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Through the Cracks

Christine Henneberg, MD, MS

(Fam Med 2014;46(2):129-30.)

Some patients have a tendency to fall through the cracks. Like the set of keys wedged deep between the car seat and the gear shift, or the spoon tumbling into that unreachable spot in the garbage disposal, sometimes details and circumstances seem to arrange themselves, conspiring against even our greatest care and utmost attention.

The summer after I graduated from college, my parents, my sister, and I spent 3 weeks together in Germany, as we had done most summers in my young life, visiting family and vacationing on a lake in the Bavarian countryside. Unlike those vacations of my childhood, this was a vacation of four adults, converging from the four corners of the globe. At the end of the vacation, we departed on a staggered schedule. My father was the last to leave; his flight was scheduled to depart 2 days after my mom and I flew back to California. In that 48-hour window—a warm, sunny weekend in late August in Berlin—he suffered his stroke.

My father was born in Germany in the late 1930s. He came to California as an engineering student on a Fulbright scholarship, the only one of five siblings to leave the country.

He is the quintessential German, and he raised us to be like him: polite, punctual, and intentional in every aspect of life. He worked for IBM for 25 years, where every day he ran a five-mile loop around the business park at noon, showered in the janitorial office, then ate lunch alone at his desk: sardines, rye bread, and fruit. He drove a BMW, distrusting Japanese and American cars. He had an explosive temper, though he never raised a hand to us or put us down. He sang us German lullabies and took us on long walks in the hills on Sunday mornings. Aside from his intractable hypertension (“which would drop right to the ground if he would relax a little,” my mom used to say), he was the picture of health.

He was released from the hospital in Berlin in mid-September with medical permission to fly. We met him at the San Francisco airport that afternoon, where the air had already begun to turn cold—the beginning of fall. At the baggage claim, he was being pushed in a wheelchair by an airline employee. He could not move the left side of his body.

My father’s stroke was an utter shock to all of us. As far as we knew, it had been completely unforeseeable—random bad luck. But over the next 5 years—and largely within that first year, also my first year of medical school—the pieces began to fall into place for me: My mom’s longstanding complaint of my dad’s “breathless snoring”—a description that had always sounded nonsensical and now reads as though out of a textbook: secondary causes of hypertension and stroke—his inexplicably high blood pressure that remained elevated despite his impeccable exercise regimen and dietary habits and “maximum medical management,” the weakness and daytime fatigue that plagued him throughout my college years, the momentary spells of confusion that passed almost as though they had never happened.

Now, looking back on the years leading up to his stroke, I cannot shake the feeling of watching an unstoppable series of events unfolding in slow motion: the keys disappearing into the dark space beside the gear shift; a child’s grip loosening on the monkey-bars; the gut-sinking tilt of car wheels on wet pavement, lifting and spinning out of control. But instead of watching these events unfold before my eyes, I am watching them unfold in my memory, where they are all the more unstoppable and untouchable.

I am now in my final year of medical school, on the cusp of graduation. My father walks—haltingly, with a cane—and manages most daily tasks without the use of his left hand. He and I have had many conversations about his stroke, but I have never confided to him my sense of remorse for those cracks through which he fell. Mostly we talk about the medical and physiologic details of his daily life. I have been able to offer him some comfort with my simple explanations: the homunculus and the motor strip, the impact of pharmacologic beta-blockade on hypertension, the concept of muscle spasticity. Perhaps these conversations are somehow comforting to me, as well.

Recently, however, something has changed. My father has begun asking me not just for scientific explanations but for medical advice. If he feels weaker on his left side today compared to yesterday, is this a normal variation or something he should report to his neurologist? Should he skip his diuretic when he notices his morning blood pressure is low? How low is too low?

I know better than to try to answer these questions, but they terrify me nonetheless. Perhaps, in revealing how little I still know, they shed a new light on the circumstances of my father’s stroke and the cracks through which he has fallen. I am not so naïve or foolish as to think that if I had only started medical school 1 year earlier—even if I had been a full-fledged practicing physician—I could have prevented his stroke. Maybe I wouldn’t even have seen it coming. I do feel some anger at his doctors for what they missed. (His blood pressure was being closely followed by his internist in the years before his stroke, though he had never had a sleep study.) But I cannot say with certainty that I wouldn’t have missed the very same clues.

Over the past 5 years I have begun to acquire the knowledge and skills to be able to help others: patients, family members, passersby. But I have also learned that I cannot be the one to help every time. None of us can. Every day, opportunities are missed; people fall through the cracks. To have medical knowledge—to see these cracks, to know how deep and unavoidable they can be—is to carry a tremendous burden.

So I am left, quite unsatisfactorily, with only the limits of my own knowledge and my inability to undo the past—two very human realities that are in no way unique to those of us in the field of medicine. What, then, is unique about my experience of my father’s stroke (and his resulting disability) seen through the lens of my medical education? Perhaps it is only the fact that medicine is such a powerful and enlightening lens through which to view our world and the people in it, including our loved ones.

So I continue to watch my father through this new lens. As I prepare to enter my family medicine residency, it is a lens that grows more powerful and more terrifying every day. Every day I see more clearly the cracks through which he fell, the moments when someone might have caught him. But that “someone” could not have been me—not this time. Not for him.

Correspondence: Address correspondence to Dr Henneberg, Contra Costa Regional Medical Center, 2500 Alhambra Avenue, Martinez, CA 94553.

From the University of California San Francisco.

Copyright 2018 by Society of Teachers of Family Medicine