Clock

Only one of my call nights so far has been particularly eventful, but it was intense. I was working up a consult (vertigo vs. syncope) when we got paged at around 5:30pm. The woman was found unconscious at a bus stop at 2:30 and brought to the emergency room. She was worked up for coma which most often suggests a metabolic abnormality or intoxication. To get coma, a lesion has to hit bilateral cerebral cortices, bilateral thalami, or the brainstem. Usually, only a global cause (infection, electrolyte problems, drugs, hypoxia) can do that damage.

However, the ICU team receives normal labs and begins thinking about other causes of coma. They call us to evaluate for stroke. The call resident sees the patient and rushes back reporting that she thinks it may be a basilar artery stroke - nearly the only place that an embolic stroke can cause coma by hitting bilateral vertebral arteries.

Upon hearing of an evolving acute stroke, the residents sprang into action. It was dramatic. The patient was about 3.5 hours out from baseline. Treatments for acute strokes are highly time-dependent. Intravenous tissue plasminogen activator (tPA, a "clot-buster") can only be given within 3 hours. Intra-arterial tPA is given within 6 hours, but a basilar embolus of this size was not a good candidate. The last alternative is embolectomy, sending the patient into surgery where an interventional radiologist pulls out the clot. This is limited to 8 hours (but often extended in basilar clots because they are so serious).

The one person who can do this intervention at San Francisco General Hospital is out of town. We begin putting into motion everything needed to get her over to the main UCSF hospital. We call the admitting neurology team there, get an interventional neuroradiologist, fire up the operating room, assemble the anesthesiologists, identify the nurses, prepare a critical care ambulance, contact the durable power of attorney, hold a family meeting, fill out the paperwork.

We need to get this woman into the operating room as soon as possible. Every minute is brain tissue lost. She went from a perfectly functional woman taking public transportation to a completely unresponsive unconscious person likely going to die from brain edema and herniation.

Unfortunately, what eventually happened was the durable power of attorney declined the intervention. We felt this was an appropriate interpretation of the patient's wishes and an ethically and legally valid decision. We put in a ton of work and in the end, we withdrew life support care from the patient the next afternoon. But our job as the medical team is to give patients (and their legal decision makers) the ability to make decisions about their care. This is just the way life and death go.