clinic pt. 6

A very interesting case came through neuro today that I'd really like to share. An elderly individual with a sclerotic right internal carotid artery came in today for a routine stent and angioplasty. The procedure seems to be going fine - the stent is put in place and the plasty works out well to alleviate the 75% blockage, so he finishes up and the nurses begin their assessments.

Immediately it's evident that something is not right. The patient displays left side paralysis of the arm and is showing facial asymmetry. Speech is slurred, probably due to paralysis of facial muscles. Immediately the doctor begins doing some perfusion tests to see if there are any arteries that have been occluded - the ultrasound done prior to the stent and plasty showed the sclerotic plaque to be soft with no calcification and it's possible that while stenting/plasty-ing, some fat could have broken off, evaded the filter wire and embolized in a smaller artery.

After injecting contrast in various areas, it doesn't appear apparent that there is any blockade. It is very clear though that the patient is stroking, so an MR and a CT scan are both ordered, the former for its detail and the latter in case the patient is hemorrhaging.

The story has a happy ending though. Patient went down to the ABACUS for an MR and the nurses down their ran their screening protocols and the patient went from being paralytic to simply showing hemiparesis. Within an hour he was squeezing away and speaking normally so it was simply a transient ischemic attack. It is still worrisome to note that most TIAs will eventually lead to a full stroke, so while this patient is safe for today, his future is at stake. I guess when we're doing interventions we often forget complications are always at hand, especially when the patient has gone back to his room and we don't see what eventually happens to them because we are just involved in a minute but integral part of their care.

In an separate note, it often makes you wonder as to how important these elective procedures are in the grand scheme of things. My friend Shane suggested an interesting article written by the ever-controversial professed utilitarian Peter Singer, who writes about the need to ration health care; spoken like a true economist. Read the article by clicking on the image below:

The article is extremely provoking and obviously offers some ethical dilemmas but his logic is interesting, even if he is abrasive and frustrating. While I've moved strongly towards thinking deontologically, my utilitarian past still nudges me in the ribs and I sometimes find myself thinking about where he's coming from and if it's actually valid. Keep your eye out for the prostitute joke, it's hilarious.