Speechless In Southside

It is the middle of the afternoon, and I am seeing patients in our High Dependency Majors area - "HD" as it is known.  The tell-tale tone of the crash box rings out from a couple of metres away, and the nurse co-ordinating the area scurries off to answer it. 

"Royal Infirmary Emergency Department receiving"

"Thanks RIE, we have a 67 year old male, probable CVA (cardiovascular accident, or stroke), GCS (Glasgow Coma Score) 12, ETA (Estimated time of arrival) 2 minutes."

Plenty of time.

The nurse who took the call heads for the tannoy:

"Crash call, resus' 1, 2 minutes" sounds out around the Department.

I head to the resus' room, and am joined by a junior doctor, a charge nurse and a registered nurse.  The patients in the waiting room with minor injuries no doubt wonder why some of "their" staff are disappearing. 

One of the porters brings in a trolley, and a sheet is put on it.  Some equipment is prepared, and just then the patient is wheeled in by the ambulance crew.  We transfer the gentleman over to our trolley, and the whole room listens in to the paramedic.

"This is Michael, 67 years old, found collapsed at home by his son at 1500hrs with right-sided facial droop and arm weakness, some sounds but no words.  His son had spoken to him on the 'phone at 1400hrs and he seemed fine.  Michael has a past medical history of high blood pressure and smoking but nothing else.  His son is on the way up by car."

OK, it's now 1600hrs - time is of the essence.  We get a drip in Michael's arm and check a blood sugar in the first minute or so.  This is normal: one less thing on the list of possible causes.

 I try and communicate with Michael, and it is obvious fairly quickly that he can understand what I am asking him but is unable to find the words to reply, a condition called expressive dysphasia.  He is able to make some words if carefully prompted, but unable to initiate their formation himself - frustrated doesn't nearly cover what patients must feel like.

His physical examination reveals a definite weakness affecting the right side of his face and his right arm and leg.  In fact, he is barely aware of their existence.  It is like someone has unplugged the wires that connect that part of his body from his brain. 

There is little doubt that Michael has had a stroke.  Our first priority now is to determine what the cause is (there are a few), and whether there is a possibility of considering clot-busting medicine (thrombolysis) to help improve the chances of Michael's recovery.  This is why the timing is so important.

Within 10 minutes of arrival, we have transferred Michael through to the radiology department for a CT scan of the brain. 

The scan shows that there is no bleeding in the brain (which causes approximately 15% of strokes in this age group) and that there is no other reason on the scan that thrombolysis would be too dangerous to consider.

It is now 1630hrs.  Michael may have had his symptoms for 2 and a half hours, and we know that the beneficial effect of the clot-busting treatment reduce after 3 hours, leaving only the potential to cause harm.  Some hurried conversations are required - never ideal when making such significant decisions. 

We get hold of Michael's son, and together with Michael, we agree to giving the thrombolysis.  This is given as a single injection followed by an infusion.  All the signs are positive within the first hour, but it will be a nervous waiting game for Michael and his family for the next 48 hours or so.


Medical Russian Roulette

The use of clot-busting medicine (thrombolysis) for the treatment of stroke has been somewhat controversial.  There has been much publicity surrounding it, but it remains a treatment that requires careful consideration.  It is only recommended in one form of stroke - that caused by a clot in a blood vessel supplying the brain - and only if certain criteria are met.  Probably less than 10% of patients who have had a stroke are likely to be eligible for this treatment.

If you are eligible for thrombolysis, and are able to receive it within 3 hours of symptom onset, then your chances of having an improvement in your disability are 1 in 10.  However, the chances of you having a bleeding complication, which could be fatal, are 1 in 20.  It is like having a 20-barrelled gun with 2 bullets that will cure you and one which might kill you, and spinning the chambers.  The overwhelming likelihood is that you will have no effect (17 out of 20), but that doesn't make the decision any easier.