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Picture Perfect Diagnosis

07/01/2013

Erica Lafond and her husband disagreed. Erica thought her right eye looked a little red and maybe even a bit droopy. Her husband didn’t think so. But no one would have been surprised if her eye was red or tired looking -- after all, she had just given birth to a beautiful baby girl 11 days earlier.

“Shelly suggested Erica take a photo of herself and text it to her. That’s when a lot of medical expertise and a little bit of fate stepped in to save this new mom’s life.”

Erica had dismissed the slight change the day before, believing it must be sleep deprivation or maybe allergies, but after seeing it a second morning, she called her mom. A woman can usually get an honest answer from her mother, and Erica had the added benefit that her mom was an operating room nurse at Tufts Medical Center. When Shelly Murphy talked to her daughter, she suggested Erica take a photo of herself and text it to her. She would take a look and if necessary show it to a friend who was also a nurse. That’s when a lot of medical expertise and a little bit of fate stepped in to save this new mom’s life.

“Does She Have Neck Pain?”

Neurosurgical nurse Lisa McKenzie had just started to look at Erica’s picture on her phone when Neurosurgeon-in-Chief, Carl Heilman, MD happened to walk by. “What are you looking at?,” he asked quizzically and jovially as Dr. Heilman usually is, peering over the nurse’s shoulder. The ever so slight droop in Erica’s eye indicated a significant red flag to Dr. Heilman but he didn’t want to overact. He found Shelly Murphy quickly and had one important question for Erica’s mother: “Does your daughter have neck pain?” Yes was the answer, and Heilman knew the situation could be grave. He believed Erica had “Horner’s Syndrome,” a nerve condition that often signals a deeper and potentially life threatening situation. Heilman wanted Erica to get to the Emergency Department and not waste any time.

Erica was surprised she needed to do anything immediately, much less get to an emergency room, but she could tell from her mother’s voice that she should heed her advice.

“She was trying to be very casual,” Erica says of the call she received from her mother. “She had this sing song quality to her voice. ‘Why don’t you just come on in’ she said. Earlier she had mentioned maybe seeing my primary care doctor; now she was sending me to the ER. I got ready, packed up the baby, had my in-laws watch after my sons and drove in. I assumed I would just have a few tests, confirm nothing was wrong and head back home soon.”

After Erica was thoroughly examined by the Emergency Department physician, an ophthalmologist and a neurologist, she also underwent an MRI.  All the evidence confirmed Dr. Heilman’s hunch and he was waiting for her outside the MRI.  Erica had three dissected arteries – one in each carotid artery and one in the right vertebral artery, the arteries carrying blood to the brain. A dissection is a tear in the lining of the artery that creates a flap that impedes blood from moving rapidly to the brain and can cause a serious, at times deadly, stroke.

“When you hear of a young woman with a droopy eye and neck pain, you hope it will be nothing, but you have to rule out a dissection,” Dr. Heilman says. “It is a strange experience for the patient. They don’t have many symptoms and they are small symptoms like a sore neck and a slight downward pull of the facial muscle around the eye. These can often be mistakenly attributed to other things. For Erica, she thought it was just sleep deprivation and maybe the neck pain was from holding the baby and breastfeeding.”

 Dr. Heilman explains why dissections are so dangerous. “Blood always wants to clot,” he says, “but it doesn’t when it is moving fast through the smooth surfaces of the arteries. However, with a dissection the blood is slowed down by the tear and it starts to clot. The next thing that can happen is a big stroke and we can’t undo that, so we need to begin treatment immediately before a stroke does any damage.”

For Erica, the diagnosis was devastating. She was overwhelmed. Just 11 days earlier she had finally given birth to a baby girl, a long-time dream of hers. This was supposed to be a magical time full of bonding moments at home together. But the medical team was telling her she was going straight up to the Neuro Critical Care Unit where they would discuss medical and surgical options for treatment. She had so many questions, but more than anything, she just wanted to see her baby Piper who had been with Erica’s husband during her tests.

