A while ago an elderly gentleman came into emerg. He lived at home with his wife, and had just returned approximately 2 weeks before from an exciting vacation. He led an active life and looked about 20 years younger then his age.
At 1:30pm he had gone out to get the paper and when he came back in his wife noticed that he was speaking nonsense, and slurred-like. Being smart, she called 9-1-1 right away. As the stroke center for the area, a full workup was completed to prepare him for the clot-busting treatment.
Upon presentation to Emerg he was slightly aphasic, meaning he had a hard time speaking, and he had a slight left-sided deficit.
When a stroke patient comes in, neurology is paged right away. We also hook the patient up to the monitor, get basic vitals, do a finger-pick for glucose, start a line, draw bloods, get an ECG, and then prepare for transport to CT. Once this is all done neurology reads the CT, and pulls together the information to determine whether or not the patient is a candidate for TPA, a clot-busting drug that can effective in ischemic strokes and that is used within 3 hours of symptom onset. The problem with TPA is that the risk of causing a major bleed is so strong that after 3 hours post-symptoms, the benefits of giving the clot-buster don't outweigh the risks.
It was well in the timeframe for TPA: there had approximately 45 minutes left. In addition, the patient was clearly a stroke. His deficits were slightly worse on one side, and he continued to be aphagic. Unfortunately, however, we did not end up giving TPA.
Why? The patient was healthy, except for the fact that he had an irregular heart rhythm; a-fib. Atrial fibrillation is caused by many areas in the atria of your heart wanting to be the pacemaker, instead of the sinoatrial node. Due to the disorganized firing of the pacemaker, there is no effective pump to get the blood from the atria to the ventricles of the heart. This can cause blood to be stagnant and form clots within the heart. Generally, to reduce the chances of getting a clot, a doctor would prescribe a blood thinner.
Since this stroke patient was a diligent patient and took his blood thinner medication every day, he no longer became a candidate for TPA. His blood was already therapeutically thinned to help his heart. TPA would have caused his blood to further be thinned, essentially creating a huge risk for bleeds had the treatment been administered.
Not only did the blood thinner contraindicate TPA, in addition the neurologist could already start seeing the stroke's effect on the brain. Typically when a CT is completed for a stroke, the neurologist is looking to see if the stroke was caused by a bleed or a clot. However, changes to the brain of an ischemic stroke are not noticible on a CT until quite a few hours after the onset of symptoms. So, ultimately the CT is completed to rule out a brain bleed. Although not seeing any ischemic changes in the CT is common, in this patient, the CT showed some darkened areas consistent with brain death of an ischemic stroke.
The decision was made not to TPA the patient, and the neurology team had an incredibly hard thing to do- tell the family of the patient what was occurring, and that a decision needed to be made as to what our next steps were. Ultimately, the family would have to decide on whether the patient would be allowed to pass on (as the stroke was huge and the patient was rapidly deteriorating), or whether other treatment would be provided so that the patient could attempt some form of rehabilitation once stabilized.
Ultimately, the family decided that the patient would not have any aggressive therapy, and instead would be treated palliatively.
The patient continued to get worse: he now had complete loss of function on one side, and his vitals were changing. He went from GCS 14 upon arrival to GCS of 10 within about 4 hours. He knew he was having a stroke and tried to communicate with his family and with me, to no avail. The reason I could tell he knew what was going on was that up until a point, he obeyed all commands.
The man was stuck in a body that was failing him, and he knew it. I hate seeing people suffer, and I know that although his family was there for support, it would have been very hard on him. I wasn't the primary nurse for him, yet I know that all of us in emerg that day tried to lend a helping hand to him and his family.
By the time he went to the floor for palliative care, his GCS continued to decline, and from what I hear he passed sometime in the night.