistent with child abuse but hard to prove. It was further complicated by the fact that the child needed a blood transfusion and surgery, and the parent's religious beliefs forbade giving the blood.

Case: In a puzzling case, 23-year-old Chelsie staggers into the E.R., her heart racing, unable to speak. Suddenly, she stops breathing. Dr. Bill West and his team try valiantly to revive her, but they aren’t sure what the problem is. Meanwhile, her young husband makes an impassioned plea for her to stay alive.

Q: What made you decide to go to the E.R. that day?

Chelsie: I remember laying on the floor while I had my baby in her swing, and I could barely keep my eyes open. She started fussing, as she had been in their for a while, and it was when I couldn't even lift her up I called my husband and told him he needs to come home right away.

Q: Were you initially worried it would be something serious?

Chelsie: I would have never thought at 24-years-old that I would have to worry about dying, let alone my heart stopping at any moment, as I have always been in pretty good health with fairly good eating and exercise habits. My heart and organs were all about to fail, and I never paid much attention to what my body was really saying. I really did not think of it to be anything too serious.

Q: What was your first reaction when you awoke from surgery?

Chelsie: I remember vaguely hearing a doctor asking me to squeeze my hand, and the next thing I saw was my mom standing above me, and I asked her, “Mom, what are you doing here?” My first thought was that I was in a car accident, and that something terrible had happened.

Q: Describe how you felt when you realized what had happened.

Cheslie: The emotions were high for me when I awoke to find two weeks of my life had passed by, my heart and organs failed, and I had several open heart surgeries. I remember looking down at my body and seeing a stick figure, as I had lost over 20 pounds and had staples down my chest.

Q: Have you had any more issues with your heart?

Chelsie: Since my remarkable recovery, I have not had any major issues other then going into the emergency room being scared of something being wrong, but having it turn out that everything is fine. In saying that, my heart is all in normal ranges at the moment, and doctors are expecting me to keep on the path that I'm on. I'm currently still being monitored carefully by cardiologists.

I am so very thankful for the amazing team of doctors and surgeons that never gave up on me despite all the odds that were against me. There are no words to describe the amount of gratefulness I have. I may never know the reason I was chosen for this experience, but I have chosen to share it with everyone, as I believe it will change lives of others. I definitely know it has changed what the medical world believes, as this was a miracle...miracles do happen.

Dr. Bill West, who worked on Cheslie's case, retells his first reactions to the case and how he made those life-changing decisions.

Q: What was your first reaction to the patient?

Dr. West: This doesn’t look good! She’s so young! What’s going on? Then you have to be professional and rely on your training and experience. I get into a mode where my complete concentration and energy is focused on the complicated decisions and procedures at hand. You get into a zone of hyperacuity. Everything gets clearer and you feel a sense of calm.

Q: How did you decide your course of treatment?

Dr. West: We always begin with assessing the ABC’s and get a history from someone at the same time. It is hectic and a sort of controlled chaos where everyone has a job to do. Anything can go wrong. As you go through the ABC’s, if there is an issue, you deal with it. Our issues started at A!

Because this patient was unstable and could not protect her airway, she required intubation and ventilation. At the same time, she was not perfusing her body with blood so large central IV’s had to be placed in her extremities. Vital medications had to be run through these IV’s based upon her heart rhythms exhibited on the monitors and with information gathered by a bedside heart ultrasound.

Q: What was the trickiest part of the procedure?

Dr. West: It was tricky figuring out why she would wake up when CPR was being performed, then become unconscious without a pulse when we stopped. Also, it was difficult deciding not to stop the resuscitation after everything we tried was failing. Then we had to find the right people to perform adequate CPR for over 100 minutes while she was transferred to a tertiary hospital.

Q: Is it difficult to separate your emotions from a case like this?

Dr. West: It is impossible to separate your emotions from your work, but you have to keep them under control. Patients expect and rely on your clear thinking and expertise. You have to be professional.

Q: How often do you see patients beat the odds like this?

Dr. West: People are tough in desperate situations. I have seen patients rally from death many times but never like this patient. She has a purpose on earth. It wasn’t her time. Also, our team was incredible for those 60 or so minutes; resilient and resourceful.

