Tag Archives: Stroke

Backdraft Postscript

post·script

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…

 

 

Backdraft

back·draft

1 – a reverse movement of air, gas, or liquid

2 – an explosion that occurs when air reaches a fire that has used up all the available oxygen, often occurring when a door is opened to the room containing the fire

Missy woke up a little early and from the start she knew something was wrong. She just didn’t feel right and the world seemed just a little more confusing than usual. She tries to get up out of the bed but the weakness is just a little more pronounced than usual and she never makes it all the way out of bed. Thinking maybe it would help to bring the world into perspective Missy reaches for a morning cigarette with her left hand, but finding she can’t quite make that work she finally reaches across her body with her right arm, grabs the cigarette, puts it between her lips, and lights it while laying in bed. With the smoke inhaled deep into her lungs she starts to relax again and nod off.

There’s shouting from outside the house – someone is yelling at her. She opens her eyes and sees the flames overhead – gently rolling across the ceiling with the smoke starting to burn her lungs on every breath. She tries to get up but again the weakness is stopping her from getting out of bed. Suddenly there is light in her bedroom, as the door opens, this is quickly followed by intense heat as the flames erupt as if seeking the oxygen from the open door. Strong arms grab Missy and start to drag her out of the house. Once on the front lawn she can see the flames well above the roof as firefighters are breaking windows and drenching her house with water.

As we roll into the neighborhood my partner and I stop following street signs and just follow the smoke to the location of the medical call. We have to park a block away as the small residential street is full of fire apparatus and supply lines. We roll the gurney closer to the house, avoiding the standing water and six inch fire hoses that snake across the road. Sitting in front of a burned-out house is my patient, leaning forward in a tripod position, sucking hard on an oxygen mask, with both arms being held out to either side.

Stacy, the fire medic, is supervising two Explorers who are simultaneously taking blood pressures, one on each arm. Our county has a Fire Explorers program for youth who someday want to be firefighters – it gives them the opportunity to volunteer with a local fire unit and learn the basics of the job. Both of the Explorers seem distracted by the commotion of the fire; they glance repeatedly from the blood pressure dial to the flames. It’s obvious they would rather be squirting water than taking care of this woman.

Finally, Tracy has had enough and asks each of them for their findings – she knows I’m not going to hang out here all day waiting for kids to check a vital sign that I’m going to recheck regardless of their findings. The kid on the left gives us a report of 90 over 60, the kid on the right tells us it’s 180 over 110. I have a dead pan stare on my face as I wait for Stacy to give me a report.

Stacy is writing the two sets of blood pressures on the patient care form and handing it to me. “Yeah, I know, you’ll have to check the BP again. Basically she was smoking a cigarette in bed and fell asleep. The blinds caught fire and the whole house went up. She got caught in a backdraft when they went in to get her. She had moderate smoke inhalation without any visible burns. That’s about it. Are you good?” Am I good? Hell no I’m not good. But I’m absolutely ready to leave.

Having moved Missy onto the gurney we start the long trek back to the ambulance. We have to double back a few times because of standing water creating small lakes in the street and fire hoses blocking our way. Throughout the ordeal I’m grumbling to myself about the poor treatment of Missy. Yeah, great, they got her out of the fire, but her treatment stopped there. Stacy knows better, she’s also an RN at a local Emergency Department, yet she released her helpers to let them fight the beast while the Explorers tried in vain to take vital signs. She didn’t have a history and knows almost nothing about this patient except she was in a fire.

Once we’re back in the rig I can start over and give Missy a proper check-out prior to going to the ED. Looking her over I can’t see any obvious burns but I’m more concerned with her breathing and airway at the moment. I slip the oxygen mask off and shine a flashlight in her mouth and nose and find singed nose hairs with soot extending the visible length of the nares – not good. Soot in the mouth and on the lips – not good. Oxygen saturation of 86% on room air – not good. Wheezing in the apex of each lung with a stridorous noise starting to come from the throat – really, really not good!

As my partner prepares the Albuterol and Atrovent nebulizer to affix to the mask I put an end tidal carbon dioxide nasal cannula on her nose so I can keep a good record of her respiration trends and quality of breathing, but looking at her face something just isn’t right.

“Missy, we’re going to give you a breathing treatment to help you breathe a little better but I have to ask about your medical problems. First off, have you ever had a stroke?” I’m seeing the telltale facial droop on the left side with an eyelid that looks like it’s being pulled down in the corner.

“Yeah, I had me a mini-stroke a while ago. They said it’s because of the A-fibs. But I all better now.” Now that I hear her speak I can tell there’s a bit of a slur to her speech.

