Brain Attack! and other Neuro adventures

Beep, beep… beep, beep….ahh the sound of the stroke code pager. It has its own distinct ring tone and whenever that pager goes off you can’t help but get a rush of adrenaline. Time is now a precious commodity. It is the only thing standing between intervention and inaction for our stroke patient. It doesn’t matter where we are, you drop everything and run. NIH stroke scale in hand, we burst through the doors of the ED with a singular mission–determine if this patient is eligible for TPA. The clot busting thrombolytic (TPA) can be life altering if given within 3.5 hours of onset of symptoms.

I’ve spent the last two weeks on the neurology stroke service. It is fast paced and full of heart break mixed with moments of joy. When someone presents to the emergency room with stroke symptoms, often paralysis of half their body, or slurred speech and drooping face a “brain attack” or stroke code is called. The stroke team arrives within minutes and is responsible for figuring out 1) is this person having a stroke and what kind (ischemic vs hemorrhagic) 2) when their symptoms started 3) and are they eligible to receive TPA–currently the patient’s best shot at regaining function.

The saying “time is brain” has been ingrained in my head. With every minute that passes a crucial window is quickly closing. With so much riding on finding out the correct “last known well” you start to feel like a detective. The stroke team usually divides up the tasks with someone doing a complete neurological exam to find out the patient’s NIH Stroke Scale number, while other members of the team work on getting the whole story. It may sound easy but when a patient arrives in the ED without family and is too altered to answer your questions you have to start digging…this includes calling people in their cell phone, co-workers, and anyone else who might have spent time with them before their symptoms started. Team work is crucial. We all rush to gather the most information we can to make the best clinical decision for the patient.

The highlight of the rotation was seeing TPA delivered and then having the patient improve right in front of your eyes. Yes, these times are rare but so rewarding when they happen. It is also crushing when a patient is either out of the treatment window or has some of the TPA contraindications and we can’t treat. At that time all we can do is prevent another stroke from happening again…often not enough when our patient now has devastating deficits. TPA is certainly not without its dangerous risks but it is among the only things we can offer.

I’ve gained a huge appreciation for stroke prevention. The best thing we can do for our patients is optimize their preventative medications and lifestyle. The tragic consequences of uncontrolled high blood pressure or high cholesterol are a lifetime of disability. Stroke is the number one cause of disability in the US, and the number 5 cause of mortality. Seeing our patients struggle to learn how to move, talk or walk again has made me feel so thankful for all the things I am able to do that I take for granted. The last two weeks have been incredibly humbling.

When I first started neurology I really didn’t it like, mainly because the brain is so complicated and it didn’t come as easy to me as other subjects. When you have to work to understand something often our initial reaction is simply to say eh, I hate this. But I have to say, I’ve learned a tremendous amount in a short amount of time and I am starting to come around on the topic. One of the main perks of spending 12 hours a day somewhere is that you learn a lot quickly! The rotation is fairly comparable to inpatient medicine in terms of hours, usually I am there 6:30 am to 6:30 pm. However, I am no longer fazed by 12 hour days, they seem pretty normal in fact. Perhaps the best “perk” is having 3 out of 4 weekends off!

I’ve had a lot of very sad cases these last two weeks so I’ll end this post by saying be kind to your body. Watch your diet, get some exercise and find a good family doctor who is interested in helping you prevent disease. Also, never forget “time is brain”–if you even suspect someone is having a stroke get them to the ER as quickly as possible. The stroke team will be waiting.


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