Elf struck

Well....
The sixteen year old girl is alive and well, extubated yesterday, sitting up in bed and discussing mosh pits with the nurses. There is much rejoicing.

And it was long QT syndrome* that kicked her heart into that rhythm, too. So she's probably going to be started on beta-blockers (Sarah says half the performers in the local symphony orchestra are on beta-blockers - they are drugs that stop you feeling the physical symptoms of anxiety: tremour, racing heart, etc., so you can fiddle your fiddle and cell your cello without performance anxiety).

From what I can dimly remember, she may be going off to have something implanted in her heart that will defibrillate when she fibrillates - I don't know if they always do that anymore. Small scar on her chest, a remarkable story to tell her children, and her with apparently most of her neurons intact.

Her extensive family are already booking in for the blood tests to find out which of them carry the same problem in their genes. The possibility of sudden cardiac death in your sleep tends to concentrate the mind wonderfully.

But all has not gone well, in the ED and otherwise, and all up it's been a rather difficult few days. I keep thinking about the girl from last shift in the ED**.

The twelve year old girl who had the stroke, who last I saw was strapped onto a barouche, was sent off to the Royal. When she left us she was unable to move her left arm or leg, her eyes were wide and staring off to the side, as if unwilling or unable to meet her mother's gaze. She had not spoken since her mother found her, nor had she shown any sign she was able to understand what had been said to her.

The prognosis here is exceedingly poor. The problem is the largest of the arteries that supply blood to the brain, the largest artery "downstream" of the carotid, the pulse in your neck. This artery supplies a huge amount of brain. When it is blocked off, areas of your brain darken and die, like fragile creatures downstream of a dammed or diverted river.

These areas of the brain which die create and control movement, including the co-ordination of simple tasks, the direction of the gaze, parts of sight, even things like the amount and extent of sweating - and language.

Language may be lost to different extents and in different patterns - some are unable to understand speech, but can speak, some can only utter single words to communicate an idea. I recall people who could write but not read what they had written.

I have always wondered about the efficacy of teaching sign language to people who had lost their ability to speak post-stroke. obviously, others would have to learn it too, and a number of people who have lost language also have profound difficulties moving, but it may be better than nothing.

And I wonder if profoundly deaf schizophrenic people hear voices? Or do they think strangers flash hostile hand-signs at them?

Eerily, in some people the part of your brain that tells you that "something is wrong with your speech" is damaged along with one of the parts that make speech.

I remember seeing a video in medical school of a woman earnestly trying to explain her situation to a doctor. Her tone, facial expressions and gestures communicated her growing frustration, she even appeared to be repeating some words - but what emerged from her mouth was fluent, well-articulated gibberish: sortof "Water lot calliope that that howitzer, ash one one one thing" and so on.

It became apparent throughout the interview that as far as she could tell, she was speaking completely normally, but everyone around her had suddenly lost their ability to understand her clear and simple English. More frustratinigly, they could understand each other, she could understand them, but no matter how clearly she enunciated and how simple the words she spoke, no-one could understand her.

Anyway, what could be done for our girl? Herein is the problem. If someone has a heart attack, we can go in and remove the obstruction, prop open the artery with a thin tube kind of device called a stent, and restore bloodflow. Alternatively we can give medications to dissolve the clot.

In stroke the situation is less clear cut, partly because of the danger of causing bleeding into the brain. There is a lot of controvery about this, but at the moment the Royal offers emergency administration of "clot-busting" medications to a select group of patients. I don't have the list of criteria in front of me at the moment, but I beleive it includes people previously healthy who have definitely suffered a disabling stroke of a particular type in the last three hours... but who aren't children.

See, there's the problem. We got her in, diagnosed her, scanned her and sent her over to the Royal in a matter of tens of minutes. She arrived there well within time, if she were an adult, for the "clot-busting" medication to be given, and she may have improved significantly once given it.

But she won't get it, because she's a child. And nobody has done trials of this medication in children, because how many twelve year olds have strokes? How much risk is there in trialling a medication like that on the damaged brain of a twelve year old? How much money is there in organising a trial on stroke medicines for the paediatric market? Who wants to be the first to guide the needle up the artery towards the teenage brain?***

So it could help her, or it could kill her. We don't know. I doubt we will.

All deeply distressing, and the kind of thing I have been thinking about too frequently over the last few days.

In times like this, when I lie awake in the early morning, my appetite alters and my mind runs over and over the same sterile rut, there is always the question of incipient depression. I feel it is counterproductive to increase my dose of mood stabilisers - firstly they don't work quickly, they aren't happy tablets, and secondly, this is a grief of a sorts, rather than any mental illness. It is not something that can or should be medicated away.

Anyway, thanks for listening the last few days. I do feel better than I did. Read Champurrado's blog, as I have been over the last few nights. I'd link to it but I don't know how - Sarah did the Foilwoman link to show me how and I didn't understand, so I'm hoping she'll relelnt and do the others soon.

It's impossible to read this and not come away feeling better about life and how it can be lived. I doubt she'd thank me, but VF girl, the one who I feared was going to be horribly damaged... I hope she goes home and her parents and her eat oysters together: "plump, fresh, cold, glistening morsels resting in half shells on cracked ice with lemon, mignonette sauce and maybe some Tabasco". I hope her life is good.

Anyway.

Thanks for listening
John

* one of the rare occasions I have been right about something medical and other people have been wrong. Don't get me wrong - when questions are asked in the ED about lives of the early Roman emporers, the enemies of Spiderman, or British SF of the sixties and seventies, I'm the "go to" man. But causes of VF arrest in teenagers? Not often.

**and increasingly about another job.

***And the other thing is, you don't get to be a neurosurgeon at the Royal by saying "to hell with the risk, who cares what those geriatric milksops say?". Neurosurgery is a very conservative field - can't think of the last neurosurgeon I met with even a tongue piercing.