About My Father

A few weeks ago I got the kind of morning call nobody wants to, especially after you've just gotten off two long plane trips to long-planned engagements: my sister saying our father had just had a stroke and was on his way to the hospital. Don't come, she said. She was driving from Boston to the hospital in Hartford he was being taken to; my brother, a gastroenterologist in New York, was driving up at the same time.

The story had a happy ending, and not just because I'm lucky enough to have such concerned and proximate siblings, one of them a superb diagonistican and a tenacious advocate for all his patients, let alone for his father. It was because my father--a longtime family practitioner who knew he was at high risk of stroke and had no desire to live an impaired life--keeps by his bedside a note asking to be given t-PA, a powerful clot dissolver. If administered within a few hours of the first symptoms, t-PA can break up clots before they choke off blood supply in the brain, causing the kind of permanent damage my father feared.

The drug, which is given intravenously, has been in wide use for just 15 years, and the risk of causing hemorrhage is so great that either the patient or a health-care proxy must give permission for it to be used. So my father had my stepmother, Joan, write out a note saying that in the event of a stroke he wanted to get t-PA as soon as possible, and authorized its administration.

No one can say whether his stroke would have been the calamity he feared without t-PA. But he feels he dodged a bullet, and we all do too.

He was fortunate in many respects. He was not regularly taking a powerful blood thinner, which can make t-PA too dangerous, as it can cause uncontrollable hemorrhaging. Because his medical history included the minor events called transient ischemic attacks, which are often harbingers of stroke, he and his doctors knew he was at high risk for an actual stroke, and that the cause would likely be clotting rather than hemorrhaging. The distinction is crucial, because t-PA can drastically accelerate a hemorrhagic stroke, the hallmark symptom of which is an overwhelming headache. In his case, he awoke with tingling in his right arm, trouble moving his hand, and some speech slurring. "I knew damn well I was having a stroke," he told me a few days later when I visited him at St. Francis Hospital.

He'd asked to be taken to St. Francis, one of two Hartford hospitals with stroke centers, because he had been an intern there in 1949, in what was then a brand-new building. It felt like "old home week," he told me, adding that he was very glad to be in a much newer building. His mood was and remains as cheerful as he's ever been--understandable, given that his minimal speech slurring (his ability to find words was luckily not affected, only his motor skills) and trouble moving his right hand are responding well to physical therapy.

No one can say whether his stroke would have been the calamity he feared without t-PA. But he feels he dodged a bullet, and we all do too. I'm even glad he can still tell me clearly that I should have gone to medical school.

My spouse, John Auerbach, is the health commissioner of Massachusetts, and happened to mention the story to a stroke specialist he met at a meeting, Dr. Lee Schwamm, a neurologist who directs the acute stroke and telestroke center at Massachusetts General Hospital. Dr. Schwamm was not just charmed by the story: he thought that other patients could and should benefit from it, by discussing their eligibility for t-PA with their doctors and keeping similar instructions in their wallets or by their bedsides. My father was able to tell the emergency medical technicians who came within minutes that he needed to go to a stroke center; "Give me t-PA," he told them, and apparently every person he encountered at the hospital. Not all patients will be so lucky as to be able to speak. And there might be no health-care proxy available to authorize administration of the drug.

Minutes count, as this dramatic account by Richard Knox, the health reporter for NPR, shows. In it a 49-year-old woman shrugs off tingling in her arm until she and a nurse friend she calls realize she needs emergency treatment; though the hospital is 75 miles away from Mass General, direct links to the hospital and to an on-call doctor's home, in which the doctor quizzes the patient to determine exactly when the stroke began, enable her to get t-PA at exactly the last minute she is eligible. It's suspenseful and incredible to hear.

Knox also liked the story of my father, and posted a piece about it on NPR's health blog, with a picture taken by my brother. I offer it here in hopes it can help someone in your life--and with great, and general, gratitude.

This article available online at:

http://www.theatlantic.com/health/archive/2009/12/about-my-father/32221/