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.


Chapati said...

I don't think they'd want to know! Over-playing the 'what-ifs' in your mind must be frustrating...

Was it clear that he started deteriorating straight after lunch? He might have started getting worse an hour or two later?

medicblog999 said...

The same thought as the previous commenter, how would anyone know exactly when the onset of symptoms was, yes we can only document what the family state, by you would hope that he medics would at least air on the side of caution and still FAST scan him. Saying that though, I have read a recent piece of research that shows that TPA has a very limited positive effect on acute CVA management and may actually increase mortality and morbidity (I will try and find the link and email it to you). No matter what though, paramedics can only fullfill their responsibilitiesand get the patient to definitive care asap, the rest is up to the medics, however that may change with prehospital admin of neuroprotector agents (my service will be doing done research on this next year.

MedicThree said...

Playing with what-ifs and could haves will destroy you in this line of work.

As crass as it sounds, we have to move on.

Notice I didn't say forget. Remembering those we could do nothing more makes us try harder for those we can. Always try.

Keep your chin up and your eyes open!

fiznat said...

Perhaps I was a little too subtle in what I was trying to get across here...

I'm not asking "what if" the stroke symptoms had began earlier, I'm asking if the family might have wanted to revise their story about these events had they known what effect such a revision might have had. Did I have a responsibility to tell them that their account of seemingly innocuous time estimations might have such a profound effect on how their loved one's medical treatment? Perhaps my next patient might want the benefit of that knowledge?

This isn't "playing with what-ifs," it's a way of considering options for the development of my patient care.

fiznat said...


It isn't clear when he started deteriorating, and that's pretty much the problem. In situations like this when there is no definite witnessed onset of symptoms, the doctors will assume the worst. They will assume that the stroke began five seconds after the family left him alone, which would place this patient "out of the therapeutic window."

Of course there remains that possibility that the stroke actually began within the last hour and was noticed right away, but there is no way of really telling, and nobody errs on this side. This is why the family might have such a compelling reason to "revise" their story to me or the doctor. Perhaps if the EMS provider made them aware of the situation here, they might make a more informed decision. ...But the question is: is that the right thing for me to do? Provide opportunity and motive for a "revision of the facts," or a lie?

Medicblog999 said...

I have had the same thoughts when administering tenectaplase for STEMI, but at least with those patients you can discuss the onset of symptoms with the patient themselves. More than once my conversation has been along the lines of:
"are you sure that the pain didn't get worse in some way in the last few hours"
I have never told them that their answer could make a significant difference in their treatment. The hardest question to answer is what would you do if you were the patient?
I have always said that if I was having an MI or CVA and I was outside the therapeutic treatment window I would change my story to ensure I got the TPA, however, now you have made me think about it, I don't think I would. The times are there for a reason and if I am out of the window then the risks are now greater than the benefits. It would still suck, but there's nothin I could do about it. Maybe families and patients would feel the same if we fully informed them to make a fully informed decision.

What would you do I it was you? Would you accept the therapeutic window or would you change your story to get the treatment, even with the bigger risks?

Chapati said...

Hmmm...If I was the family and I really had no idea when he started deteriorating, I would definitely want to know if a revised time made a difference.

If I found out about this (that had I happened to see my family member was OK two hours later he might still be alive) I might get very angry.

And I'm a fairly mild person who takes death of loved ones in her stride...heaven knows what someone less mild would feel!

fiznat said...


I've said the same thing to myself many times, that I would lie about the onset of symptoms to give myself the best chance for rehabilitation. ...Especially if the situation were like this, where the supposed onset of symptoms is only *just* outside the window if I didn't lie. In all probability this patient likely was within the window, only nobody was there to witness it.

...But still, is it our responsibility as EMS providers to explain these kinds of things to family members, knowing full well that they would probably use that information to lie on behalf of their sick family member? The family probably WOULD want to know, and probably WOULD be grateful for that information, but like you said: those rules are there for a reason, and it seems contradictory that instigating a lie could be the right thing to do.

brendan said...

Something to keep in mind is that if a stroke center in your area does endovascular stroke therapy, the data is showing the window for treatment can be as long as 6-8 hours. Definitely worth finding out if any facilities near you does it.

Medicblog999 said...


Firstly, Kudos to you for such a good post. It's good to see a good discussion going on.
Here's one final dilema for you!
Let's say you do tell the family all the facts and they then change their story (this is in a case where you do know that the patient is out of the time frame).The onus would then be on the paramedic to handover the 'new' history to the docs who would then treat the patient and possibly cause a severe side effect, increase morbitity or even cause the patients death. Would we then be negligent in our duty of care to the patient?
Don't know the answer, but isn't this what makes our job so damn interesting!!!

Anonymous said...

Somehow it seems like in EMS, the family or the patient gets turned into the "enemy". Hell yes I would want to know. Most people are smarter than we give them credit for, and if they want to play dice with their health, that's their decision.