“So you’re saying you didn’t have any lasting deficits from the stroke; like facial droop or weakness on one side?” My partner just finished setting up the nebulizer but I need to finish this line of questioning before putting it on and obscuring her face with a mask. He moves up to the front and starts getting us out of the neighborhood; I haven’t given him a destination yet – we both know that destination will be critical with this woman – yet we need to get moving.

“You know, now that you say it, it feel kinda like that mini stroke right now. I could’t get out of bed and my arm jus’ seem like it don’t want to move like it should.” That’s enough for me. I run Missy through a series of stroke tests; facial droop, slurred speech, left side weakness, change in sensory appreciation from left to right side and minor cognitive disassociations (how many wheels on a tricycle, what color is an orange, that kind of thing).

I glance out the front window as I place the mask over Missy’s head and see that we’re just exiting the neighborhood. Rechecking her blood pressure I discover that the Explorer on the left was closest – she’s 84 over 48. I start to set up the Sodium Thiosulfate drip for the IV.  “Okay, you ready for this?” I yell up to my partner.

“Yeah, go ahead, where we headed?” He yells over his shoulder as he lights up, turns on the siren, and heads for the freeway.

“Well, you already guessed we’re going Code-3. We’re going to Hilltop ED; 44 year old female, moderate smoke inhalation, hypotensive, tachycardia, tachypnea, Albuterol/Atrovent/Sodium Thiosulfate running. She’s also got a cold stroke, unknown onset time, left side weakness, with a history of.”

“Seriously?”

“Yeah, seriously, that’s what started the fire.”

 

 

T3 2/2

Since the drive to the ED will take a while, I strike up a conversation with Mrs. Duval to pass the time.

“They built this place maybe three years ago, how long have you lived here?”

“We moved here after the hurricane sir.” She has a polite manner and a southern twang. – apparently a transplant after hurricane Katrina. I’ve run into a lot of people who have relocated here after the hurricane. There are no definitive numbers because of the chaos at the time, but estimates are that over one million people were scattered around the country. Some have since gone back, some are still displaced.

“Do you like it here?” This area is a destination for many across the US who would love to move here, although not necessarily to the Projects – but to this general area. I’m curious about here perspective.

“It’s okay sir, but we don’t fit in so well.” I wish she wouldn’t call me sir but something tells me I couldn’t stop her.

“There’s a lot of crime in this area – are you guys doing okay?” The city PD call this area Beat-55x; it’s one of the worst in the city.

“Oh yes sir, we do fine, don’t no one bother us too much. It’s just not what we used to you know?” I’ve spent some time in the south and I know that our version of the hood is a lot different than their version. For starters no one in my hood has ever called me sir except for this charming lady.

“Do you have family here?” I’m curious to know what kind of support structure she may have.

“No sir. They all over the place after the hurricane.” Families were broken up, support structures destroyed, people displaced. Some never reconnected – it’s not like they are on Facebook and can post a status update to their wall.

“Your husband’s pretty sick. Does he always go to the emergency room or does he see a regular doctor?” I already know the answer.

“We don’t have a car sir. This the only way we can get there. I don’t understand though, he gets betta for a few day, then he has to go back. They jus can’ seem to make him betta.” It’s common – we see it all the time. It’s the other trifecta: poverty, location, and lack of education.

“You know, it’s the high blood pressure that’s the big problem right now. Is he taking his medication?” It may not be his biggest problem but you have to start somewhere.

“Yes sir. I make sure he take it every day.” She obviously loves him and she’s worried about him. But the care that they get from an emergency room will never fix this. Emergency rooms just treat them and street them. They seldom take the time to explain the overall condition, much less the causality and eventual complications. The mechanism for continuing care is non existent – there is no such thing as a house call.

“I’ve spent a lot of time in the south; that’s where my mother’s people are from. I know what y’all eat down there – lotsa fried food and salt. You know he can’t be eat’n that.” Possibly gaining a little rapport with the remnants of a southern twang that never really stuck with me.

“Oh, yes sir, I know but he like to taste his food. He always put the salt on.” No wonder his blood pressure is into gasket-blowing range.

“How bout the sweet tea, I know y’all like some sweet tea. How much sugar you put in a sweet tea?”

“Oh yes sir, he love the sweet tea. I put ‘bout a cup in a pitcha.” Yikes! A diabetic drinking that much sugar??

“You ever hear of Splenda? He’s got the diabetes, he can’t be takin’ that much sugar.” I can see the headlines now; Paramedic prescribes Splenda; man dies of cancer. Hell, but what else can I do at this point?

As I’m explaining sugar and salt substitutes I realize that Kevin has been having an almost identical conversation in the back of the rig. There’s nothing emergent to treat here – it’s their lifestyle that needs treatment and they’re not going to get it from the hospital. She tells me that she tries to help him but he won’t listen to her. She pleads with me to tell him these things because maybe he’ll hear it coming from a man.

