triage troubles

It is a well known fact that quite often bloggers need to rack their brains to find a topic of discussion for their daily post. That's why I really enjoy days like today, where I encountered such an amazing set of cases at work that I really don't have enough space to talk about it all.

A patient was flown in from southeast Edmonton today and found their way to our unit on an ASAP call. The history is quite fascinating - two days ago this patient (whom I will refer to as 'X') presented to a Medicenter with an earache - doctor concluded it was an ear infection, prescribed run of the mill antibiotics and sent the patient home. In the wee hours of this morning, patient started having difficulties focusing and began to receive a blistering headache. The patient went to the neighbour's house and asked them to call the health authorities because 'X' couldn't remember the number.

Patient was transported sirens and lights to the local hospital emergency where 'X' waited in triage for hours. I was reading the nurse's notes. 6:30 AM patient was stable. 8:10 AM patient began to show obvious signs that something was wrong - left side hemiparesis (weakness), left pupil fixation, worsening headache, slurred speech. By 8:30 AM the patient had depreciated considerably and was immediately sent to CT, where a temporo-occipital intracranial hemorrhage (ICH) was noted. 'X' was immediately sent to U of A hospital's OR, undergoing a unilateral decompressive craniectomy (removal of the skull bone on one side to allow a drop in intracranial pressure (ICP)).

When we received 'X', the symptoms were classical of right side temporo-occipital ICH: 'Worst headache ever' presentation, left sided visual issues, some degree of memory loss, left side hemiparesis, speech pattern abnormalities, and depressed breathing rate due to possible brainstem compression. Scans showed an obvious venous sinus thrombosis developing/developed with the midline being shifted to the left due to ICP. We don't usually do interventional neuroangiography on Thursdays, but this case so obviously needed to be fixed that our radiologists didn't hesitate to jump in.

We have this device called the Penumbra Separator which basically is a clot-sucker. We used a microcatheter and sent it up via the venous system and basically attempted to debulk the clot using the separator. Basically what happens is suction occurs to pull out the clot from the vessel, and the separator is used to poke and claw at the clot to break it up, hopefully allowing suction to remove the clot and improve circulation. We watched for about half an hour as the radiologists attempted this technique to limited success - angiography photos showed the contrast moving rather turbulently through the vessels, only slightly improving circulation through the right venous drainage. They continued this way till about 20 minutes past the end of my shift (I was so interested I stayed longer to watch), and talk was starting about possibly using angioplasty to compress the clot (they inflate a balloon to push the clot against the sides of the vessel wall).

There are a number of crazy things about this case that become very obvious. One of them is the blatant issues with our triage system, which failed to send an extremely critical patient to the CT immediately. Instead, this patient sits around until their assessment is basically in a life or death situation until they act. The patient declined from an 11 to a 9 in the Glasgow Coma Scale (GCS) on the way to the U of A hospital, a scale that measures level of consciousness. Basically, anything less than 8 is a certified coma, so 9 is as low as you can get without the patient being completely unconscious.

Second, this can happen to anyone. Patient was an adult in their mid-30s and an avid marathon runner. The doctors postulate that the cause of the clotting was because of oral contraceptives, which are known to increase the chances of clotting. While clotting can occur anywhere, it was very unfortunate that this developed cerebral-ly for this patient. The timeline is so dramatic - in two hours the patient depreciates considerably, showing that every minute counts in neurological interventions.

I'm looking forward to tomorrow - my nurse friend at work is going to tell me what ended up happening with the patient when I see him tomorrow. I can only pray that everything went well, but the sad fact is that cases like this get ignored so often due to their lack of dramatic presentation at the start of their distress. Patients complaining of headaches are simply thrown on the CT list and wait their turn. By the time the patient has declined, it may already be too late to save them. I can only hope that this patient gets revascularization to the right side of their brain with minimal brain damage occurring.