Floating in the ICU

When Internal Medicine residents are doing electives -- typically clinical rotations that do not involve night call, they are often circulated through the medical critical care unit for 4-5 nights of the month. We call this floating in the MICU.

That night I was called to the ER to see a 42 year old that was unresponsive to commands and combative. He had been dropped off by an outside facility emergency medical team with scanty information. He had brought in by his colleagues at work. Here is the reconstruction of events.

Joe (not his real name) was working on a roof. He was a roofer. Witnesses say they saw sparks fly from an instrument he was using and they saw fall back. When they went to him (still on the roof), he had a left sided facial droop and right sided weakness. He became disoriented, combative and unresponsive to speech.

When he arrived at our facility, we diagnosed him with a stroke (cerebrovascular accident) and began appropriate treatment. He did not make a complete recovery, although several days later could answer a few simple questions.

Here's the rub. Joe was a healthy guy -- a typical roughneck. He had had some run-ins with the law, worked hard, drank hard and occassionally used amphetamines and marijuana. He was tough as nails and in our emergency room it took 5 of us to hold him down. He did not have any history of high blood pressure. He did not have a high cholesterol or LDL or other signs of atheroschlerosis. In short, there was no predicting that his life was going to change drastically at 42 years.

Much as we know about strokes, this one had no easy explanation. It was a massive infarct of the right middle cerebral artery with subsequent hemorrhage into the ventricle on that side of the brain. Why? How? We will never know. But Joe will never be the same again.

Reminds me of words by Moses in one of the Psalms: "Teach us to number our days that we may gain a heart of wisdom." My take home from this was to use each day wisely and fully, never knowing what tomorrow will bring.