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A patient's girlfriend and wife meet face to face in the E.R.

Case: Dr. Nicole Jasper has her hands full when she realizes that her paralyzed stroke patient has a wife and two girlfriends who each claim to be the one who really cares for him. And with all that commotion, she can’t get his blood pressure to go down, risking a relapse!

Q: Were you shocked when you saw this case?

Dr. Jasper: I was completely surprised when I saw this case for several reasons.

  • It is very unusual to see such a young man having a stroke, much less one with such profound symptoms.
  • I could not believe that not only did the patient’s wife, but his two girlfriends showed up in the ER.
  • I was very surprised by the behavior of all three women while they were in the ER.

Q: Have you ever seen other cases like this?

Dr. Jasper: I definitely have seen other young people with strokes, but I have not seen one with all the personal drama.

Q: What was your first reaction when you saw the patient?

Dr. Jasper: I was very worried when I first saw the patient. He had profound deficits from his stroke. I knew that if he did not qualify for, or respond, to TPA (tissue plasminogen activator), he would have significant life changing disabilities.

Q: How did you decide your course of treatment?

Dr. Jasper: Based on the patient’s symptoms timeline and the fact that his head CT (computed tomography) did not show an intracranial hemorrhage, I knew I wanted to use TPA (tissue plasminogen activator). TPA has been shown in multiple studies to help improve the symptoms of patients who have had ischemic strokes. Even though TPA has bleeding risks, I felt that the benefits outweighed any potential risks.

Q: What's the weirdest case you've encountered?

Dr. Jasper: This is definitely one the strangest cases I have seen. The awesome thing about emergency medicine is that you see strange things all the time!

I have had numerous cases with rectal foreign bodies – men, women, old, young. You can only imagine the explanations I received.

I had a cardiac arrest that I coded for 45 minutes. I finally stopped the code and was going to speak with his wife when his heart restarted. The patient was gravely ill, but walked out of the hospital three weeks later without any brain damage or complications.

I have delivered babies in the ER from women who were “not pregnant” and were having “menstrual pain.” I could go on and on!

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A man is admitted to the E.R. with an amputated finger.

Case: Dr. Natalie Newman takes a job as a cruise ship’s physician, thinking that she will enjoy a relaxing and restful trip. Instead, it is an action-packed journey, during which she discovers that there is no 100 percent effective medication for seasickness!

Q: Why did you decide to take the job on the cruise ship?

Dr. Newman: Although I love emergency medicine, it can, at times, become stagnant, subsequently leading to complacency. Therefore, I consistently look for challenges which keep me stimulated and my skills sharp. Maritime medicine demands that one be prepared to handle any emergency while at sea, with minimal support services (ie consults, ancillary, radiology, etc.). I also wanted a vacation.

Q: What were your initial expectations?

Dr. Newman: I fully expected to eat, sleep and get fat - perhaps a little seasickness as well, but I was prepared (I thought)! I thought patient interaction would be at a minimum because most people on cruises are basically young and healthy. My expectations could not have been more off-base. Had I been psychic, I would be unemployed.

Q: What was the most difficult case you encountered, and how did you deal with it?

Dr. Jasper: An American passenger with a retinal detachment (back part of the eye tearing away, resulting in blindness if not treated expeditiously) who refused to disembark because she could not pay for the emergency services she would need at the hospital to which she would have been transferred. She required definitive care that was beyond my scope of practice. Her refusal led to a delay in her care. Unfortunately, I had to inform her that she would have permanent loss of vision. I could do nothing else for her but make her comfortable.

Her insurance refused to pay for the necessary services because the incident occurred while traveling on international waters (many U.S. insurance companies consider medical services at sea out of country, thus they are not obligated), despite the fact that she would have been disembarked and treated at a hospital in the United States.

Q: What was the craziest case you encountered on the ship?

Dr. Newman: An accidental finger amputation secondary to the drunken activity of a "wannabe" pole dancer.

Q: Where are you working now?

Dr. Newman: I travel between hospitals in coastal Northern California and upstate New York.

Q: Would you do it again given the chance?

Dr. Newman: Absolutely! The experience enhanced my skills as an emergency physician. Although the sway of the ship was romantic, the sway of my stomach was not and is the one challenge I could do without.