At about 9:40 last night we had a guy come in with a stroke. He was young (64), in decent health, and had an absolute certain time of the event occuring: 9 o'clock on the dot. 9 o'clock when he said "Urgk!" and collapsed to the ground with loss of speech and total flacidity of his right and leg. In one way, it is the stroke presentation that I always fear and hope to avoid. All the factors he pressented with--exact recent time of event, good health prior to event, youth, and a sudden life destroying loss of speech and motor function--make him a good candidate for TPA. Which, in turn, puts me on the horns of a dilemma. Because TPA has the potential to reverse the effects of the stroke, but it also has the potential to cause bleeding--and while I can handle bleeding in the gut, I can not handle bleeding in the cerebrum. The risk is compounded by the fact that in the event of a good outcome (approx 12% chance) no one says a word, but in the event of a bad outcome (6% chance) some jackhole malpractice lawyer had 18 months to cull through all the possibly available medical history to find a single possible contra-indication that should have been ppicked up on by me in the rapidly closing 3 hour window of opportunity. I start the process by ordering a STAT CT Head (and calling the CT tech to make sure she gets the F'ing message) and starting the talk with the fiancee about TPA. Then I call the radiologist--except I don't because no one at NightHawk radiology is picking up the phone. Then I try to call this guy's PMD. Because it's a Saturday night at, now, 10:20 I get the entirely uninterested in being helpful on-call guy who, frankly, is not just useless but also a prick. A do a little more fruitless phone calling while I check the XRay (unreadable) and re-assess for any change in his neurologic function (none.) Eventually I get in touch with the guys kids. A son and daughter who live thousands of miles away. Well, does a pair of kids trump a 5 year fiancee in life and death proxy decision making? I agonize over this for a few minutes before the daughter announces that she has the durable power of attorney. Asking her to fax it to me seems a bit extreme, and to be honest I'm glad to have an unambiguous answer to what might have been a stick legal/ethical issue. The two kids really grill me about TPA, but they are obviously understanding the gravity of the situation and all their questions are very apt. All this time I'm wondering when, if ever, I'll get my CT report. The odds are against me because I happen to be waiting for another patient's CT that has taken the better part of 4 hours to be read. But all of a sudden the report come in and it is negative for bleed. Okay, I check the clock--11:40--and tell the kids I need a go-or-no-go directive. They say go, and I tell the nurse to draw up the TPA. We need 75 mg and in the ED MedSelect we have 2mg--enough for a embolic stroke in a 29 week preemie. Great. Pharmacy is called, a resident is dispatched, and at 11:58 we start the TPA bolus. So, we made the 3 hour deadline. I watch anxiously as the TPA runs in and really, theres nothing more boring than watching IV fluid run--even if there is the chance of a horrible intrecranial bleed in the cards. After an hour I am so relieved to be able to document that nothing has happened. Yes, yes, it would be nice to be able to say that I had helped this poor guy, but it is no exageration to say that my ability to pay the mortgage and feed my family may well depend on whether this guy bleeds. Malpractice is all about outcomes, not practices. I call his daughter to report the mixed news and then I go on with my night. Much ado about nothing it appears: the statistics show that if 12% of the time you get a good outcome, and 5% of the time you get a bad outcome, then over 80% of the time nothing really interesting happens. Because of the bad risk profile of TPA (1 in 20 bad outcome, limited time within which to act/gather information, etc.) a lot of ER docs just refuse to give it. Most of us look for excuses not to give it; I know I do. Part of it is the whole Primum Non Nocere thing--but that precept is often just a fig-leaf for moral cowardice. And, you carry higher medico-legal risk for acting than you do for finding an excuse not to act. My basic feeling is its a difficult, uncomfortable, risky thing to do--but that's the job I've chosen. Someone has to accept the risk, and every now and again it's going to be me. It's just shitty that that's how our malpractice system works. So, the punch line is that about 2 hours after the TPA the guy said "Yeah....", then "No." and, a little later he looked at the nurse angrily and said "Look!" So maybe we did a little good. In any event the nurse was relatively young and did a great job with this difficult case. Very good. U-561