I had my first stroke patient last week. It was a great learning experience, but also a reminder of how amazing the mind is. Mr. H presented with sudden onset of right sided weakness and word-finding difficulties. His left internal carotid artery was complete occluded. By the time he reached the emergency department, his weakness and word-finding had already improved, but not completely. Then on Hospital Day 2, when I saw him in the morning, his weakness and word-finding had worsened compared to how he was when I met him in the ED. What do I do?! What can be done?! What does this mean?! He went from responding to my questions immediately but with difficulty finding certain words to not being able to say "hello" after picking up the phone.

Turns out there was not much to be done. Even the neurologist kind of just took a shot in the dark by saying he needed ICU care for more frequent nursing checks. Luckily, he improved again and returned to how he was when I met him in the ED. Rehab is the only treatment for him now.

The internal carotid artery is a huge artery to the brain. This patient had managed to form collateral blood vessels over time to still supply enough blood to his brain even with the ICA being completely occluded to only have some R-sided weakness and word-finding difficulties. His life is going to be harder, but not as tragic as it could be with that type of occlusion.

A few weeks ago at the VA, I was involved in the incidental diagnosis of an aortic dissection. It was all really chaotic and confirmed my dislike for chaos in the face of a critical medical situation. Mr. C is a 79 year-old man who I had followed briefly in the ICU after he had surgery for a small bowel obstruction (also found incidentally) and was on a mechanical ventilator. I remember giving him sponges for him to moisten his mouth with and he was very appreciative. He was then transferred to the floor and I was no longer following him, but the cardiology service was because he had a bunch of heart problems. I was shadowing the cardiologist who was just going into Mr. C's room to do a bedside ultrasound to look for something cardiac-related (I honestly can't remember what we were looking for, but it wasn't serious). Mr. C was screaming in pain that had started pretty acutely. We didn't think much of it, just a very old man with probable arthritis in his back sitting uncomfortably in the chair. Then the cardiologist saw what looked like a false lumen in the patient's left carotid artery on ultrasound. That coupled with back pain = aortic dissection.

This mad just had surgery. He had heart disease, a recent heart attack, blood in his urine, and bacteria in his blood. He was not a candidate for aortic surgery. And he didn't want it either.

We all knew this meant the end for Mr. C. The cardiologist even used the word "goner" with nervous laughter. Not out of cruelty, but just matter of fact. This made me very sad. David's maternal grandmother also died from an aortic dissection. I felt the heaviness of it all.