When watch and wait is the only option

Neurosurgeon Michael Cawley at Emory University Hospital.
Neurosurgeon Michael Cawley at Emory University Hospital.

 

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In his mid-20s and physically fit, Adrian Duffy had every reason to think his three-day headache was a fluke, except for the numbness in his face and fingers and some double vision.

The hospital wrote off the patient's ICU stay and rehab as charity care, and social workers helped his family with housing and travel expenses so they could be near their son.

Imaging done at a nearby hospital found a cavernous malformation, a collection of abnormally dilated veins, filled with blood slowly leaking into the brain. Duffy was transferred to Emory University Hospital (EUH), the only facility in north Georgia with specialists to treat this form of angioma. More imaging, more tests.

Neurosurgeon Michael Cawley has seen a lot of cavernous malformations but never one as large or as dangerously positioned as Duffy's—it was in the middle of the brain stem, which regulates cardiac and respiratory function. The only treatment for cavernous malformations is surgical removal, but in Duffy's case that would mean cutting into normal brain stem tissue with irreparable consequences. The good news is that, unlike aneurysms, which run the risk of exploding, cavernous malformations tend to hemorrhage slowly, and then stop, allowing the blood to be reabsorbed.

After discussion with the Duffy family, the decision was made to wait unless an emergency dictated otherwise. Duffy would stay in Emory's neuro-ICU, recovering under close observation of Cawley and a team of round-the-clock neuro-intensivist physicians and specially trained nurse practitioners. Cawley's hope was that Duffy's bleeding episodes would be small and few and far between—or that the malformation would migrate to the outer edge of the brainstem, allowing for easier removal. After two weeks, a greatly improved Duffy was referred to the Emory Center for Rehabilitation Medicine for physical and occupational therapy to help him recover from the deficits caused by his initial hemorrhage.

Such care is complex and costly. Duffy had been employed but had no health coverage. After his weeks in the ICU and more time in rehab, his hospitalization costs had climbed to more than $230,000. EUH wrote it off as charity care, meaning he is not expected to pay. In fact, social workers also have helped his family with housing and travel expenses to be near their son. In the weeks ahead, as Duffy's medical situation progresses, Cawley will talk with Duffy and his parents about how to proceed. If the best path at the time appears to be removal of the malformation, the costs of the surgery, intensive care, and rehab will dwarf the charity care already provided. "But if he needs it and we think it will work," says Cawley, "then we will make it happen."

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