So, as you may have gathered from previous posts, I am not a huge fan of TPA in many cases of acute stroke for a whole variety of reasons – however, one of the biggest ones is that so many people that have acute strokes are ancient. Anyone I see with a stroke under age 80 is effectively an infant (and much more deserving of TPA in my opinion owing to lower incidence of side effects, etc) in my ER. Generally in those super old people with stokes there is underlying dementia and serious difficulty in ascertaining the onset of symptoms. However, once and a while you have a fairly straightforward story and exam and solid evidence of time of onset. However, even in those cases, when you are over 90, there is a real chance of bad outcome (bleeding, etc) so I always grit my teeth when we push the clot-busting juice. Even if these folks don’t bleed, it’s pretty uncommon for me to hear about, let alone see significant improvement of symptoms.

The other day was different however. We pushed TPA on a 92 year old fully functional guy within 2 hours of onset of symptoms and BAM !, he started improving during the 2 hours he waited for an ICU bed. His aphasia improved and he lost his facial droop. For once I felt good about the decision to give it in people born before WWI. Time will tell how he does over the next few days to weeks though.

So, I often blog about drug seekers (all ER bloggers do) and recently our new state narcotic database has become a formidable weapon in our armamentarium against them.
However, just as importantly, it can help people. For example, perhaps your personality is kinda whiny. Maybe you are melodramatic or demanding. If you have these attributes, you are likely to be looked at with a quizzical eye when you come in screaming for pain meds, especially when there is nothing obvious going on and your work up is negative.
A quick look on the database can show us that you haven’t had any narc prescriptions for the last year, thereby verifying your story. Of course you could have gone to another state for them of you could be buying them on the street but I’ll give you the benefit of the doubt and chalk up your screaming, swooning, and drama to the unfortunate personality you were born with.

The reason I went into Emergency Medicine is to treat sick patients and hopefully make them better. I enjoy the surge of adrenaline and the feeling of deep satisfaction when I bring someone back from the brink of doom. It used to be that a bad attack of acute congestive heart failure afforded me just such an opportunity. Support the airway (intubate if necessary) and get ‘em on a nitro drip and blast them with Lasix. Very satisfying watching the patient start to breathe easier.
Anyway, no longer. Why? No, not because patients are taking better care of themselves and watching their salt intake. It’s because of our paramedics! They take away my chance to shine because they have gotten too good at managing it themselves in the field! Then can give endless sprays of sublingual nitro. The have 100 of Lasix. And most importantly they have BiPAP. It’s not uncommon for me to field a call from them where it sounds like the patient is going down the tubes and by the time they get to the ER, they are smiling from under their face mask asking for a urinal to diurese in! Sats that go from 78 to 98 by the time they are with me are not uncommon.
The only good thing about this is that I can fart around on the Internet for a few more minutes before I have to get off my ass and go see them….
Good job crew!