News & Events: Member Articles
When the Ray Strikes Your Heart.....Leave the Barb In
By Fred Ginsburg, MD, MBA, FAAEM
Steve Irwin was clearly a man of action. When in a tough situation the instinct was to DO SOMETHING. Thus when jammed in the chest by the sting ray's barb instinct drove him to reverse the situation by removing the barb, DO SOMETHING. However, in this case, the damage was already done on entry of the barb. The barb’s design consists of a bunch of hooks which catches, rips and tears when going out. When pulled out of you it:
- Increases the amount of damage.
- And unplugs the hole which the barb acted as a stopper.
In this case the best thing would have been “DO NOTHING”, except getting to a location where the barb can be removed under controlled conditions with the plan to repair the damage with the object’s removal.
Let's now turn that concept to another devastating process, a stroke, otherwise known as a Cerebral Vascular Accident (CVA) or the new marketing name of “Brain Attack.” A stroke develops when a section of the brain loses its blood supply. A clot can clog the artery or an artery can rupture both causing the same problem. Stroke symptoms can include:
- Weakness of one side of the body or the other, to a various degree. (Example: Losing strength in the right arm, the right arm and leg, the features of the right side of the face, facial droop).
- Loss of the ability to speak and/or understand speech.
- Loss of vision, balance, coordination.
- A brain stem stroke can even paralyze the patient below the neck.
Thus we can all agree, Strokes are bad to very bad, thus the strong desire to DO SOMETHING.
DOING SOMETHING can add its own set of problems. On presentation it's often impossible, or extremely difficult to tell exactly what's causing the problem. While a blood clot is often causes the stroke (or stroke like symptoms) it's not the only cause and one needs to consider:
- A break in a blood vessel could cause the stroke (think of a broken pipe in the house)
- A large bleed causing pressure and dysfunction of that section of the brain, often goes with:
- A tumor causing pressure on the blood supply or a section of the brain
- Diffuse plaque (think of corrosion of the household pipes) causing greatly reduced blood flow.
- Damage to the nerve supply to that part of the body, a pitched nerve, spinal cord damage, or damage to the nerves of the face “Bell's Palsy”
- Low blood sugar (an embarrassing thing to find out when the patient's already in the CT scanner and the stroke team has been activated)
- Spasms of the artery due to very high blood pressure.
- A seizure causing temporary stroke symptoms (“Todd's Paralysis”)
- Some other neuromuscular disorders such as Multiple Sclerosis or ALS (“Lew Gehrig's Disease”) can mimic a stroke
- And some folks, for some reason, TRY TO FAKE IT.
But you have to DO SOMETHING. The great SOMETHING that has generated the excitement among physicians and investors (oops I mean INVESTIGATORS, sorry Freudian slip there) is tPA for Brain (Tissue Plasminogen Activator). You've seen the commercials telling you to rush the stroke victim to the hospital so they can receive this multi-thousand dollar drug. A magical “DO” SOMETHING which promises to save massive disability and the related complications. Though, one must consider with every benefit, there lies risk, and in this case a large risk.
This drug is a super clot busting drug which should, if the stroke is caused by a clot, bust up the clot, open the blood supply the brain, thus allowing for brain function to return and save the death of the brain cells supplied by the blood supply, and don't forget, you're DOING SOMETHING.
However, there are a couple of downsides to this drug that needs to be understood before use. Explaining all these downsides in the time compressed and emotional moments during the stroke might not be the best time, so let's go over it while you’re reading this article sitting in the waiting room for whatever awaits you.
- This drug isn't an “oh well” if it didn't work drug. No this drug in this situation has a 5% chance of doing something really bad to you. Remember, this drug is designed to break up clots. Clots can be good if it's stopping something from bleeding. Since there's a chance this stroke is caused by a bleed and not a clot, stopping clotting can sure make things worse rapidly by causing a huge bleed into the brain...quickly becoming fatal. Or, maybe it just causes that stomach ulcer to start bleeding uncontrollably, or some area to start bleeding. I don't mean drip, drip I cut my finger bleeding, I mean oozing from every area you can ooze from bleeding.
- This drug has strict criteria for use which makes it very difficult to actually place into action. The first factor is time. There's a 3 hour window from “LAST TIME KNOWN NORMAL” to give the drug. That's a very tight window. This means that if someone goes to sleep normal, and wakes up with the stroke symptoms, their out of the window. If they arrive 2 ½ hours after on set, and it takes 35 minutes to get the CT scan (a detailed x-ray of the brain) and have it evaluated, you're outside the window. To use this drug the symptoms must be recognized, the other causes, especially bleeds, eliminated and the drug delivered all within a 3 hour time frame.
