Stroke Protocol

Working a Sunday and it gratefully has been as slow as Saturday. I got in a nice nap this morning, brought in a patient with the flu, and had just fallen asleep again in the early afternoon when we got a call for a stroke at a nursing home.

The lady was flaccid on the right side, and although she had some dementia, was a full code. The nurse told me that she was summoned by nursing aides at 1:45 and found her leaning to the left. The aides said she was fine, then they noticed her leaning to the left. So 1:45 is the onset time? I repeat. That's right, the nurse says.

The time of onset is critical in order for the patient to recieve a therapy called TPA, a drug which can bust the clot causing the stroke if administered within three hours of the onset.

Here's a link with the guidelines for use of TPA and one about its benefits:

www.stroke-site.org/guidelines/tpa_guidelines.html

href="http://www.medicinenet.com/script/main/art.asp?articlekey=38883"


We go to the hospital on a priority and I notify the hospital of a stroke alert. I tell them on the radio that onset is 1:45. After I finish my report, they ask what time the onset was. One forty-five, I say, quarter to two. When was she last seen? they ask. She was seen at 1 forty-five by people in the room who said she was fine before. What is her normal baseline they ask. Dementia, but alert, This is a new event. One forty-five onset. She is a full code. No history of stroke.

I am a little aggravated because as sometimes happens they don’t listen to you, forcing you to repeat yourself when you are busy trying to take care of the patient. It didn't matter so much with this patient, as I have done everything I need to -- Ecg, IV, blood sugar, 02, neuro tests, the works -- and she is stable.

At triage, the nurse asks me when it began. One-forty-five, I say.

But when was she last seen before then? At one-forty-five, I say. A nurse was summoned to the room because the aides noticed she was leaning to the left. The aides had been in the room with her and said she was normal, and then they noticed she was leaning to the left, and they summoned the nurse. So the onset is 1:45 or maybe a couple of minutes before.

We could call the nursing home, the nurse says.

1:45, I say, Quarter to two. Onset. She was alert, then she was not. The stroke clock begins at 1:45.

I have to then go over all the rest of my findings with the nurse, who finally calls the stroke alert, and we take the patient down to the room.

A doctor who I have never seen before comes in and I give my report. Onset 1:45, I say. She was noticed leaning to the left. She had been fine.

What was she before, when was she last seen? One forty five onset, I say. The aides were in the room with her. She was fine, then she was leaning to the left. Time of onset 1:45.

We have to be certain, the doctor says, it is critical.

I know I say, that's why I called in the stroke alert. 1:45 onset. I went thorough this on the radio twice, and in triage three times. I want to be clear, one-forty-five. I glance at the clock. That means you have two hours left on the stroke clock.

Jeesh.

And then my partner tells me they go ahead and call the nursing home anyway, and guess what they tell them. The same thing that is written on the paperwork I also showed them. 1:45 onset.

So I am maybe a little cranky. Maybe I still need a little more sleep time to laugh about it rather than feel testy.

Stroke is an interesting issue, but there is a great deal of politics involved with it. Only a few patients meet the criteria for TPA and in only helps a small few. I have heard people from some of the smaller hospitals say the stroke center hype business is just a gimmick to get stroke patients brought to the bigger hospitals. But I hear some other people say it can be life-saving. I just do what they tell me. When the patient is with-in the wthree hour window, I go lights and sirens and call the alert. When they ask time of onset, I tell them:

One-Forty-Five.

Next time I will draw a big sign and hang it around the patient's neck.