Saturday, June 2, 2007

Code status

Yesterday, I finished up my 2 weeks on the stroke service as part of my neurology rotation. On this team, we admitted and managed all patients presenting to the hospital with acute strokes. This last week has been one of the most emotionally difficult times I have experienced in medical school. The situations of some of our patients are profoundly sad and tragic. Imagine that you are partnered to a vibrant and beautiful 30 year old person, a caring partner and parent. Now, you hear them complaining of neck pain and a headache, so you offer your partner some sympathy and suggest ibuprofen or rest. Unbeknownst to you, your partner, or anyone - the blood flow through a major artery to the brain has slowed to a trickle and your partner's brain is dying. Some time later, you notice that they are slurring their speech or they seem to have weakness on their left side or their personality is now a little different from baseline - you take them to the hospital and are told that they are having a stroke. If you are lucky - your hospital will have a stroke service to admit and manage your partner; if not, hopefully they will be airlifted out to a hospital that does have a stroke team. If the stroke is identified early, a few very effective interventions are available. If stroke is severe or identified too late, not even the most heroic of measures can improve the final outcome.

I suppose I always knew strokes were bad news, but I wrongly assumed that the stroke population largely consisted of elderly men and women with serious risk factors (ie poorly controlled diabetes, history of blood clots, a bleeding disorder.) I learned this week that anyone can stroke. Granted strokes are tragic at any age - you are no more prepared to lose a partner at age 70 than you are at age 30. But really - 30 year olds with spouses and children and lives full of promise should not have strokes that result in clinical brain death, but they do.

So, in the past two weeks, I have seen patients and their families devastated by an event that often occurred without warning. In med school it is sometimes easy to lose perspective - you see the very sickest of patients and begin to think that that is the norm. I must remind myself that not every headache or neck-ache is a stroke. And there are things that you can do to make this situation more bearable should it ever occur - first, recognize it early. Should anyone you know ever experience slurred speech (sudden onset, not due to intoxication), or a one-sided weakness of face or body, or loss of sensation on one side of the face or body, or personality changes, take them to the ER for evaluation. Time is brain. And second, clarify your code status with someone that you would want to act as a surrogate decision-maker should you ever become incapacitated. It is not a fun discussion to have, but you need to talk about what kind of life saving measures you want undertaken if your chance of survival is low. Let your partner know how you feel about living with severe disability. The families of patients with severe strokes are the ones called upon for medical decision making - it is a terrible position to be in, to be faced with such important decisions while overcome with grief. It seems to provide some comfort of family members are able to act in accordance with the patient's wishes.

So, long post. And likely not an uplifting one. I am sorry - this has been a tough couple weeks, and I felt I needed to say this. I am also presenting a very simplified version of stroke neurology - strokes have varying etiologies and mechanisms and can affect various parts of brain and produce different signs and symptoms, but I will spare both you and I a painful neuroanatomy lecture. Also DNR/code status issues are much more complicated than the questions asked above. If you have more specific questions, please ask, I would be happy to discuss any and all topics in more detail.


homeinkabul said...

wow, this sounds really difficult to deal with and to watch. I hope you are giving yourself some time to decompress.

Can't wait to see you!

Raul said...

Shannon, you're an angel. I wish there were more people like you to help sick people through difficult times and help their families cope with their grief. If I weren't already spoken for, I would totally try to date you!

J.Po said...

Oh man, sweets. That sounds awful. But as Raul so aptly stated, you're one of the best folks to help people through the tough stuff.

...and you've so wonderfully reminded me why I could never ever go to med school. Too sad.

grandma lorrel said...

You are really getting hammered with this rotation. So sorry you have to endure this and you will endure. It seems to me that you have attained so much compassion and love for others through your rotations. Hey, I would love for you to be my doctor.

Wish I could be of help to you????
Much love.

Amanda said...

Sorry for the rough couple weeks you had. I can't imagine doing what you do. Raul's comment made me get teary eyed. You are a very special person, Shannon! And so is Raul!

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