Not Your Normal Patients

Patients in the Michael Neely Neuro Critical Care Unit are often unconscious due to a major head trauma, recovering from a major brain or spinal cord surgery or of an older age. Rarely do you find a new mother and her 11 day old baby in the NCCU.

But what Erica found during her stay in the NCCU was an unusual team brought together for her unusual circumstance.

The traditional team of neurologists, neuroscience nurses and neurosurgeons were joined by a team from obstetrics, pediatrics and the Mother Infant Unit. And Piper was safely welcomed into the NCCU just 45 minutes after Erica settled into her room.

Erica made it clear to her medical team that she wanted to continue breastfeeding Piper and to have as “normal” of a new mom and daughter experience as possible. The team supported her desire but needed to make careful medical decisions concerning treatments and medications to ensure Erica’s dissections began to heal and her risk of stroke could be decreased while in the hospital.

“The team absolutely rallied around me. The nurses were amazing. They would sit with me and explain things to me. They would ask me how they could help me. The knowledge they had was ridiculously impressive – about the procedures I was having done, the medications I was taking,” says Erica.

The Mother Infant Unit team arrived in Erica’s room with a bassinet and supplies just for Piper, the one like they provide to mothers who have given birth at Tufts Medical Center.

“It was loaded with everything we needed to keep Piper with me for 13-14 hours a day.  Diapers, onsies, pacifiers.  They had everything short of balloons welcoming her to the critical care unit,” Erica said.

“The nurses even arranged to get my husband formula for that first night when Piper left. It was late at night, we had never bottle fed her so we had to adjust quickly and the nurses and staff helped us every step of the way.”

The first night Piper went home to sleep was devastating for Erica.

“I just bawled; my nurse just sat with me and listened to my fears, my frustrations. I worried that I almost died, that my children wouldn’t have a mother, that I wouldn’t get to fully enjoy the first weeks and months of my baby’s life,” Erica says. “I am not sure Justine, my nurse, ever spoke during that time. She just sat with me and listened. She was so good to me.”

Treatment and Healing

The following day, the medical team and Erica decided that she would remain on a regimen of the blood thinner Heparin to reduce her stroke risk while the dissections healed. This would safely allow her to continue breastfeeding. They agreed she would not need to have a surgical procedure to stent, or prop up, the dissection. She would need to stay in the hospital for approximately a week so her progress could be monitored, she could get the rest required to heal and any adjustments in her care could be made as necessary.

During that week, Piper became a regular part of the NCCU and the adjoining Neuro Intermediate Care Unit.

“From 9 am until 10 or 11 at night every day, Piper was with me.  It became a bit of a joke as people would walk in and say ‘Congratulations,’ not a greeting you typically hear in an ICU. I began to tease people and say ‘Do you mean for having the baby or those three big dissections?’” The doctors who would check in on me at night were disappointed if Piper had left already. They would say, ‘Where’s Pipes?’.”

The team also allowed Erica the time she need to breastfeed or pump. “Sometimes they would come to evaluate me, see that I was nursing and say ‘No problem, we will come back in a bit.’”

“It just speaks wonders,” Erica says. “I wasn’t just getting the best care but the doctors and nurses were keeping in mind that there was another piece to this person. I needed certain things and they went out of their way to do that for me. Those nurses were unbelievable.”  

After six days from her arrival at the Emergency Department, Erica – and Piper – were able to leave the Medical Center to continue her healing process. She receives a MRI every four to eight weeks to check her progress.

“The body has a wonderful way of healing itself with dissections,” Dr. Heilman says. “But it takes time – often three to six months – and during that time Erica has to take care of herself. No bending over, no vacuuming, no dishes, no lifting over 10 pounds. And we have to ensure that the medications are still working so the risk of stroke is at a minimum. We want Erica to continue to be there for her children and have a long, energetic life.”

“This has been an amazing experience for me,” Erica says. “From the moment I sent that picture to my mother, not only I have been held in the greatest medical hands, but also the most caring hands. The people that surrounded me treated my medical condition but they also loved and supported me and my baby – it is more than any person could ask for.  It has truly made a difference in my life.”