1 : making no utterance : mute, speechless
2 : indisposed to speak : not loquacious
3 : free from sound or noise : still
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.