Coming Soon: the Trauma Center 1.2

We'll be hosting the next issue of the Trauma Center here next Tuesday, November 20th. The Trauma Center is a new blog carnival covering all aspects of emergency medicine. To be included, please send an email to lshevchik at healthline dot com by 12 midnight PST Sunday, November 18th.

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A Stroke of Luck

Last night, John was enjoying dinner with his wife. Suddenly he dropped his fork, a pain seared through his head. His right arm went limp, he tried to talk, but only incomprehensible slurs emerged. John at just 55 years old had suffered a massive, debilitating stroke. When he arrived at the Emergency Room a team of doctors and nurses had to quickly calculate if John was a candidate for a specialized drug therapy which could reverse his symptoms. Saving a life is a team effort. Not only must Paramedics, Nurses, and Physicians work together in perfect harmony, in a race against time, to make the correct medical decisions, but families must place their trust in those caring for their loved ones as well. John and his family had to hold out hope that all was not lost.

Stroke is the leading cause of adult disability worldwide, and is the 3rd leading cause of death in the United States (1). Last year in this country, there were over 5 Million strokes among adults older than 20, and on the average, every 45 seconds someone has a stroke, and every 3 minutes someone dies of one (1). The symptoms can be far ranging from sudden onset of weakness of a particular part of the body, difficulty speaking, or vision loss, to numbness or dizziness. Approximately 80-89% of all strokes are caused by a blockage within the blood vessels of the brain (Ischemic Stroke), while 10-15% are caused by an actual ruptured blood vessel (Hemorrhagic Stroke) (2).

Sometimes we are able to “stack the deck” in our favor of lessening the damage from a stroke. Stanford University Medical Center is a nationally recognized Stroke Center and holds many of the cards needed for a positive outcome. A dedicated team of Neurologists and Nurses, known as the “Stroke Team”, Emergency Department personnel, and Paramedics must work in concert to not only properly diagnose, but to treat and manage individuals who may be suffering from a stroke. In my career as an Emergency Department Resident, I have never seen a higher level of teamwork, or corroboration amongst care providers, as when a caring for a stroke victim:

7:15 pm: John’s wife realized that something was drastically wrong, she dialed 911.

7:22 pm: Paramedics arrived at their home. They realized John was suffering a stroke. Their rapid response, and correct diagnosis, set in place the optimal chain of events to aid in his care.

7:40pm: The Paramedics called Stanford University Hospital and notified us of a “Stroke Code.” Immediately the Stroke Team was paged to the Emergency Department. The radiologist and technicians were immediately notified to have a CT scanner ready in order to obtain pictures of the patient’s brain. These pictures help determine if the sufferer is a candidate to receive certain life saving treatments. In perfect synchrony, all necessary Emergency Department personnel arrived at the currently vacant bed…

7:48 pm: John arrives in the Emergency Department. Within minutes the general diagnosis of stroke is confirmed, and he is whisked away to the CT scanner for a more detailed inspection. The Radiologist confirms that John did not suffer a bleeding stroke, but instead, a blockage in one of the major blood vessels of the brain.

8:00 pm: Because John’s symptoms were detected within 3 hours, and because of the nature of his stroke (Ischemic rather than Hemorrhagic ), he is deemed a candidate for tPA, or Tissue Plasminogen Activator, a potent clot buster- the only FDA approved drug for the treatment of Ischemic Stroke. We explained to John and his wife that approximately 6% of patients receiving tPA suffer bleeding into the brain, but there is a 30% or greater chance of a good neurological outcome after 3 months (3). These odds are a calculated risk, and both John and his wife are willing to take the risk and proceed with the medicine.

8:15 pm: After John is deemed stable enough to receive the drug, his treatment is started. His wife sits silently holding his flaccid right hand.

“I have never been so scared in my life,” John proclaimed. His words came out crystal clear. “My right hand still feels weak, and a little numb, but I think I’ll be able to work on my truck again!” He gave me a thumbs up. John was lucky. Less than 3-5 % of patients who present with his type of stroke are able to receive this drug for therapy (1). Unfortunately, most are beyond the 3 hour window, or are too unstable, and at a greater risk of having severe complications. The dedication, experience, and efficiency of every team member involved in John’s case played a crucial role in his recovery. “We never gave up hope,” his loving wife said, “we trusted you all knew what you were doing.”


