She was 50. Prior to being transported to our ER, her only complaint had been for non-traumatic elbow pain over the past two weeks. She was on no medications and had no significant medical history.

She was at home, preparing to visit her doctor for a scheduled visit, when she collapsed. Because she didn’t drive, her elderly father had planned on swinging by to pick her up. He had just called and spoken to her minutes earlier to let her know he would be there shortly.

He arrived at her front door and knocked. No answer. He rang the doorbell. Again, no answer. Panic set in. This was not like his daughter to not greet him when she was expecting him. He knocked again, harder. Nothing. He kept his finger pressed to the doorbell, hoping his daughter would hear its continuous ringing and come to the door. She didn’t. He tried turning the doorknob, but it was locked. He banged his aging shoulder against the door. It didn’t budge.

He remembered the spare key she had given him months ago. “I’ll never need this,” he had said, trying to give it back, but his daughter had insisted he put it in his glove compartment. He stepped off the concrete porch pad and ran down the sidewalk, back to his pickup truck to retrieve the key. He found it, hidden under a pile of napkins.

Returning to the door, he struggled to fit the key into the lock. As a father, he knew something was wrong, very wrong. With trembling fingers, he finally succeeded in properly jamming the key into the door’s lock. He turned the doorknob, barely breathing now, his mind racing of the possibilities he would encounter.

The door opened. He stepped into the small kitchen and yelled his daughter’s name. No response. He listened to hear if the shower was running, but it wasn’t. He strained his ears for anything, any sound of activity that would reassure him he was overreacting.

That’s when he heard the moan. It was garbled and low, guttural almost. He followed the sound into his daughter’s bedroom. That’s where he found her, lying on the floor, beside the telephone nightstand.

He tried to rouse her, but he couldn’t. Knowing something was terribly wrong, he dialed 911. Waiting for the prehospital team to arrive, he sat down on the floor beside her, caressing her head. Talking quietly to his daughter, he filled her ear with the promises that everything would be okay. It had to be, since they were all each other had.

The ambulance team arrived. After briefly interviewing her father and performing an exam, they prepared the daughter for transport to our emergency department. They were concerned that this patient may have had a stroke. They offered the elderly father a ride in the ambulance, with his daughter, but he decided to follow them in his pickup.

In the ER, the prehospital radio went off. They reported that a 50 year-old woman with a sudden onset of right-sided weakness and garbled speech was being transported to our facility. There had been no signs of trauma. Confirming that the time frame was adequate, a stroke alert was called in preparation of this patient’s arrival. She would be a perfect candidate for tPA therapy if she did indeed suffer a stroke that was not hemorrhagic.

I, with the rest of our ER team, waited for this patient’s arrival in Room 26. In three short minutes, she was being wheeled through our ambulance bay doors and down our hallway. Quickly, we were able to slide the patient from the prehospital stretcher to our hospital cot, all the while listening to the medical report given by one of the paramedics.

Her vital signs revealed that her blood pressure was quite high. She had no fever, her respirations were slow and erratic, and her pulse was normal. On exam, she had a flaccid right side, was nonverbal except for her occasional moaning, and teetered between some minimal form of consciousness and being unresponsive. It appeared that this patient had suffered some catastrophic brain event.

We emergently intubated this patient, both to protect her airway as well as ensure adequate oxygenation to her ill body. After a repeated exam by the neurology team, the patient was hurried to the CT scanner to determine the extent of her stroke.

While she was out of our department, escorted to CT by our nurse, the respiratory therapist, and a neurology resident, I went to the family room to speak to this patient’s father. I was accompanied by our social worker and nursing supervisor.

I knocked on the door, opening it slowly to reveal a gentleman in his mid-seventies, tearful and distraught, running his hands through thin wisps of graying hair as he sat in the corner wing-backed chair. He had the look of a hard-working, honest man, dressed in a pressed flannel shirt and brown Dickie pants. He was alone.

“Sir,” I said quietly, after introducing myself and my team, “I’m so sorry about what you are going through. Can you tell me what happened or anything that might help us with your daughter’s care?”

With great detail, he told me about their plans to visit her family doctor that morning regarding her elbow. He was not aware that she had any medical problems. “She’s a hard worker, that one. Never had time to be sick, really.” He shared how he went to pick her up, only to find her collapsed beside her bed prior to his calling the ambulance. I listened intently, watching this father struggle to be stoic in his misery.

After maybe five minutes, a faint knock on the family room door preceded one of our nurses stepping in and interrupting our conversation. “Dr. Jim,” she said, “can you come here, please.”

I excused myself, leaving the father with our social worker and nursing supervisor. I stepped into the hall. “What is it?” I asked the nurse, herself wearing a worried look on her face.

“The CT scan, it’s bad. The radiologist wanted me to get you.”

I rushed to our physician work space, pulling up the patient’s head CT images on the computer panel while I dialed the radiologist’s number. What I saw saddened me. This patient had a significant brain hemorrhage, one that was shifting her brain from its midline and filling her ventricles with blood. The radiologist confirmed what I was looking at–that this patient most likely had a ruptured brain aneurysm. I called neurosurgery and the OR stat, since this patient needed emergent decompression of her brain’s swelling and bleeding. Her problems were life-threatening.

I went back to the family room, where I sat down opposite the father. His expectant eyes bore into me. Slowly and deliberately, I explained all of the results to him. He unabashedly cried, his shoulder’s shaking. “She’s all I have left,” he muttered. I was affected by his emotions and, looking at the tearful social worker and nursing supervisor, I knew that I wasn’t alone.

We escorted the patient’s father back to Room 26, where he was able to sit with his daughter as we awaited the go-ahead from the OR. I hovered in the room with several techs, the patient’s primary nurse, and a respiratory therapist, overseeing the quick preparations of getting his daughter ready for surgery. I continued to watch the father, unable to turn away from the deep grief and ache that enveloped him.

This patient was taken to the OR. Thankfully, she made it through her emergent neurosurgery. She remained far from a successful outcome, however, since her following few days after surgery would be fragile and tenuous.

Usually, I follow-up with these types of emergent cases, the types that pull at my heartstrings. But, for this case, I didn’t. I couldn’t. I thought of this patient and her father frequently, yes, but I couldn’t bear to think of this father losing his adult-daughter. I was willing to risk not learning of a possible successful outcome if it meant I also didn’t learn of a sad, heartbreaking one.

I recognize what I am doing. I am protecting myself, adding another cement block to that protective shell that surrounds my heart. Building it up. Tearing it down. It is a constant but necessary struggle for each of us in the medical field.

I hope and pray, though, that this patient did well. After all, this father’s daughter was all he had left.

StorytellERdoc is an emergency physician who blogs at his self-titled site, StorytellERdoc.

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