Practitioners’ Corner Look Out for Zebras William Davison, MD email@example.com It was a quiet Saturday morning in the ER in a semi-rural area 75 miles north of Tampa. The shift had just be-gun when the EMS radio crackled with notification of a “stroke alert.” EMS was transporting a 48 year old female who had gotten up that morn-ing neurologically intact and suddenly developed aphasia with right sided hemiplegia. She and her husband had just arrived into town to stay at a local golf resort. Upon arrival, the patient was placed in one of the largest ER suites. We greeted her and the above story was recounted by the paramedics. The patient was unable to speak but was fully awake and in touch with everything going on. She had a look of fear and concern on her face. No doubt she was suffering from an acute ischemic event which caused the aphasia and right sided hemiplegia. Her mild tachycardia would easily have been explained by her anxiety. However, it became very clear some-thing else was also wrong when her pulse oximeter reading was found to be in the mid 80s even on the face of mild tachypnea. Such a picture could probably be explained by a number of things but her tachypnea, tachycardia, hypoxia, and low blood pressure argued for an immediate concern for pulmonary em-boli (PE). She also had symptoms of an acute cerebral vascular accident (CVA) that needed to be evaluated. A quick trip to the CT scanner revealed a normal brain scan but massive pulmonary emboli. The explanation now became more apparent: she had pulmonary emboli as well as an acute CVA, almost certainly connected to the shower of emboli. Although hypoxic, tachycardic, hypotensive, and anxious, we explained to the patient that we needed to treat her stroke symptoms and her PE. We went over the various possibilities as quickly as we could. However, it seemed like the best answer was treatment with tissue plasminigen activator (TPA) for both the PE and CVA. The hospital had a TPA protocol for PE as well as another one for stroke. We chose to use the PE protocol as it would also incorporate treatment for the CVA. The TPA was administered and by the end of the hour, the patient had regained her speech as well as her ability to move her right side, although still weak compared to normal. The HCMA BULLETIN, Vol 63, No. 4 – November/December 2017 27 pulse oximeter had improved to the high 90s and her hypoten-sion had disappeared. The success story was continued as she was moved to the ICU completely free of all stroke symptoms as well as effects of her PE. Ultrasound evaluation showed large deep venous thrombosis (DVT) in her right leg and the patient was maintained on heparin. Echocardiograms revealed her suspected atrial septal defect (ASD) which explained the acute episode. After several days of total body ecchymosis, the pa-tient was transferred to a tertiary care hospital for closure of her ASD by interventional cardiology. This case brings up several questions as to whether immedi-ate transfer to tertiary care would be the best alternative. In the face of an acute CVA where time is paramount to saving brain cells, and the patient with unstable vital signs, the decision to use TPA then and there proved to be the best alternative. Trans-fer to a tertiary care interventional radiology program would have delayed her treatment for at least another hour. The pa-tient and her husband understood the risks inherent in what was done and “thank God” it worked! The moral of the story - just because you are in a small hospi-tal 75 miles from the nearest tertiary care center does not mean you are not going to be presented with awesome and perplexing problems. In other words: look out for zebras even though the hoof beats sound more like horses. We all got lucky on that day! P.S. It is so nice to practice in the large medical centers where everything is available to you. It seems like, at least in my ex-perience, we see the weirdest, as well as very unusual, things in our smaller hospitals as opposed to the big ones.
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