Neurology has traditionally been a rather laid back specialty.  The delight of it for me is the chance to ponder the inner workings of the brain as it affects the nervous system in a systematic and reflective manner.  We don’t usually go into for the thrill of racing to save someone in a life and death situation.  In fact, at least for me, this is when my brain functions at its worst.  Thoughts begin to race, focus is scattered, and things become less clear.  However, times have rapidly changed with the advent of thrombolytic therapy for stroke.    What is thrombolytic therapy you ask?  Well essentially it means we have for the first time a way to treat a stroke, or “brain attack” by giving medicine to patients to break up the blood clot closing off the artery to their brain, causing the brain cells to rapidly use up fuel, and die.  When a person experiences a sudden numbness or weakness on one side of their body,  sudden loss of vision on one side, arrest of speech, or any of the other painless symptoms of stroke they have a three hour window in which we can save more brain cells breaking up the clot than we might lose by flooding sick cells with blood.

    This is our chance to save a brain in a race against time, and every second delayed means more brain is dying.  We have to make sure there are no recent injuries or surgeries healing in the patient. 

We have to CT scan the patient to make sure it was not bleeding, or seizure and tumor, or anything but a lack of blood that caused the symptoms.  We have to make sure they clot okay. 

We have to examine the patient quickly to determine just how severe the stroke is.

   We have to compare  the risk of bleeding into the brain, possibly killing our patient to the benefit of allowing them to talk, walk, see, or function normally in whatever way, ever again.

Then we have to sum all this up for the patient, who may or may not be able to talk, and their family, and let them make the decision, which is essentially

  Treat–>chance of dying or permanent coma–> chance of actually saving my brain and functioning normally increased, more than chance of bleeding and getting worse in general.

Versus

Don’t treat—> let the brain cells go and get on as best I can.

If myself as a physician can have difficulty thinking clearly through all of this, I can only imagine it is doubly true for patients or their loved ones. 

      This is not an easy decision.  It’s consequences are life and death, lifelong disability and chance of stopping it all together.  This is the kind of choice you could convene a family meeting and spend a couple of weeks mulling over.   When we offer it, typically the patients have minutes to make a decision, with brain cells knocking off each second they take.

tic, tic, tic

     I recall one of the first patients I ever gave this choice to actually wept.  He didn’t know what to do.  I didn’t know what to tell him.  His spouse had not yet arrived, and he did not want to make this decision alone.  It was heartbreaking.

       He got the treatment, his condition improved and everyone lived happily ever after, but I wonder sometimes, was the principle of informed consent in this instance worth it.  There are situations where informed consent can truly be an unbearable burden.

   We all want to be in control of our lives.  How in control are we in the face of terror, with our brain literally dying as the minutes go by?  How do you determine someone in that situation competent?  How can anyone comprehend all the relevant risks and facts in such a situation?  These are the questions that remain unanswered to my satisfaction.  What do you think?

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