And sometimes you do know...but not what you're doing.

Follow up to the previous post.  A much longer narrative, sometimes a bit technical.  Happy ending, though.

What could've happened.

And sometimes you do know which ones you help, however surprising it may be.
The night after I posted the last post the following happened.

I was called at 1:05 AM by the junior doctor about a patient 'gasping' which, here, usually means their heart has stopped already; I was pulling my pants over my pajamas before I was off the phone and sprinted at full speed to the hospital (about 100yds).

I arrived to CPR and, fortunately, a heart monitor already hooked up behind them showing ventricular fibrillation ('Vfib').   He had arrested shortly after arrival (he only managed to say, "I've been having chest pain since 8 PM" before his heart stopped) and only 5 minutes had elapsed - all with good quality CPR.  I grabbed the defibrillator paddles, pausing only to put a little jelly on them, and said, "CLEAR" and .... Ka-Thump.  We really do it just like TV.  We promptly had a rhythm back and, shortly thereafter, a pulse.

Next an ECG confirmed a large heart attack (a 'widow-maker' sized one).  Exam revealed total flaccid paralysis and almost no brainstem function, but, despite the appearance of brain death, you have to wait: it can take a while for everything to 'reboot' after a full cardiac arrest.  We confirmed details with the family and began streptokinase to try and reopen the artery.*

Over the next 20" or so the patient began to move a little (hooray!) so I returned to the bedside to repeat the neurologic exam.  He was moving his right arm, but not his left.  (that's not good..) He had blink reflexes on the right but not the left (oh no...not again).  It appeared he was having a stroke - and you'll recall from my last post that the biggest risk of streptokinase is a massive hemorrhagic stroke.  I shut off the infusion of streptokinase - he'd received 30% of the dose.

Over the next hour or so, as various bits of his system began to come 'back on-line' (he could sit up and try to pull out his nasogastric tube) it became clear he had profound left-sided paralysis.  I was afraid we had two in a row.

But...it was just a bit too quick.

I asked the staff if anyone had noticed any weakness before he collapsed.  Most said no, but one had noticed that he hadn't seen him use his left hand.  We asked the family if they'd noticed anything; sure enough, he'd had trouble walking and complained of weakness in the left leg before arriving.**

Now I was upset.  Not because our medication had harmed another patient, but because I had no CT scanner to confirm for me whether his stroke was a blood clot (which could helped by streptokinase) or a hemorrhage (in which case streptokinase would kill him).  I couldn't risk the latter.***
We stabilized him and I eventually went home at 4 AM.

I arrived on the ward the next morning to check on him and from the door saw his left arm in the air.  He still had some weakness, but his paralysis was almost 90% better.  His ECG was also improved.  We had, with 30% of a dose of thrombolytics, accidentally fixed both a heart attack and a stroke we didn't even know about.



*For any of you medical types who know that recent CPR is a relative contraindication for thrombolytics, the risk benefit ratio is generally considered positive if CPR is less than 10 minutes. Given the size of the MI, we felt the risk worthwhile.  Angioplasty is not available here.

**An illustration of Benson's rule #4.  The family didn't know the symptoms of a stroke and didn't think it important.  
    Now you medical types know, simultaneous stroke and heart attack make you think aortic dissection.  He had equal blood pressures in both arms and no murmur.  That was the best I could do given our limitations.

*** primum non nocere means, 'First, do no harm'.  

Finally...yes.  We're seeing a LOT of heart attacks.  Currently about one big one each night.  It is winter, but it also represents a move away from infectious disease toward 'non-communicable' disease in the developing world.  With developing world governments (in some places, anyway) having to focus less on simply feeding folk, they are able, with the help of the WHO, to create massive programs to treat things like TB.  Don't imagine TB isn't an issue any more - it's still #1, but with Bangladesh's economic improvement, we're having more and more 'first-world problems' like heart attacks and diabetes.