In search of the source
Amazed at the detailed pictures in front of him, the man asked if the clots could be removed. They couldn’t, Wang told him; What has been done has been done. But it was important to find out where these clots came from, otherwise it could happen again. Blood clots like this usually come from either the heart or the arteries that run from the heart to the brain and eye. The CT done in the hospital showed his carotid artery. No clots there. You would have to look into the heart. Wang added that up to 40 percent of strokes fail to find the source of the clot.
The most effective way to see the heart in action is to have an echocardiogram, Wang told the man. Most of the time the echo is normal. However, when something does come up, it is often important information.
A second stroke is most likely within a few days of the first. That patient was still in that window. Wang sent the patient to the emergency room at Yale New Haven Hospital and sent a message to the doctor on duty. It seemed clear to him that this was indeed some kind of emergency.
Joshua Hyman was a fourth year medical student just starting an ultrasound elective in the emergency room. The attending physician Dr. Karen Jubanyik suggested seeing this new patient who was there for an Echo. Jubanyik gave the student a brief overview of the case. Hyman introduced himself to the patient, then asked if it was okay for him to look at his heart. It would not be the official response, Hyman told the patient, it was just a way for him, a student, to learn.
The patient agreed, and Hyman rolled the bulky machine into the tiny cubicle. He squirted gel on an ultrasound probe and placed it a few inches below the patient’s left collarbone, just behind the sternum, in the space between the third and fourth ribs. He was still learning this technology, but he loved how it can give you information about what is going on in a patient’s body faster and sometimes better than anything else. When the probe is in this position, you can usually see the light gray muscles of the two chambers on the left side of the heart pressing around a dark black center that is the blood. This is the best way to see the business side of the heart. where blood from the lungs is injected into the bloodstream.
What he saw instead took his breath away. In the middle of the dark pools of blood moved a huge bright ball that raced back and forth across the screen with every heartbeat. What was that? Hyman froze the picture and took a measurement. A normal heart is about the size of a fist. This hitting circle was the size of a kiwi fruit.
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