REFERENCES:
1) Adams HP Jr, Del Zopo G, Alberts MJ, et al. American Heart Association; American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke. 2006.

2) Braunwald et al. Harrison’s Principles of Internal Medicine. 15th Edition. 2369-2371. McGraw Hill, New York City, NY 2001.

3) Bellolia F, Stead L et al. Stroke update 2007: Better Early Stroke Treatment (BEST). Emergency Medicine Practice . 2007; 9,8: 1-21.

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Too Many Chefs

I am now in Los Angeles visiting my sister and her newly born daughter. Immediately after work I drove straight for San Jose and Southwest Airlines to see the first new member in our small family. The stark transition of my last two hours in the emergency room to the joy and hope I immediately encountered in the delivery room has left my head spinning. The ER blog about boarding brings me back to those last two hours and keeps me thinking of how I can improve my care.

Stanford Hospital is currently modernizing and expanding components of its residencies because of the surge in its daily census that often reaches capacity. For us, in the the emergency department, this means patients that require an internal medicine team and hospital bed instead wait in the ED.

In my recent case I was signed out a "boarding" patient, awaiting a hospital bed, and followed by an internal medicine team. This 76 year old woman presented with dizziness, abdominal pain, and one episode of bloody stool. She had some abnormal laboratory values which included elevated markers of infection, but otherwise looked "good." By that I mean she seemed very safe for a floor bed and medical management without any emergent interventions such as colonoscopy or invasive procedures.

Now I see the danger of her ED stay being that though she is under our care the major thrust of her treatment is being managed by the admitting medicine team. This sets up a situation where we know less about her direction because communication is difficult to constantly update between the two groups. Also, each of us may feel a little too comfortable because there is someone else taking on responsibility for her care, and being too comfortable is alway dangerous.

Needless to say, her pressures dropped near the end of my shift and after 14 hours in the ED. We called the ICU, started central intravenous lines, and transfused her with blood and saline. Soon the surgeons also showed up concerned about ischemic bowel and took her to the operating room. Though I think we all worked well together to arrive at her best possible plan, it was at times difficult to determine who should be directing her care and who had the most current information about her.

There are certainly other problems with having patients managed long term in the ED related to work load and nursing but as a resident this issue looms the largest. Next time in the ED I will try to help these patients as if I am not only responsible for them in the ED but also as a de facto member of the medicine team, pushing them on issues of care and staying in the loop.

This patient did go to the operating room with the surgeons who looked inside her abdomen and did not find ischemic bowel and then did a colonoscopy that did not show any evidence of bleeding. Her low blood pressure was most likely due to an unknown infection progressing to sepsis.

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The Trauma Center, 1.1

Welcome to the inaugural issue of the Trauma Center, a blog carnival covering emergency medicine. I received an overwhelming number of submissions for our first time out and would like to thank everyone who sent in a submission. So without further ado, I bring you...

Fat Doctor gives us a crash course in Japanese in this moving post about the benefits and limitations of virtual critical care.

Our own Sean Donahue, DO shares his experience treating Frank, an uninsured patient, who is a frequent visitor to the Stanford Emergency Department.

"Boarding patients in the ER is a problem, a big problem," says ERnursery. Find out more in this insightful post.

Healthline blogger Dr. Nancy Brown describes how important it is to a family emergency plan in her post In Case of Emergency.

Alexandra shares her personal experience with a staph infection in 2006.

Do you know how to survive a wildfire? Healthline blogger Dr. Paul Auerbach tells us how in this informative post.

TherapyDoc at Everyone Needs Therapy separates fact from misconception in his post Borderline Personality Disorder and the DSM.

Natural disasters and other emergencies can be especially difficult for individuals with chronic illnesses. Healthline blogger and nurse JC Jones reminds diabetics to be prepared for emergencies.

Davex presents discusses many potential treatments for acne scars.

That's it for this time. The next issue of the Trauma Center will come out on Tuesday, November 20th. Thanks for your support.

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