It's OK if Your Stroke Code Feels Like a Cluster#@$%

Leah Croll, MD


August 30, 2022

"Stroke codes are the hottest of messes." That's how one of my emergency medicine colleagues put it to me recently. And you know what? She's probably right.

The problem is that a ton of things have to happen both immediately and simultaneously. The second those stroke alarms start sounding, nurses, physicians from multiple specialties, CT techs, and pharmacists start swarming. A lot of data has to be collected, stat. And it has to be accurate — the safety of any possible intervention depends on that.

Even the most well-oiled stroke machines will cause a lot of commotion. While nursing is rushing to get vitals and good IVs, the primary team is getting the story straight. Confirming exactly what the concerning neurologic symptoms are and exactly when the patient was last at their neurologic baseline sounds easy enough in theory, but in practice it's almost never straightforward. Then there's the matter of understanding the pertinent medical history. The relevant questions you could come up with are endless. Any anticoagulation on board? History of subdural hematomas in the past? Endocarditis?

By the time a neurologist arrives on the scene, things are kicking into high gear. Neurology will want to hear from both the patient (and/or their loved ones) and the primary team straightaway. A stroke scale exam needs to be performed, probably while the patient is being rushed for a CT scan, and neurology needs to run through all the tPA inclusion and exclusion criteria so they can be prepared to make a decision once the scan is complete. The whole thing is disjointed and repetitive. It's also pretty spectacular.

Then there's another decision to make around whether or not to pursue CT angiogram and CT perfusion. It feels like it takes forever to process those images. And finally, once the imaging is done, a very fast and very crucial huddle needs to be held between the stroke team and neurointerventional radiology to determine whether or not the patient is a good candidate for thrombectomy.

That's a pretty incredible amount of ground to cover in as little time as possible. Basically, to run a stroke code is to gather complete and accurate information, perform a neurologic exam and workup, and make a series of decisions that will impact the degree of disability the patient will be stuck with moving forward. No pressure.

In the midst of all this frenzy, the patient and their loved ones are terrified and confused. If they're lucky, one of the people who responded to the stroke code is able to take a moment to explain what's going on. Those discussions are exceptionally difficult, especially because this is an emotionally charged situation for both patient and provider.

I've been involved with plenty of stroke alerts over the years, and it never stops feeling rushed and exciting and scary and frustrating. There are so many things that could go wrong or could be missed. Even the slightest difficulty with obtaining a clear history or a problem as simple as a blown IV can result in devastating delays.

No wonder stroke codes tend to feel like a total cluster#@$%. When you really consider everything that needs to get done (and done accurately and efficiently) to provide the appropriate care in these high-stakes situations, how could they not?

The chaos is understandably unpleasant for all involved parties. But in a way, that frenzied, rushed energy is encouraging. If things are feeling chaotic, it means that all the providers responding to the stroke alert not only understand how important time is in neurologic emergencies, but also understand that a lot of bits and pieces need to be orchestrated to make good outcomes happen.

A 5-minute delay could be the difference between the patient walking out of the hospital or never walking again, for example. Any missed information could be crucial enough to hamper the stroke team's acute efforts to recover communication abilities, mobility, and more.

Being stressed in a situation implies that something is at stake for you. In this case, the stakes are life, death, and disability. So really, you could consider the chaos a sign that the whole team is invested in those stakes. It's no one's favorite way to carry out patient care, but it's the best we've got for now. Let the stroke code cluster#@$% be proof-positive that people are making a genuine effort to pursue time-critical interventions for patients who really need them and really benefit from them.

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About Dr. Leah Croll
Leah Croll, MD, is an Assistant Professor of Neurology at the Lewis Katz School of Medicine at Temple University. She completed her neurology residency and stroke fellowship at NYU Langone Health. Aside from clinical practice in stroke neurology, her professional interests include education and medical media. In her free time, she is working on trying all the pastries in Philadelphia, one bakery at a time.
Reach her on Instagram @DrLeahCroll and Twitter @DrLeahCroll


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