Sunday, January 4, 2009

Arbitrary Medicine

I brought a patient to the hospital today who was clearly having a stroke. The Cincinnati Scale was a three out of a possible three and the family was hysterical over the dramatic change that their loved one had experienced over such a short period. They wiped their eyes clear and tried to concentrate when I asked them when this man was last seen in his normal state. It was at lunch, they think. Yes, at exactly twelve twenty they brought him a ham sandwich and everything seemed fine at the time. It wasn't until four hours later that they found him slumped over in his armchair with that terrible slackened look in his face.

My heart sank as I heard the story. A possible four hours since the onset of symptoms puts this patient right around the cutoff point for a clot-busting therapy that might otherwise have made all the difference. At three hours the doctors might have made an exception, or allowed the desperate and emotional family to overpower a general clinical guideline. ...But not at four. The window of opportunity had closed and what was done, was done.

I had the patient's wife sign my paperwork after I transferred care to the hospital staff. She looked at me and gave a genuine thanks for the work I had done. Her eyes welled up as she spoke, and I could tell it took not a small amount of strength for this woman to maintain her composure. She didn't quite understand what had happened to her husband or what events had transpired that would dictate his foreseeable future, but she seemed to know enough.

The difference of an hour. I wondered later what damage it would have done if I had asked the family to perhaps reconsider what time they recalled giving this man his lunch. They had no clue what repercussions such a seemingly mundane detail might have, but I knew. I sat there and listened to it. I wrote it down on my notepad.

The TPA might never have done any good. It would in all likelihood have been a fruitless, expensive, and emotionally taxing exercise that ended with the same (or worse) end. Still, I wonder what the family would have thought if they knew the whole story. ...If they knew how close they came to the potential for a different future.

Something tells me they would have wanted to know.