This physician couldn't rest until he solved the mystery of his patient's untimely demise.
The author couldn't rest until he solved the mystery of his patient's untimely demise.
Maria Sanchez was one of many migrant farm workers who move through this part of Texas each year, working their way up to Indiana and then back toward Mexico for the winter. The beautiful 20-year-old mother of two came to see me about her severe headaches.
Her neurologic exam was normal, and nothing explained her relentless pain. I had her admitted to our 19-bed osteopathic hospital and did a thorough workup. Skull X-rays, spinal tap, and lab studies were all normal. So why did she hurt so badly? I began to wonder if there was something other than an organic causeperhaps the stress of her backbreaking labor in the rosebush fields and the worry over how she'd care for her children. The Mexican women work as hard in the fields and packing sheds as the men.
The INS could have been another cause of stress for Maria. She was in the US without a visa and immigration authorities were looking for her so they could send her back to Mexico. Maria's husband was serving time in a federal prison in El Paso for illegally transporting other farm workers into this country. Without a husband to help, she and her children would starve if they were sent home.
Maria related her story in Spanish. I didn't need the interpreter to understand that she was an honest person whose deepest concern was to be able to work to keep herself and her children alive.
With a few days' rest and a balanced diet, Maria's headaches became less severe, but they never went away completely. I could buy her another month or so by certifying as her physician that her health was poor and that she shouldn't be deported until she got stronger.
Maria was visibly relieved when I told her I had interceded with the authorities and gotten her a 30-day extension to stay in the United States. I was proud of myself for being a truly holistic doctor.
The next day I discharged Maria. I watched her get into a green Ford pickup and joyfully greet her two children. I wished there was something more I could do to help. I even called an attorney and offered to pay the legal fees myself if he could find a way to keep her in this country.
Maria returned to my office three weeks later, again complaining of severe head pain. She was ashen and terrified. There was no change on the physical exam. I learned that immigration authorities had been to her house and told her that she and her children would have to go back to Mexico next week.
I gave her some pain medication samples and told her I would call the lawyer first thing in the morning and see what could be done. I never made that call.
At 3 am, my home phone rang. "Maria dead, Maria dead, Maria dead" is all I heard. I asked questions, but the woman on the other end didn't understand my English and I didn't understand her Spanish. "Está bien, I'll come," was the best I could do.
I picked up Maria's chart from my office and headed toward her neighborhood. I knew the area and its historical architecture well; I had often driven down its streets to admire the old three-story homes with their stately columns. As I turned onto Maria's street I saw an emergency vehicle with blinking yellow lights parked halfway down the block.
Every window of the gingerbread-style house was lit. The crowd of perhaps 30 people became silent as I approached, moving aside to create a path for me. Some of the women made the sign of the cross as I walked through the door. "I'll take all the help I can get," I thought.
Inside, the house was eerily silent, although I could discern cigarette smoke, cooking oil, coffee, and a diffuse human smell. I moved across the living room, a grand area with a 14-foot-high ceiling and elegant baseboards. Judging from the arrangement of beds, tables, and chairs, at least two families lived in each room of the house.
As I walked toward the stairway, I couldn't help but notice how the beautiful balusters dovetailed into the worn oak treads and the solid mahogany handrail gracefully curved upward. Curved crown molding flowed high above. The stairway's elegance and grace seemed undiminished by the poverty of its current occupants.
When I reached the second floor, I walked toward a man's voice coming from one of the rooms. "Hell, I don't know who she is or how it happened. All I know is she's dead." Two EMTs stood inside the room; one of them was talking on a phone.
"Where is she?" I asked.
"Up there," one of them said. "Here, take this," he added, handing me a flashlight. "There ain't no lights."
I climbed up a narrow staircase into a small room in the north turret. The walls sloped into a small hexagonal ceiling you could reach up and touch. The entire city was visible from a single open window.
Maria lay in a fetal position on a mattress. The arrangement of bed covers and pillows indicated that the two children usually slept here with their mother. A brown stain seeped from Maria's mouth onto a pillow. The samples I had given her were on the floor beside the mattress, most unopened. I was relievedat least she hadn't committed suicide. But I was puzzled. A 20-year-old, seemingly healthy woman doesn't just die.
The sun was coming up when I got home. As I took my usual morning run, I wondered what would happen to Maria's children. Would immigration officials send them back to Mexico?
I attended the autopsy, performed by Virgil Gonzalez, one of the best pathologists I knew.
We explored the chest and abdomen and opened her stomach. We saved some of the blood from her heart for toxicology studies. Perhaps she'd been poisoned, I thought. Reluctantly, we decided to explore her skull.
There was our answer, a small saccular aneurysm in one of the trifurcations of the circle of Willis. The cerebral artery contained a small congenital defect, a bubble with weak walls. As this bubble expanded, it had worn away the surrounding brain tissue and bony tissue directly adjacent, causing those excruciating headaches. During the final minutes of Maria's life, this vascular balloon ruptured and blood surrounded and compressed the brain stem.
I knew, of course, that a small volume of extravascular blood in the skull could be fatal, but until that moment I did not fully realize that it could happen to a young person like Maria.
Virgil sensed my shock and confusion. He was kind as he explained that even if I had known that the aneurysm was there, it was in an area that was inaccessible to a neurosurgeon.
My doctor's magic seems a little less powerful after Maria's death, and my own life and the lives of the people I love seem a little more precious. I no longer assume that there will always be a tomorroweven when you're only 20.
Neal Pock. What caused this young mother's sudden death?. Medical Economics 2002;12:47.