“When we are no longer able to change a situation, we are challenged to change ourselves.” Viktor Frankl
One of the most challenging experiences as a physician is to witness a sudden change in a patient’s life. As physicians, we are truly blessed and privileged with the opportunity to be a guide and confidant to others on their health journey – and ultimately their life journey. We listen to others explain their stories, of how lives went from a steady state to one of change and turbulence. Whatever they are grappling with, we aspire to meet it with open ears and offer advice in approaching the work-up. In most cases, it is regarding an emerging condition that is addressed over a series of visits. Sometimes, things can happen more suddenly, as if by a lightening strike, forcing us to make more impactful decisions faster or to witness something that we may not have the resources to correct.
Recently, I observed a sudden change in a patient, to whom I was consulted for bacteria “growing in the blood”. She was in her late seventies and noticed some changes to her usual state of health over a period of two to three weeks. During that time, she grew weaker and more fatigued. There were no accompanying fevers, but she did have an episode of rigors, shaking chills, one week prior to her admission. Her initial admission was regarding the fatigue. An ER work-up showed a low blood pressure and an elevated white blood cell count. Blood cultures were taken. One day later, these were positive for a less common bacteria. Follow-up blood cultures were also positive. She felt better after fluids and antibiotics, and it was decided that she could be discharged.
When a patient has blood cultures that remain positive, we often check for a central vascular process -namely an infection of a heart valve – with an ultrasound known as an echocardiogram. Her study showed mild valve issues in the mitral valve.
About four days later, her weakness worsened and she returned to the hospital. I saw her after a more sensitive test, a trans-esophageal Echo showed a sudden worsening in her valve function and saw a 2cm infectious growth (“vegetation”) on the mitral valve. Her therapy was switched to intravenous from oral. She didn’t feel well but was in the right place. I evaluated her and we discussed timing and possible need for further intervention, such as valve surgery.
Approximately 1 hour after her evaluation, a code “stroke” was called. She was found by her nurse to have a sudden neurologic change: a left facial droop, right arm paralysis, and speech difficulties. These are part of the indicators to spot a stroke, which go by the acronym F.A.S.T. by the American Stroke Association (below). The “T” stands for time, and after witnessing her stroke, she was quickly sent to the radiology department for a CT scan. The CT scan is not always very accurate in showing a stroke, but it is useful in ruling out hemorrhage as a cause. After the study showed that it was an ischemic stoke, in her case that likely a clot was sent up into her brain’s left middle cerebral artery and blocked the circulation, she was arranged for treatment considerations with thrombectomy or thrombolytics. These are two intervention options in the setting of an acute thrombotic (clot-related) stroke.
When I saw her, I quickly was able to determine that she had a stroke by the above changes. I spoke to her gently and supportively, “You are having a stroke. We will get you evaluated promptly and address this with the options available. You are going to be OK.”
She seemed to understand this. She reached out with her functioning arm, and I held her hand, breaking the barrier that I made about shaking hands during the pandemic. If there was ever a time to hold someone’s hand it would be this time, I thought. Like the flick of a light switch, she was faced with this sudden change of her body, alone in her head, unable to express her feelings.
The return of function can occur over ensuing days to even after six months. Although there is some variability of recovery with gender, severity of the stroke, and a person’s underlying conditions, approximately 10% of people experience a full recovery after a stroke; 25% continue to suffer minor problems; 40% are classified as moderately to severely impaired; 10% will require long-term care.
A person who survives a stroke faces an adjustment to a drastic change. A stroke is an attack on a person’s steady state, where they are forever changed. The only recourse is to adapt, to adjust, and to rebuild.
As a provider, to see a dramatic change unfold before my eyes is a humbling experience of the limitations of medicine. It continues to challenge me to look for ways to prevent and inform of these drastic changes in health. Although this patient’s stroke was a result of an infection, most strokes are related to a chronic health condition, like diabetes and hypertension. It encourages me as a physician to target prevention and behavior change.
A condition such as a stroke or a heart attack is a reminder that, although our life is counted in years, some of the greatest changes in life occur in a matter of seconds.
“The secret of change is to focus all of your energy, not on fighting the old, but on building the new.” Socrates
“Perhaps it’s the people whose lives have taken sudden new twists – people who have learned to embrace the creative possibilities of change – who stand the best chance of penetrating life’s mysteries.” Hugh Mackay
Life after Stroke Guide from the American Stroke Association