Discussions

The story typically begins something like this: old mate has had a sudden onset of headache followed by partial or complete loss of motor function down one side of his body. He calls to his wife for help but the only thing that he manages to exclaim is a garbled slurry mess of non-sense. Inside his own head the words are being thought of correctly, but there is something wrong with them making their way to his mouth. He meant to say my head hurts, but all that his wife could distinguish from the slurry mess was something something my hurts.

It would seem pretty clear to most that this resembles a clear cut picture of a stroke. Not exactly a great position to find yourself in as a patient, that being said however, should you be fortunate to live within a reasonable distance of an acute neuro-endovascular or clot retrieval service, not the worst possible sudden onset medical complication to have. It is phenomenal the sort of work that neurosurgeons (or brain plumber as I like to think of them) can do. They can feed a tiny wire up through one of your arteries in your leg all the way to your brain, navigate the maze of cerebral arteries in your head, then remove any blockage sometimes instantly resolving symptoms of stroke as blood flow is restored.


And that is exactly the thought process I undergo as we cover the short distance of four kilometres to the patient and his wife’s house in the ambulance. To us, there is very little we can do to treat an acute thromboembolic stroke itself. Nothing actually. We can certainly address complications from the stroke, such as injuries from any fall at time of onset, or manage the patient’s airway and breathing should their conscious state deteriorate. But the stroke itself, no way. I would love to be able to administer medication to “bust the clot” as it is colloquially known, but there is the all too unavoidable possibility that a bleed is the cause of the symptoms, as opposed to a blockage by clot. In this case, administration of the wrong medication could kill. We can however do what paramedics do best, and that is manage the logistics of getting someone from wherever they are in their house and into the back of the ambulance off to hospital. Nobody can size up a hallway for millimeters of clearance with the stretcher by eye better than we can. It comes as a natural by-product of many, many failed attempts earlier in your career to push a stretcher into someone’s home, only to realise that a giant immovable glass vase has once again foiled your extrication plan. So here we are, not three minutes earlier I was enjoying the last of my spaghetti bolognese, and now here I am, desperately trying to power chew some gum to freshen that meaty, tomato-y breath as my partner reverses the ambulance through the electronic gate of this home. The van stops, I open my door and I grab the assessment bag and lug it in the direction of the patient’s front door. “Around the side here mate, better access to the patient!” I hear someone’s voice announce from further up the driveway. Diverting away from the front door and up toward the back of the property I see an elderly man of about seventy waving his arm about. Surely this must be our fellow. “G’day mate, my name is Dave, what’s yours?” “My son is inside with his wife, he’s the one you’re here to see.” The plot thickens. As the elderly man motions in the direction of what looks to be the living room another man in his forties materialises into view. “Hey mate, my name is David”, I attempt a second introduction, “are you the person we’re here to see?” “Yeah mate, I’m John, sorry to get you out here for nothing”, he states suspiciously clearly. And as I take this scene I, I am presented with a man far younger than would typically be expected to present with a stroke, and currently not appearing to be all that strokey for lack of a better word. He doesn’t appear to have any facial droop, he seems to be walking about the living room fine, he has a phone in one hand and a packet of cigarettes in the other so he must have some degree of comparable bilateral hand strength going on. And most importantly, he doesn’t really seem all too concerned about anything that’s going on, annoyed if anything. “Well, whilst you’re up and about, let’s get you out to the ambulance and we’ll have a bit of a chat about what’s going on”, I gently suggest. John complies. A woman of roughly John’s age follows with a much more concerning look across her face. As John exits the house I notice his left shoulder collide with the door frame before recoiling back on track. Interesting. Now seated in the ambulance, I have to attempt to work out what is actually going on here. I arrived at this scene expecting to find someone a bit older with all sorts of stroke action going on, but instead I’ve got a younger, relatively fit looking individual with no immediately obvious stroke in play. John explains that whilst they did call 000 just three minutes before we arrived, the stroke symptoms started thirty minutes before. More interestingly, they began to resolve almost as quickly as they appeared. Now well over half an hour since then, John is claiming to be completely free from symptoms. Now the picture is becoming clearer. Seated in the rear of the ambulance engaging with John, I am not completely privy to the conversation John’s wife is having with my partner outside the van. I pick up words here and there, like stubborn, stoic, and workaholic, but without any further context it’s difficult to piece much more together. As I gather a history it becomes clear that as the symptoms disappeared prior to our arrival, John became fairly resistant to the idea of someone calling an ambulance for him, much less being evaluated at the hospital. It was only when his wife confronted his Dad, who lives in the property to the rear, that John’s mind was made up for him. “I just figured that because all the symptoms were disappearing, and because they all started after I stood up after lying down for a while it was probably just a blood pressure thing. “Plus you know I don’t exactly have time to go to the hospital tonight, I have to work tonight because I got tomorrow off to go see the doctor about my cholesterol results.” Another red flag appears. I pause for a moment, preparing myself for the verbal joust that is likely to take place over the coming minutes. What is likely to have taken place in the last half an hour or so is that John has experienced a TIA or Transient Ischaemic Attack or mini stroke as it can also be known. It has all the symptoms of a stroke that fortunately completely resolved within minutes to hours of initial onset. Transient, but not without ongoing risk. And so I begin my gently scalable insistive argument as to why John needs to be seen at the hospital, despite there being next to no residual evidence of cerebral blood flow misadventure. I personally stand conflicted on how best to approach these types of discussions. On one hand you need to respect that it is the patient’s decision to choose whether or not they want to access healthcare, but on the other hand there is a very real chance of significant harm coming to him, should these symptoms return and not self resolve. Do I ease gently into it, or tell him straight up that if he doesn’t get seen at the hospital he might die? The answer is probably somewhere in the middle. I begin by repeating back the history he has given me, laying down a foundation of facts that he can’t refute because he was the one who told me them. I then begin to explain what a TIA is and, whilst not the only cause, how it would seem to be the most probable cause of today’s events. I finish by saying that the best course of action from here will always be an evaluation at the hospital by a medical team in the emergency department. “So what you’re saying is that what’s happened has come and gone, and I still need to get checked out at the hospital? Because I mean what are they going to do? Run a few tests, get me to say what happened again? Sounds like a bit of a waste of time to me if I’m already going to see the doctor tomorrow” I was prepared for this response, it is from this point that my argument has to take a darker turn. “John”, I begin in the most deliberately serious tone I can manage. “You would agree with me that it is not normal to lose motor function down one side of your body for an extended period of time, would you not.” He nods in skeptical agreement. “If you had called us at the time this all started and we had arrived whilst this TIA was still progressing, we would not wait for the symptoms to resolve. We would be taking you as fast as we safely could-” I pause and point upward in the direction of the roof of the ambulance. “-And I mean with the lights and sirens on, straight to the emergency department. And even if the symptoms resolve on the way, you would still be evaluated by the doctors there immediately. The only thing that has changed in this situation is that you have disagreed with your family for half an hour and luckily enough the symptoms have resolved on their own. I don’t want to scare you, but I need to be honest with you. You’re way below the normal age range we typically see in this job for experiencing stroke-like symptoms.” I purposefully switch the term TIA with stroke.

