He is 93 and has numerous medical problems, most of which involved aging blood vessels, as well as multiple orthopedic issues, including compression fractures and diffuse arthritis. The bony issues have resulted in a severely compromised mobility of late.

Despite ongoing treatment with both aspirin and clopidogrel, he presents after numerous hours of focal neurologic symptoms. A CT scan shows no evidence of bleeding and the diagnosis is a major stroke in a 93-year old who is already taking two anti-platelet medicines. The issue is what to do next?

Reportedly, a rhythm strip somewhere shows atrial fibrillation and so heparin is given in addition to the two other blood thinning drugs. It was clear that this case was destined to end poorly — “rock and a hard place” comes to mind.

The next day brought a worsening of mental status and another CT scan showed bleeding in the brain. Soon, he drifted off into an unrelenting sleep, and passed away that same day.

Much discussion centered around the question of adding a third blood thinner in a 93-year old with a stroke. The discussion was detailed and rigorous, and studies were cited. Important tenets of acute stroke care were learned and a medical education continued. However, what struck my brain more than the medical details was a distant childhood memory.

I was a little boy, and the memories have much fog and a face is barely seen. He was my great grandfather who lived with my grandparents in the home next to mine. Four generations lived within a baseball throw. He was very old and grumpy and always sat in the same chair next to the Frigidaire. Little else is recalled except the coffee can under his saggy bed upstairs. My grandmother, Nellie, emptied it each morning and now after many years of observing the elderly, I understand the difficulties in nocturnal ambulation to the only downstairs bathroom when in your ninth decade of life.

One day after school a commotion happened next door and soon an ambulance came. “Naunoo,” as he was known to the children had a stroke and died very soon in the hospital.

I was told he died of “old age.” Before the era of anti-platelet drugs, CT scans, MRI and angiography one could die of old age.

In modern day medicine, since there is so much to see on scans and many tools to treat, we often forget that humans are mortal and the body eventually loses. The CT scan revealed bleeding in the brain, but the inciting event was a large stroke in a very old man, who likely was destined to live in a nursing home for the remainder of his life had he not passed.

With so many trees sometimes the forest is difficult to see.

John Mandrola is a cardiologist who blogs at Dr John M.

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