I started the neuro rotation on the stroke service with one other student; as with other services and other rotations, each of us had a few patients to see in the morning and were expected to present to the attending and the residents on rounds–i.e., give progress updates, report on physical exam findings and lab/imaging results, and formulate a plan for management for that day.
In addition to these typical med student duties, we also accompanied the team for “stroke alerts” which came through the teams’ pagers. When someone comes in and it’s thought that they’ve had a stroke, one of the most important questions to ask is whether the patient can receive intervention in the acute setting, in the form of tPA (tissue plasminogen activator, which breaks down blood clots). There is a very structured approach to answering this question, and the process is executed as quickly as possible–“time is tissue,” as they say.
In order to determine whether the team can give tPA, the patient is immediately sent down to the CT scanner to get imaging that may help diagnose the type of stroke–put simply, whether his/her symptoms are a result of a bleed (hemorrhagic stroke) or compromised blood flow to the brain (ischemic stroke). Ischemic stroke patients can be given tPA if they meet certain criteria, while hemorrhagic stroke patients can’t receive it at all (if you’re already bleeding, tPA would make you bleed worse). While the patient is in the scanner, the team gets background information such as the time when the patient was last seen normal, medical conditions and risk factors, and current medications. At some point during this process, the patient is examined using the NIH Stroke Scale protocol to get an idea of the severity of their stroke; a score that is too high may prevent the team from administering tPA. Usually, the patients are then admitted, and the stroke team orders labs and imaging studies to figure out what caused the stroke. The team also starts medications to lower the risk of another stroke, which may include a baby aspirin and/or Plavix to prevent clot formation, antihypertensives to start lowering blood pressure, or a statin to manage cholesterol.
Sometimes we’d admit or get pages about people who hadn’t actually had strokes; there were one or two people who had weakness due to hypoglycemia, a man who had trouble with balance due high blood levels of one of his medications, and a patient who had symptoms that may have been secondary to extreme stress. The latter is a phenomenon typically called conversion disorder. Which brings up an important point–don’t ever tell a patient that his/her symptoms are “psychosomatic,” or get a psychiatry consult without telling him/her first, because this endangers the therapeutic relationship and makes the team’s work that much harder.
In addition to all of this, there were a number of aspects of my time on the stroke service that made me feel like a true part of the team. I gave a few presentations on topics that I found interesting or that the team suggested for me–thankfully they were brief with no powerpoint slides required! The residents sometimes had me lead the discussion about the current treatment plan or new lab results with patients I was following, and I also had to call a few family members and outside hospitals for information about their care. I was present for a family meeting where my clerkship director expertly delivered the grim news that a patient would not survive his stroke. I saw another interaction in which a patient admitted that she had been under intense stress which may have manifested itself as stroke-like symptoms. One of the attendings we worked with, a neurointerventionalist, even invited us to the OR to observe angiograms and Wada tests being performed. All in all, this service was a great learning environment and a fantastic way to kick off the rotation.