Is it a stroke or a secret?

Seconds after I arrive at the ER on a Sunday afternoon, I’m called to see an elderly woman who can’t breathe. She’s ninety-four, and gurgling for air. On my way, I pass two middle-aged women. They are hovering outside a nearby room, trying to get my attention. One gestures like a traffic guard as she tries to wave me into the room. The other throws up her hands as I pass, saliva punctuating her sigh: “Puh!” They can see the elderly woman fighting for her life, and I can see their sister — sitting comfortably with a blanket pulled up to her waist.

“I’ll see her just after this,” I say. I enter the resuscitation room and whip the curtain closed.

The elderly woman is scared. Her heart is a broken pump, and fluid is gathering in her lungs. A respiratory therapist straps a mask over her nose and mouth. “If this doesn’t work, I may have to put a breathing tube into your lungs, and put you on life support,” I say.

She closed her eyes and shook her head no. “No,” her daughter says. “She doesn’t want that. No heroic measures.” I put a hand on her shoulder and nod. I’ve never been sick, and have never had anyone close to me become severely ill. I’ve never had to be this brave.

I open the curtain and leave. As I walk, footsteps are behind me. I feel a woman’s hand before it taps my shoulder.

“You said you’d see my sister next.”

I speak without slowing down, without turning to look at her. “Let me get her chart first.” She follows me to the nursing desk where the nurse gives me a look and hands me the chart. I point the woman away, “Please just wait in the room. I’ll be there in two seconds.”

The patient is 46. Her vital signs are perfect, and on the chart, her presenting complaint is “other.” This can mean anything. It can mean pain all over for months, fear of contracting hookworm or Christmas lights in my bum.

“They want a carotid Doppler,” the nurse whispers.

“There’s no way,” I say. “It’s Sunday.”

“I told them already.”

“Finally,” one of the women says, as I enter the room. I introduce myself as the patient smiles.” I ask what brings her in.

“I had another mini-stroke,” the patient — Danielle — says, at the same time that her sister says, “It keeps happening, and we need answers.”

“Mount Sinai should have never discharged her,” the other sister says.

“Hold on,” I tell the sisters. “Can you let her speak?”

A day earlier, at a restaurant, Danielle’s sister had noticed that she was slurring. Danielle said not to worry — that a chicken bone had scratched her throat — but when she stumbled on her way to the restroom, 911 was called. The paramedics had taken her to Sinai, the closest hospital. By the time she was seen — four hours later — her symptoms had resolved. The doctor ordered blood work and a CT scan of her head.

“Did it show anything?”

“All normal,” a sister says.

“You’re speaking fairly clearly now,” I say to the patient.

At the foot of the bed, there is another sigh. “You’re not sending her home. The same thing happened last time.”

She has no pre-existing illnesses. She’s only had one surgery — her gallbladder. She smokes half-a-pack, and she doesn’t drink.

“What happened today?”

A sister jumps in, “She came to my house for a visit. When she arrived, she was unsteady and wasn’t acting normal. I called 911, but she refused to go.”

I look to Danielle. “Then how did you end up here?”

The sister answers, “I called my other sister and we forced her.”

“How is she now?” I ask as I begin to examine her.

“We were asking for a doctor to see her earlier! Can we do the ultrasound of the neck?”

“There’s no way to get a carotid Doppler right now, but I can get one for tomorrow.”

“Well, then we’re wasting our time.”

Her physical exam is normal. An ECG is also perfect. I order blood work, and say we’ll go from there.

Before I leave, a sister steps in front of me, “What about another CT scan?”

“You told me it was normal two days ago.”

“But they told us it might be a brain-bleed, and sometimes they can only be seen within the first six hours.”

“If they can’t see it on a scan, and it’s a suspicion, then usually they do a spinal tap to look for blood.”

“Yes!” she says. “They wanted to!”


“Danielle refused, so they made us sign out ‘against medical advice.’”

“I’m not worried about a bleed,” I say. “She has no headache.”

A sister turns to Danielle, “You do have a headache, don’t you? Tell him. You have a headache.”

I review the nursing note, and it’s documented — headache, light sensitivity. I ask Danielle if she still has these symptoms, and she looks to her sisters and says, “A little.” I mention that I’d just asked her if she was in pain and she’d said no. I also explain that I flashed a bright light an inch from her eyes and she didn’t flinch. In fact, she smiled.

“She has all the symptoms of an aneurysm,” a sister says.

A nurse pops out of the resuscitation room and calls for me. I order the scan and head out.

Over the next hour, I see a seventy-year-old with profuse rectal bleeding, two elderly people who’d swallowed food down the wrong pipe, and a seven-year-old with a badly broken wrist.

When I return to the acute room, Danielle is being wheeled back from CT, as one of her sisters complains to the porter, “I don’t see why we both couldn’t go with her.”

Just as I pass them, a unit clerk calls out, “There’s a tech on the phone for acute nine.” My heart sinks. Danielle. The techs do this — when they see something that needs attention, they call over to the ER and let us know right away. Danielle’s nurse takes the phone and scribbles on a loose page.

I pull up her scan, flipping slowly through slices of brain. I sharpen the contrast and scroll through again. I can’t find what I’m looking for — areas of white — signs of blood.

The nurse hangs up and shows me the note. “That’s strange,” I say. “Do you see any signs of this?”

“No,” she says.

Just before I head to Danielle’s room, I see a three-month-old in respiratory distress. As I’m assessing her, one of Danielle’s sisters is pacing outside the room. It’s as if she can’t see the child, or the respiratory therapist holding a mask to the screaming child’s face.
It is eight-thirty now, and Danielle’s been up to the bathroom twice. She’s anxious to leave. “What did the scan show?” a sister says. “The nurse said something was off with one of the tests.”

“Maybe the two of you should leave the room while I talk to Dan -”

“Absolutely not! We’re her sisters, if …”

I speak directly to Danielle, “It’s your choice. Do you want them in the room for this?”

A sister wags a finger at me. “How can you even ask her? She’s not right.”

“Sure,” she says.

“The CT scan is totally normal, just like the one you had yesterday.”
“Then what’s wrong?”

I turn to the sister. “What’s wrong is that she’s drunk. Her alcohol level was through the roof.”

A nurse pops in. “Can you come re-assess the baby? I think she needs another mask.”

I step out. “She was slurring and stumbling because she’s been drinking. A lot.”

“I don’t drink,” Danielle says.

“That’s absurd,” a sister says. “It was the middle of the day.”

“I’ll let you talk about it,” I say leaving the room.

Ten minutes later, a sister approaches as I’m finishing a chart. “She admits it. What do we do now? How can you help her?”

“My first duty,” I say, “is to inform the Ministry of Transportation.”

“Okay,” she says.

“And I can have a crisis worker bring you some resources on alcoholism.”

She nods.

A few minutes later, I overhear her discussing this with Danielle. Danielle is suddenly angry, and snaps at her sisters for bringing her to the hospital. Seconds later, she’s walking swiftly toward an exit, cursing.

Raj Waghmare is an emergency physician who blogs at the

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