- Even if all the above works out, there's the real question if this is actually a TIA (Transient Ischemic Attack) where the patient recovers within the next few hours or day versus a long term severely debilitating event. Example: I was called down as part of a stroke team to see a patient who met all the criteria and was ready to get tPA. The drug was ordered and drawn up. Just as it was about to be delivered the patient woke up. The symptoms disappeared and the patient improved. If the drug was given a few minutes earlier everyone would have declared it a great success, assuming no disastrous results.
- The next issue to consider if the benefit outweighs the risk. If the deficit is relatively minor (weakness in the hand, or some difficulty speaking) the question becomes: “Is the 5% chance of a very bad outcome is worth the benefit of possible improvement?”
Aron Ralston, like Steve Irwin, is truly a man of action. At age 27 while hiking in Colorado his arm got trapped under a boulder which he was unable to move. I’m sure Aron really wanted that arm, but after 5 days with no hope of escape so he clearly decided he needed to DO SOMETHING. So he made a tradeoff, his arm for his life. He cut off his arm with a pocket knife. An extremely gutsy and what was possibly a rather painful move. He could have died from the bleeding, but the alternative was clearly worse. He survived by trading a known loss (the arm), and possibly a larger loss (his life), against the chance of saving his life. The knife, which was not FDA approved, was included free with his flashlight. You can see Mr. Ralston in the Miller Beer’s “Man Law” commercial, clearly earning a right to sit at the square table.
So a patient arrives, relatively young, relatively healthy, with a sudden onset of a stroke. The deficiency is large, right arm, right leg, inability to speak, inability to understand speech. The tradeoff huge. The tradeoff becomes a 5% risk of bleeding death versus regaining function, saving brain, and saving death from stroke complication. DO SOMETHING. Clear the way to the CT scanner, get the labs cooking, get the drug up from pharmacy and get ready to break the seal. Get that heavy duty tool in here and give this fellow a fighting chance. But the stroke could resolve on its own.
What about if he’s outside the time window? He woke up with the stroke, it could have started 5 minutes before waking up or 8 hours ago…do you consider busting protocol since this might be the patient’s only chance? DO SOMETHING? If successful it was a heroic decision, if disaster strikes you might get a call from the folks who live on the back of the phone book. What about if it’s 3 hours and 15 minutes from onset? Some folks in the know, says if it’s them use the: “Cure me or Kill me” approach. The idea being that if the stroke appears to be so severe that would leave such debilitation that it would be better to risk giving the drug outside of protocol and possibly regain function then live with the results of the stroke.
The key to all of the above is weighing the risks, and weighing the benefits and to have a strong appreciation that the best thing to do in many of these situation is “DO NOTHING” instead of looking for the potentially very harmful “DO SOMETHING.”
Now to take another extreme, the hemorrhagic stroke, “wet stroke” or simply stated, a “brain bleed.”
This dramatic tragedy often wreaks havoc beyond that of a “dry stroke.” While the characteristic one sided weakness is often part of the presentation there are multiple other elements:
- The skull surrounds the brain, and since it's made of bone, tends not to stretch. When blood starts filling the brain, it displaces brain. This might cause pressure on parts of the brain, or it might case the brain to “herniate” pushing its way down the spinal cord, a fatal blow.
- The brain is bathed in a clear fluid known as Cerebral Spinal Fluid (CSF) circulating through various structures, including the deep brain structures known as the “ventricles.” If a bleed finds its way into the ventricles, blood starts to clog the CSF filters causing a back flow of CSF into the skull, swelling of the brain, as in the above, causing pressure on the brain with ultimate herniation of the brain into the spinal cord, a fatal blow.
- Blood in the brain shows up in a bright and frightful white on the CT scan. Even a novice observer of Brain CT's can have a quick tutorial and visualize the devastation of this process.
So when the brain bleed comes roaring in to the emergency department, we go again into the “Do Something” mode. But what to do? Tpa? That would be bad, very bad. Surgery? Sounds reasonable, however for many locations for these bleeds surgery accomplishes nothing, and often makes things worse. A dramatic injury, not repairable, but DO SOMETHING!
What would you want to have happen to your loved one? A horrible injury to the brain, surgery will probably make things worse, not that they can get much worse. The family members brain is still bleeding, they might even be partially conscious or responsive, but not doing well. Do you always have to DO SOMETHING?
So let's look at two alternatives for this person's last days or even hours of life.
Would it be better to spend the last few hours of life having their head shaved, skull removed, and brain manipulated in the bowels of the hospitals operating suites or might it be better to gather family members together, have them spend the final hours with the loved one, even if unconscious. Often they are on a breathing tube breathing for them, why not allow that removed, and have the family together for this sad moment while they're allowed to pass in peace?
In many medical situations, the question always seems to be “What CAN we do.” In this discussion the view changes to the rarely asked question: “What SOULD we do.” So while taking out the barb seems like you're DOING SOMETHING, the real question becomes is DOING NOTHING what SHOULD be done?
Fred Ginsburg, MD
Academy of Medicine of Toledo and Lucas County