Stroke Patients Face Life or Death Decisions


Stroke patients across America face a potential life or death decision that may affect the quality of the rest of their lives. Most of the time, however, they are not even conscious when the decision has to be made so that their wishes cannot be assessed by emergency medical technicians on the scene.

When given within the “golden hour,” the first 60 minutes after the onset of an acute ischemic attack caused by a blot clot, the clot busting drug called tissue plasminogen activator (tPA) has been proven to decreasing mortality while reducing long-term impairment from the after-effects of a stroke. Unfortunately for the 795,000 Americans who suffer a stroke each year, only five percent of the nation’s stroke patients receive the tPA within the golden 60 minutes. Almost 130,000 people die from strokes each year in the United States alone.

Studies have shown that tPA and similar drugs may have a decreasing positive effect for up to four and a half hours after the stroke. After that, there is an increasing risk that the clot-busting drugs can actually cause brain bleeds that, in one percent of the cases, have resulted in death. The delays in the administration of these anti-stroke drugs are related to the fact that only specially equipped ambulance teams are able to administer the drug safely. In a German pilot study, the ambulance team included a neurologist, a paramedic and a radiology technician. The ambulance was equipped with a CT scanner, an on-board point-of-care laboratory and mobile computer system linked to the hospital’s telemedical system.

The high-tech computerized “crash-cart” is necessary to help caregivers distinguish between an acute ischemic stroke and hemorrhagic bleeding resulting from a previous head trauma. The distinction is important because, while the clot-busting drugs can save a stroke victim’s life, and may speed a full recovery, they can also kill patients suffering from trauma induced hemorrhagic bleeding.

This puts caregivers into a double-bind dilemma. Most emergency medical teams do not have an on-board CT scanner, let alone a neurologist riding along for the simple reason that the dispatchers can only dispatch the equipment they have available at any given time. A standard ambulance costs $125,000 for the vehicle itself. Fully equipped, that standard ambulance costs around $300,000. A fully equipped ambulance specialized for stroke care will cost $1.4 million. No jurisdiction can afford to equip all of its ambulance teams in this manner. If the specialized “crash-cart” is not available, the patient will have to be treated traditionally, without tPA.

At top, German demonstration project stroke unit. Above, the interior of the ambulance. Note the doughnut at the back of the van is the CT machine.

Even if the “crash-cart” were available, dispatchers would not know whether or not to dispatch it because they would have no way of knowing whether or not the victim was suffering a stroke. Most people recognize the symptoms of a heart attack.  Many people do not recognize the symptoms of a stroke and, by the time the patient passes out from the stroke, everyone is in crisis mode. More often than not, such cases get called in as heart attacks.

A further complication is that strokes do not always happen all at once. The onset of the symptoms can be so gradual that it can take hours before the victim, or those around the victim, realize that they have a medical emergency. This means that an emergency medical team would have no way of knowing whether or not they were within the 4.5 hour window within which tPA treatment makes good sense.

It is not easy for non-medical observers to identify a stroke. Symptoms include sudden numbness, tingling, weakness or loss of movement in an arm or a leg, along with sudden vision changes, trouble speaking, confusion, inability to understand simple statements, walking or balance problems, or a sudden, severe, and unusual headache. Many of the same symptoms are also present, however, with a heart attack.

If the victim is conscious, one of the best ways to distinguish between a stroke and a heart attack is a victim interview. If the patient cannot add up a list of simple numbers, repeat a social security number, or any other simple mental task, the chances are that it is a stroke rather than a heart attack. Another giveaway is the absence of chest pain, but many heart attacks do not present with chest pain, so that distinction may not be reliable

Once the stroke has been identified as such, the question then becomes what to do about it. In a widely cited survey, Dr. Winston Chiong, of the University of California at San Francisco, found that 23.8 percent of 545 respondents reported that they would prefer not to receive tPA in the event of a stroke, compared to 24.1 percent who said they would decline CPR in the event of a sudden cardiac arrest.

Respondents cited fears of reduced functionality, reliance on family members for care, and loss of earning ability as reasons for not wanting tPA. Among physicians, there is a similar reluctance to use tPA treatments due to the risk of complications that increase after 4.5 hour mark is reached. If the patient is uncommunicative, it is difficult for physicians to ascertain the risk factor associated with the treatment.

Between patient reluctance and physicians’ concerns, it is not surprising that this potentially life-enhancing treatment regimen is only used for five percent of the stroke victims that receive treatment. Given the high cost of a fully equipped “crash-cart,” the chances of one being available when needed are very slight. The small risk of an adverse reaction, however, dissuades many people from seeking what could be a game-changer in terms of the severity of the recovery from a stroke.

Within the four and a half hours during which tPA treatment makes the most sense, there is minimal risk of adverse reactions. After that point, there is a one percent chance that a stroke patient who might otherwise have lived might die after receiving tPA. That one percent is what gives doctors pause because of the legal ramifications as well as the medical ones.

By Alan M. Milner
Look for me on Twitter:@alanmilner

Daily Digest News
American Heart Association

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