Backdraft Postscript


1 – a paragraph added to a letter after it is concluded and signed by the writer; or any addition made to a book or composition after it had been supposed to be finished, containing something omitted, or something new occurring to the writer

As it turned out, Missy was a WUS. That’s not a disparaging comment about her intestinal fortitude – it’s a classification of stroke known as a “Wake Up Stroke.” According to a recent article in the American Heart Association / American Stroke Association entitled Thrombolytic Therapy for Patients Who Wake-Up With Stroke, approximately 25% of all strokes are WUS. Given that people may sleep 25%-30% of their life it can only be expected that a stroke will happen during that time in a proportionate number. EMS currently deals with a short (4-hour) window of time to rush a patient to a stroke center for thrombolytic therapy – if a stroke has a known onset of four hours or less, the patient is eligible for thrombolytic therapy. Outside of that window it is considered a “cold stroke” and thus ineligible. If the onset time of the stroke cannot be verified, such as in the case of a WUS, the patient is automatically ineligible for thrombolytic therapy. This latest article, however, states that the therapy may be safe in longer periods of time from onset of symptoms. Further studies are being conducted to explore the possibility of an extended time period for this treatment.

I recently attended a lecture series by a panel of neurologists on strokes and the latest trends in therapy. During the session the extension to the thrombolytic window was explained in greater detail. To paraphrase four hours of lecture, in the event of an ischemic stroke there is a proportion between necrotic (dead) brain tissue and the surrounding ischemic (under-perfused) brain tissue which can be visualized with a Functional MRI. With a proportion of 80/20 thrombolytic treatment would have very little effect. With a proportion of 25/75 thrombolytic treatment may have a greater effect and the potential benefits of extending the window would then outweigh the possible risks. The ramifications of this line of research is that every patient has their own personal window of opportunity for thrombolytic therapy which can only be viewed once that patient reaches a stroke center. This same research is showing that an extension of the window to as long as sixteen hours may be safe in some situations.

In the case of Missy I took her into the hospital running Code-3 because of the smoke inhalation and potential for an airway that may be in the process of closing. Yet I transported her to a stroke center, bypassing a regular ED with no specialties, to ensure that neurologists would be on hand to quickly evaluate her recent stroke symptoms. Unfortunately the extension to the thrombolytic window is still in the research phase and has not progressed to cover the WUS scenario at the local hospitals. The deficits from Missy’s stroke did not immediately resolve and she was not a candidate for thrombolytic therapy. She will undergo extensive physical therapy in an attempt to regain some of her left-side functionality.

Meanwhile, Stacy, the fire medic/RN who got caught up in the excitement of the fire to the point that she missed an obvious stroke in her patient, has since been promoted to Lieutenant…



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