Sitting in a Tin Can

Pushing tPA feels a lot like coordinating a space shuttle launch. There's such a long checklist to work through before this powerful clotbuster can be administered -- and the drug is so dangerous that if any contraindication is found, the show's off.

The other day, our little corner of the ER sounded like mission control:

  • The patient's family reported that stroke onset was within our three hour window.

  • The medical record revealed no recent surgeries or history of intracranial bleed.

  • The nurse noted the systolic blood pressure had fallen below 185 mmHg.

  • The radiologist phoned in the negative head CT results.

  • The neurologist confirmed our patient's weakness and lopsided smile weren't improving.

  • The emergency medicine resident emerged from behind the curtain to proclaim, "guaiac negative!"

  • And we were go for tPA.

    The only difference is, compared to the fire and noise of a NASA launch, the stopcock and syringe of tPA is a little anticlimactic. Ten percent of the drug goes in as a bolus, then the remaining 90% as a drip over an hour.

    During that hour, the neuro resident made arrangements for our patient, upstairs in the stroke unit. I went back to seeing other patients.

    When the tPA drip ended, as the nurses set up the portable monitor, I checked in again on our patient. Her pupils were still equal and reactive , but her left side was still weak. As far as I could tell, the medication hadn't done any harm, but didn't seem to have done any good, either.

    I wheeled her out of the department, into the elevator, and we glided up to the unit. Her family members rode along, silently.

    The elevator doors opened, and the neuro resident greeted us. I handed over her chart and said goodbye to the patient. Her family thanked me, and she acknowledged me -- with a bright, symmetric smile.