The drama of using tPA in stroke within the three-hour window

Before telling this story, I’m going to have to lay some background for my non-medical readers.

The most obscene word in English, in my opinion, has three letters and is an acronym. It’s tPA (it stands for Tissue Plasminogen Activator).

This drug gets a lot of press as a “clotbuster.” It has the potential to break down clots and reverse a stroke. That potential, however, has a dark side. By breaking down clots it can also cause catastrophic bleeding into the brain.

As a result, I’m not a fan of this drug. I use it very judiciously, with a solid understanding by the family and patient of what they are getting into. It can lead to both great rewards and serious complications.

Compounding this is the fact that the drug must be given within three hours of a defined stroke onset, or the risk of bleeding really goes up. So if I’m told that the symptoms started at 1:45, then a clock immediately starts running, and if the drug isn’t given by 4:45, then it’s not going to be given. In that three hour window I need to get to ER, confer with the emergency physician, assess the patient, get a CT scan and labs, explain the situation and drug (and it’s dangers) to the patient and family, and get their understanding, and approval (or refusal) to give it.

Those three hours become a very frantic, fast-paced blur. It’s even worse if the patient gets to ER one hour after an event, meaning I only have two hours to work with.

And with that background, I now present tPA – A Play, which was performed this weekend at local hospital.

Our play opens in ER, where our hero, Dr. Grumpy, has just arrived. The patient is an elderly gentleman with abrupt onset of speech difficulties and right-sided weakness at noon. He got to ER at 1:30, our hero was called at 1:45, and arrived in ER at 2:00. He hurriedly examined the patient and met with the wife, and then discussed the risks and benefits of tPA.

(Curtain rises)

2:15 p.m. Dr. Grumpy: “What are your thoughts about this treatment, or any other questions?”

Mrs. Smith: “Let me call our children.”

Mrs. Smith then whips out a cell phone, frantically calling people all over the country, leaving messages on their voice mail, then calling back to see if they’ve picked up their voice mail yet. Dr. Grumpy wanders back to nurses’ station to review labs.

2:22 p.m. Nurse says wife wants Dr. Grumpy to come discuss this with the patient again. Because of the stroke Mr. Smith is unable to speak or understand speech, but Dr. Grumpy attempts to do so anyway. He reminds Mrs. Smith of the urgency of the situation. She continues to make phone calls. Dr. Grumpy goes back to nurses station.

2:28 p.m. Mrs. Smith reaches a daughter, and tries to explain situation to her. Then gives cell phone to Dr. Grumpy to explain to daughter.

2:29 p.m. Daughter becomes hysterical and asks to talk to her mother again.

2:31 p.m. Mrs. Smith hands phone to Mr. Smith, and tells him to explain his symptoms to the daughter. The unfortunate stroke patient can’t speak, just stares at phone, saying nothing. Dr. Grumpy leaves the room to keep from breaking down, again reminds wife of urgency.

2:35 p.m. A four-minute attempt to get Mr. Smith to talk to daughter on cell phone ends, with no decision. Highlight was when Mrs. Smith turned up the volume on the cell phone, figuring that might help patient understand daughter better. The look on Mr. Smith’s face makes it apparent he’s suddenly regretting his choice of spouse.

2:38 p.m. ER volunteer says wife wants Dr. Grumpy to come back and explain to patient for second time what is going on. He good-naturedly attempts to do so. Mrs. Smith repeats everything Dr. Grumpy says, screaming loudly into patients ear, hoping that will help. Again reminds wife of urgency.

2:41 p.m. Parents of screaming child in room next door ask Mrs. Smith to stop yelling at Mr. Smith, as it’s upsetting their child. She goes into their room to argue with them.

2:43 p.m. Mrs. Smith starts making more phone calls. Dr. Grumpy reminds her of urgency.

2:46 p.m. Mrs. Smith somehow decides that the reason she can only reach voice mails is because the cell phone reception inside the hospital is poor.

2:47 p.m. Dr. Grumpy goes back to see if Mrs. Smith has made a decision. Discovers she’s absent from room.

2:49 p.m. Dr. Grumpy and nurses stand at window, incredulously watching Mrs. Smith walk across the street and get in line at a Starbucks, still frantically dialing phone numbers.

2:55 p.m. Mrs. Smith gets a coffee and starts coming back to ER. She walks in front of an oncoming ambulance, which slams on it’s brakes and swerves to avoid flattening her. Mrs. Smith goes over and pounds on the driver’s side window to cuss out the driver, arguing with him in the middle of the street.

2:58 p.m. Mrs. Smith attempts to enter ER again through ambulance entrance, which only opens for a paramedic or hospital ID. She frantically knocks and waves at the paramedic who she just finished cussing out. They get into another argument about which of them needs to pay better attention.

3:01 p.m. Mrs. Smith finally finds way back to patient room, asks nurses to call Dr. Grumpy.

3:03 p.m. Mrs. Smith says she’s made a decision. She wants to do whatever Dr. Grumpy thinks she should do. Dr. Grumpy informs her that he is not going to do anything, as the tPA window has closed.

(Curtain falls)

Doctor Grumpy is a neurologist who blogs at Doctor Grumpy in the House.

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