Once at the hospital Kevin gives a report to the charge nurse and I’ve got a minute to lay it on thick for him. I cover all the points that we talked about: limiting salt, no sugar, no fried foods, eat a vegetable for God’s sake.

“Do you think this could kill me sir?” He’s a little scared with a small voice on the verge of tearing up.

“It will if you don’t fix it. Look at it like this: you didn’t have diabetes when you were a kid right?” He shakes his head. “Well, now you do and you take a pill every day to control it, but right now your blood sugar is super high. In a year you’ll have to take a shot twice a day to control it. That means sticking a needle in your belly every morning and every night. You don’t want that do you?”

“No sir, I don’t ever want to do that. Thank you sir, thank you for explaining it to me.” I didn’t give him an explanation, really, I just gave him some precautions and scared him with some possible results. It’s not enough and I know it. I even went to the EMS break room and grabbed a hand full of Splenda and gave it to the wife. They were both so appreciative and thanked me repeatedly, but still I know it’s not enough. Ultimately they escaped a hurricane and landed in the perfect storm.

After cleaning up the rig I went back in and had a conversation with the charge nurse. I learned that they have no one in the hospital for dietary consultation. Maybe, if he was admitted to the floor, they could call in a consult from their network of hospitals. I also learned that the county hospital has better dietary consults than this private hospital. Apparently they’ve cut all the “non-essential” programs. The Governator has already laid the ground work for further cuts to police, firefighters, hospitals, home health care, and education. Unbelievable!

I don’t pretend to have the answers yet I see the problems every day. This man needs a dietary consultation and someone to check on him once a week. Someone to go through the cabinets and suggest substitutes for poor eating habits. Someone to take him on a field trip to a dialysis center and see the sad people sitting in their chairs for three and four hours at a time – watching their blood get siphoned off and returned. The answer is not to spend more on health care. We need to give people the health care that they need and stop passing the responsibilities off to the next shift and by extrapolation passing the responsibilities off to the next generation.

This is the Trifecta cubed: T3

 

Hypertension –> Diabetes + Heart Disease

Location –> Lack of Education + Poverty

Poor Economy –> Unemployment + Cuts to Social Services

 

The perfect storm…the only question is which horse comes in first?

 

Silent Alarm

Si·lent

1 : making no utterance : mute, speechless

2 : indisposed to speak : not loquacious
3 : free from sound or noise : still

 

Alarm

1 a call to arms <the angry trumpet sounds alarum — Shakespeare>
2 : a device that signals
3 : sudden sharp apprehension and fear resulting from the perception of imminent danger
Synonym: see Fear

Walking up to the car I can see he’s scared, eyes wide, head moving rapidly as he looks first at the fire medic, then at me, then back at the fire medic.
His compact car is perfectly parked in a parking space at an urban park, with no visible signs of damage. We have both of the front doors open. “Hey, what’s going on today?” he turns his head back in my direction and his eyes lock onto mine, but he doesn’t answer. Fear!

“Hey, what’s your name, can you talk to me?” No answer, head shaking side to side. I notice the cell phone sitting in the cup holder of the center console. Deaf guys don’t use cell phones, “Can you usually talk?” He nods his head emphatically. Now we’re getting somewhere.

I look over at the fire medic as he’s finishing up with a blood pressure and ask, “How did this guy call 911 if he can’t talk?”

“It came in from that jogger over there, he said this guy came up to him waving his arms, dialed 911 on the cell and handed it to him.” Strange. “I got a BP of 210 over 120, heart rate in the 130s” Crap, we’ve got a good idea where this is heading.

The fire medic walks around the car to help me transfer the man to the gurney. Standing next to the open driver side door, “You think this guy is stroking out?” We’re standing so the patient can’t see our faces. He’s already scared and things are about to start moving fast. “There’s a good chance, but I can’t run a decent stroke test while he’s sitting in the car. I’ll work him up in the rig.”

I have the man grab onto my hands so he can stand up out of the car and sit down on the gurney. No weakness on either side, at least not obvious weakness. Now I can see him from the front without having to turn his head. That might be a little droop to the right side of his mouth.

Closing the door to the car I see the cell phone again. I grab it and throw it on the gurney. I suspect this guy is going to be spending some quality time in the hospital for the next few days. This is a bad neighborhood and a cell phone in plain sight is reason enough to break into a car.

Once in the rig I start a Cincinnati Stroke Scale while my partner is getting him on the monitor and oxygen. Minor facial droop, no slurred speech as he’s not talking (aphasia), minor arm drift and leg weakness on the right side. Okay that’s good enough for a stroke. Blood sugar and 12 lead are all normal, but his blood pressure is still through the roof.

