I guess this really shouldn’t irritate me, except in light of the fact that we had four sequential codes in the ER today, the urgency of this case escaped me. Basically a nice older lady in a personal care home with 5 minutes of facial droop totally resolved. Physician appropriately called. Patient appropritately transferred to ER for evaluation. Son promptly notified, and informed that the patient is back to normal, even as she sits in her bedroom.

Patient arrives in the ER, smiling, says she feels fine, but basically can’t give any reasonable history, just smiles and entertains her family. Family is kind & patient. Son sees me at the desk writing orders for patient not breathing next door. I explain to them that I could look for a pillow for his mother, but it would delay my evaluation of their mother for another 20 minutes if I go to look for one before coming into the room. He invites me in without the pillow.

So it’s clear she’s had a TIA (transient ischemic attack), in which, by definition, the patient has returned 100% to baseline. “Clot busters” clearly not indicated. I explain to the family my plan for workup, excuse myself to take a phone call and come back to the room.

The son casually asks, “Isn’t there a shot she’s supposed to get?”


It takes me longer to explain WHAT the “shot” is, WHY it’s given, WHY it’s not given, and why it might KILL their mother if I give it.

I’m all for education of the public regarding early stroke warning signs, but get very grumpy when the family wants “THE SHOT” (that might kill her). Please, people. This is my job, this is what we do here in the EMERGENCY ROOM. We have been trained when to reccommend “the shot” and when to not.

For all who are wondering, “The SHOT” is a thrombolytic drug (“clot buster”), that not only prevents future clotting, but DISSOLVES existing clots. Sounds like a good idea until you consider the fact that our body is constantly doing a fine job on it’s own of balancing the clotting process between too much and not enough. One of the real risks of the clot buster, whether it’s for your heart or your brain, is causing a brain or intestinal hemorrhage.

Furthermore, it’s only idicated for people who present within 3 hours, with potentially debiliting symptoms (hand numbness is not debilitating, whereas full sided body weakness is), who do not have any one of a number of absolute and relative contraindications to it’s administration.

What is ironic about this whole story is that while I was explaining to the family why I would not give her “THE SHOT”, there was a patient 3 doors down who GOT THE SHOT, after a tele-consultation with our friendly neighbor neurologist. That’s the first time in my career that I’ve been in the department, let alone had a patient, in whom “THE SHOT” was indicated, despite the fact that I have treated many hundreds of stroke and TIA patients.

Bottom line, if you think you are having a stroke, call 911, do NOT drive yourself to the hospital or call your friend/wife/mother/daughter. Call 911. We’ll give you “the shot” if you need it.