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First Person

When the Emergency Disappears with Admission

Janson, Paul MD

doi: 10.1097/01.EEM.0000578604.08723.69
First Person
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I have written in EMN many times about using the emergency department as a model to offer solutions for wider social and medical problems. I feel that the intensity of the practice in the emergency setting encourages adopting practical solutions that can sometimes be ignored in other less-intense situations and areas of medical practice.

Now I am writing about one of my own experiences that I believe may be helpful, and I must say that I will attempt as much as possible to avoid an emotional presentation, specifically any judgmental characterization. A few months ago, my 30-year-old daughter Maria died of a cerebral hemorrhage.

She was shopping Saturday afternoon when she developed a headache and then had a generalized seizure. She was diagnosed promptly at a local ED and med-flighted to an excellent referral center. She stabilized briefly, and it was elected to watch her overnight.

The next day the bleeding extended, and she suffered cerebral herniation. She was brain dead less than 24 hours after admission, the brain death literally occurring right in front of my eyes.

This course may have been inevitable, but what I would encourage practitioners of medicine to learn from this is that the ED handled her care as an emergency, but at some point that sense of emergency was lost.

She was felt to be stable and the need to investigate on a Saturday evening was lost. By the time the need to know what was happening was fully appreciated, it was too late. That evening an angiogram showed the venous thrombosis that had caused the raised arterial pressure that precipitated the bleeding.

I learned to treat every situation as an emergency until I was sure, absolutely sure, that it was not an emergency. I am not sure that anything would have helped my daughter, but I wish I could be sure that it would not have helped.

She presented with a serious disease. There was an available treatment, but that treatment had significant associated risks. I believe her physicians had to make difficult choices and tried their best. I offer no criticism of the care they gave, but I also hope they will feel the urgent need to know what is happening and not be dissuaded by an apparently stable patient the next time they face this situation.

It would be wise for all of us to heed the lessons forged in the fire of emergency medicine.

Dr. Jansonis an emergency physician affiliated with Lawrence General Hospital in Lawrence, MA. He is the author of a novel, Mal Practice, a children's book, The Child in Our Heart, and a nonfiction account of the 19th century arms race entitled Battles and Battleships, all available onhttp://pauljanson.com.

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