While I’m finishing up my assessment I’m doing rapid fire questions about medical problems and looking for head shakes to confirm or deny. Yes for diabetes, hypertension, and high cholesterol. Well there’s your trifecta that leads to everything that goes wrong in the head and heart. Of course the obesity probably kicked off the cascade but that’s a discussion for later when time isn’t critical.

One more question; “Did you stop talking right before calling us? This is important – I need to know exactly when this started.” He once again emphatically nods yes.

Okay, good enough for me. This definitely warrants a Code-3 trip to the CVA receiving hospital, which fortunately is just 5 minutes away. I have my partner call in a hot stroke activation and we get moving – everything else can be done on the way there. I have a three hour window where I can call it a hot stroke and the hospital still has the option of using thrombolytic drugs (clot busters) to break up the occlusion in the cerebral vasculature, assuming it’s not a hemorrhagic stroke (a bleed). But this is somewhat minor in presentation so I doubt it’s a bleed. I left my portable CT scanner at home again…

Bouncing through the downtown traffic, I can’t get an IV. He’s just too fat – his veins are too small and too far down to find, and I only give it one try. There’s a good chance this guy is going to a cath lab where they will need multiple IV access points and they don’t need me blowing all the obvious sites on a blind fishing expedition.

With all of my immediate tasks finished and just a few minutes out from the ED, I go through his wallet to get an ID so the hospital knows who they are treating and I have info for my paperwork. I decide to ask for a phone number and give him a piece of paper to write it down. Five numbers into it his brow scrunches up and the pen squiggles off to the side. He’s confused and can’t translate what’s in his head to the motor skills required to do a simple task. Crap, decreasing mentation!

I find his driver’s license and look at his name, “Okay Charles, couple of quick questions for you. How many quarters in a dollar?” Confusion, frustration, anger; wrong answer… “How many wheels on a car?” Eyes closed tight, left fist pounds the paper on his lap. He knows the answers, or at least he realizes that he should know them but he can’t make the intellectual jump from visualization to quantification – he can’t jump from right brain to left brain like he could just a few minutes ago. The insidious thing is he is fully cognizant of his deficit and still can’t make it work. Decreasing mentation and impaired cognitive ability. Crap, there goes my only reliable witness to time of onset!

Pushing the gurney into the critical care room filled with the stroke team I recognize the MD and start giving him my report as we’re helping Charles move over to the bed. I finish my report with the observations of the cognitive changes of the last few minutes. We both understand the ramifications of that finding. If Charles is not a reliable witness to his own condition then he could have been sitting in his car confused for the last 5 hours and doesn’t know the difference. The three hour window for thrombolytics is unconfirmed and the risks then outweigh the potential benefits of the treatment.

The nurses are hooking up their monitor, taking vitals, and unfortunately searching fat skin for any sign of a vein. Sorry guys, I couldn’t find anything either. The MD pulls some cards out of a drawer with pictures on them. The pictures are complex line drawings of scenes showing people, animals, cars, and buildings, with a twist. Every picture has elements that don’t make sense, like a three legged person or a dog with balloons for a tail. Charles doesn’t see the problems with the pictures. He can’t point to anything that is wrong with any of the pictures.

The MD turns back to me. “You sure you don’t have any other witnesses?”

“No, the only other person was a jogger but Charles was already aphasic when he approached him to call 911.”

My gurney is pushed up against the wall behind me. The MD reaches over and picks up the cell phone from the empty gurney. In the rush to get Charles moved over to the bed and all of the people in the room it got overlooked. “Is this his phone?” YES!

Flipping through the recent calls we see 911 and then another call made 25 minutes prior with a duration of 12 minutes. The MD hits dial for that number and gets a person on the other end. He’s able to confirm that Charles was acting normal and talking at that time. We now have a definite time stamp for onset of symptoms.

————

It would be nice to end with the MD pushing the magic clot busters and Charles thanking me as I strut out of the ED. Sadly, that’s not the case. I checked with the MD the following week and learned that they struggled for hours to get his blood pressure down to a safe level where the thrombolytics could work. They were never able to get it to a good range before exceeding the safe window of time. Charles regained speech eventually but still has minor right sided motor deficits. He may slowly recover in time but I’ll never know unless he calls 911 again and I’m in the area. Sadly that’s a real possibility also.

The experience of the MD and his insight to look at the history of the cell phone taught me an important lesson on using cell phone time stamps when dealing with CVAs. I honestly only grabbed the cell phone to keep the car safe. Now I realize the invaluable use cell phones serve in these situations and make it a point to find it in the house or car whenever I have similar patients. The good thing to come from this is that I’ve used them three times since with favorable outcomes. That doesn’t help Charles but I know that Charles has helped others. 

At the end of the day, that’s all we Paramedics can hope to have: the knowledge and experience that makes a difference.