always 50/50......

The 70+ y/o pt was sent over by a ambulance. He was having his breakfast and later felt dizziness and he had just laid his head over the table. The restaurant owner had help him onto his car and sent him to the local rescue ambulance. He had reached our ED 30min after the incident. He was alert and initial neurology examination had revealed left eye hemianopia but muscle power was well over both limbs. I had did a quick NIHSS evaluation and found out it was 9; just slight above the requirement for tPA therapy. The brain CT was normal and diagnosis of rt PCA infarction was made. The patient is a loner and no spouse nor child was available. His nephew was on his way and it would be more than enough time to start the tPA in 4.5hr window. However I was in a stranded condition due to delay of CT(CT was done slightly more than 25min) due to chest discomfort of patient(EKG was ordered…). If this case had made it to tPA therapy list, it would made our treatment result index ugly.(we do only a handful of cases per year and any case which failed to achieve the therapy standard would down pulled the total data of the TCPI). Well, CT did not show any hemorrhage and he was definitely a candidate. The condition had worsen as his relative would be arriving late causing another violation(tPA should be given within 1 hrs of arrival in ED).

Double violations and after I obtained all the lab data and completed the check-list, I had gone to talk to the patient for a final time explaining the risk and benefit of the therapy. He had however expressed that he would not want to take the risk of intra-craninal hemorrhage and refused the suggestion of tPA therapy. A relief for me and I had reassured him that with proper therapy and rehabilitation he would recover fine. I informed the neurologist about the situation and he was admitted to ICU.

Few days later, I met the neurologist and he told me that despite of the MRI done on next day that revealed a large area of involvement of rt PCA region, his condition had however improved.

The tPa infusion sometimes worked like a miracle and sometimes…My colleague had a bad experience where the patient did not suffered from hemorrhage but still deteriorated few days later, the case had nearly ended up in a lawsuit. I always tell my patient, the possibility of an incidence to occurred means nothing to the patient, the odds of happening is always 50/50 for any incidence to occurred; it is either yes or no. Those statistic data is only useful reference for the doctor; you never know you are the 99 or the 1….

Well, sometimes, do nothing is better than do something....