“The problem here is not that you had stroke stroke-like symptoms and now they’re gone. The problem here is that you had stroke-like symptoms in the first place at all. You have already told me that your cholesterol level is high, plus I can assume that you smoke too given the pack you were holding earlier?”, I don’t wait for a reply. “These are both very real risk factors for stroke, and at the end of the day if these symptoms you’re experiencing return again there is no guarantee that that will resolve. If you are at work tonight alone and the symptoms return, you may become so incapacitated that you are unable to call for help. And that is not a situation you want to be in”. I pause again here and let him process my argument. He looks over at his wife who has been listening attentively to every word I have been saying who seems to be even more concerned than she was before. “Just go with these people to the hospital John, forget about work for once in your life”. He finally caves, “alright, but I'm not lying on the stretcher.” He declares, attempting to regain some sense of control over the situation. I agree with his compromise despite knowing that if something happens on the way to hospital I will have no way of moving him from the seat to the stretcher myself. But we’ll cross that bridge when and if we come to it. And so we head off without much urgency to the hospital. I have arm twisted a grown man into doing something he doesn’t want to do, and scared his wife senseless. Convincing people to do something they really don’t want to do is certainly an art form that I didn’t fully appreciate when starting my career. People can be so wilfully ignorant and stubborn for reasons they don’t need to explain. But sometimes you just need to tell people they may end up horribly disabled if they don’t comply with your instruction, even if you don’t actually know the chances of that happening. It sort of leaves a bitter taste in your mouth when you finally say goodbye to someone and handover their care to the staff at the hospital. You can tell that they aren’t too happy with you for doing your job, but hey what can you do. The reality for John is that statistically speaking, 4-10% of those who experience symptoms suggestive of a TIA are thought to go to have a stroke within the next 48 hours. So whilst I have physically done nothing for this man since I first met him little over an hour ago, if he is one of the unlucky ones who does have a recurrent stroke, I may have done everything for him and his family.

 

Patient names have been altered to maintain anonymity