Why do we get to treat so few strokes?

American ER Doc Gone Walkabout Episode 024

We’ve been treated to a number of papers pointing out that a very small proportion of acute strokes present within the “treatment window” (I’ll avoid the controversies as to whether thrombolytic treatment is a good idea, or a bad idea) compared with STEMI’s which often present within a time period where thrombolytics or PCI is clearly efficacious.

I decided to embark upon a little study to try to determine why this might be true. ( I actually didn’t understand, at the time, that I was setting up the study, but we’ll get back to that later.)

After a good night’s sleep, I awoke at about 6:30, and soon realized that there were two of everything where on previous mornings that had been only one. Rather interestingly, they were offset to the side only a little but were pretty dramatically offset one image above the other. Stuff to the left seemed to be offset only about a foot, but on right gaze the offset was more like 5 or 6 feet. And one of the images was jerking back and forth and rotating rapidly clockwise, then slowly coming back to position before repeating the fast clockwise rotation of perhaps 30 or more degrees ( I presume that an outside observer would have noted rotatory nystagmus and I was seeing the nystagmus from the inside looking out). No vertigo, but I was rather unsteady on my feet, especially if I tried to open both eyes where the discrepant images and motions really messed with my mind and balance.

Being a well trained Emergency Physician with some degree of interest in strokes (and member of the hospital stroke council) I recognized the symptoms of a posterior circulation stroke, and moved on to staggering into the bathroom, brushing my teeth and combing my hair (hmmm, no limb ataxia), getting dressed, going downstairs – not too bad with the nystagmus eye covered, and making a cup of coffee (which I unfortunately didn’t get around to drinking). I called my wife (also an ER Doc) and ascertained that she was already at the med school so wouldn’t be able to get home for an hour (roads were bad) even after I casually mentioned that the reason for the call was a probable stroke. She brought up the possibility of a 911 call to EMS, but with no pain, I thought that sounded excessive. Good thinking, there, Abbott.

While I was sitting around thinking that maybe things would just get better on their own, my very wise wife called my daughter and son-in-law (they live next door) and they walked over and eventually convinced me to accept a ride to a nearby hospital.

Why tell this story? I should know better, but in the absence of pain, it was remarkable just how unconcerning these symptoms were! I immediately recognized that my symptoms were completely consistent with a stroke. I knew that “time is brain”. And yet, I messed around rather unconcernedly for nearly an hour before my conscious brain overcame inertia and said, “You know, mate, this isn’t getting better, why don’t you just accept the fact that you’re getting old and might have a serious disease, and get a professional opinion.” I can imagine that a layperson in this situation would have delayed much, much longer – double vision is not generally listed as prominent on the “time is brain” billboards from the American Stroke Association.

I tried to take some teaching videos of myself while in the car enroute to the hospital – they didn’t come out good enough to post, but when I looked at them this evening, noted that I did have some facial asymmetry and quite a lot of unilateral ptosis. Many of you may have guessed by the fact that I’m typing this up about 12 hours after the event, that I’m doing well. When they pulled me out of the MRI tube, I realized that I no longer had diplopia nor nystagmus, and my wife noted that the ptosis had resolved. Shortly thereafter, I developed a rather significant unilateral headache and nausea. I’ve had occasional migraines since I was a teenager – mostly with the visual scintillating scotomata and only occasionally with the follow-on unilateral headache, and they’ve been less common as I’ve gotten older. They are pretty caffeine sensitive.

Which brings me to my experimental methodology in setting up this case study: we’re having some repainting done in our house, and I was unable to get into the kitchen yesterday to make coffee. I had a single cup of coffee first thing in the morning, and never had my usual 3-4 cups of coffee later in the day (no lectures on the dangers of caffeine toxicity, please). I feel pretty good now, and am heading off to bed – I’ve got to get up early since I have a 7 am shift tomorrow, and there is a blizzard going on, so it will be a long drive. Time will tell whether my current working self-diagnosis is correct.

The headache is better after some paracetamol and caffeine.

The MRI and MRA were normal except from some “incidentalomata”.

I’ll be willing to entertain any and all thoughts as to what the true diagnosis might have been. A couple last thoughts: ER Docs in the US do crappy neurologic exams. The exam today consisted of pupillary light reflexes, EOM’s, facial motor, tongue protrusion, palate elevation, and shoulder shrug (not sure if he noted the absence of my left sternocleidomastoid muscle – lost when I broke my neck, not sure where it went). Hand grasps, and active straight leg raising were tested. Missing were any sort of formal mental status exam, facial sensory testing (he would have found that I was missing one supraorbital and the other infraorbital nerve – I lost them in my LeForte II fracture), optic funduscopic exam – a lost art, auscultation for carotid bruits. No sensory testing at all. No pronator drift, visual fields, finger-to-nose nor heel-to-shin, no DTRs nor plantar responses. And, I think there must be an implicit penalty if any ER MD tests this: gait testing. I swear that EM residents must be taught that getting a patient out of bed is cause for termination from the training program. We seem to have learned how to efficiently order the CT, stroke team consult, and MRI, but the ability to do a brief but thorough mental status and neurologic exam is rapidly disappearing with the glaciers of Greenland.

Actually, it’s not just neuro exams, and it’s not just ER Docs: a couple years ago I had a bout of atrial fibrillation and no stethoscope touched my chest during evaluation by ER Doc, internist, nor cardiologist. 3 days later when I came back for cardioversion, a second cardiologist actually removed her stethoscope from being draped a round her neck, placed it in her ears, and listened to my heart – will wonders never cease? Of course, I got bills for “comprehensive” exams from each of the first 3 non-listening doctors. Prior to the propofol for the TEE and cardioversion, my total pre-anesthetic evaluation consisted of a masked man with a syringe of white stuff asking: “So, ‘ya ready?” (Incidentally, being a firm believer that for sedation with propofol, NPO status is irrelevant, I had bacon, eggs, and toast – with coffee, of course – immediately prior to going to the cath lab for the cardioversion. I didn’t vomit.)

Time for some more paracetamol for my headache.

Later, Mates.

Next time:  If you die, do you want to stay dead?