Stroke Alert on its way. Wild story. Apparently the ambulance crew was having breakfast at Allen's when they witnessed an 86-year-old woman keel over in the parking lot. Sounds like she had a big stroke just 15 minutes ago. She should arrive here sometime in the next 15 minutes. Sounds like you've got a good candidate for your clot-buster, tPA."

"Gee, I don't know, Rick," I replied. "Eighty-six is getting up there for using tPA." Tissue plasminogen activator, or tPA, had been approved by the Food and Drug Administration for treating strokes and was known to be a powerful clot-buster, but it hadn't been tested yet in patients older than 79. The drug was also known for its high complication rate—producing uncontrollable, often fatal brain hemorrhages in 6% of patients who received it.

"Going with tPA is your call, John," said Rick. "In any case, expect her here 30 minutes out from symptoms."

I hung up, excused myself from the rounds team, and headed directly to the ER. When I arrived, Claranne and Joanne, two seasoned stroke nurses, were already calling the pharmacy, the CT unit, and the blood lab to make sure they'd received the Stroke Alert page. We were a well-oiled machine, but I could still feel the muscles tighten in the back of my neck. In a few minutes, I would have to ask an 86-year-old woman for permission to inject into her veins a drug that might save her life. Or that might instantly kill her.

Minutes later, Jerry and Bill wheeled Irene in. She was bundled up like a baby, her face bright pink from breathing the supplemental oxygen. In seconds, many hands were upon her. She was removed from the gurney and placed on a hospital stretcher. The nurses quickly removed Irene's clothes and dressed her in a gown, then started another intravenous line and a Foley catheter to drain her urine. Meanwhile, blood was drawn from her forearm and sent off for immediate analysis.

I bent down toward her. "Mrs. Polosky, my name is Dr. Castaldo," I said gently. "I am a neurologist who cares for folks who have had a sudden paralysis such as yours."

"Pleased to meet you, Dr. Castaldo," smiled Irene, her gracious manner at odds with her stuttering slur. "Have I had a stroke?" "Well, let's take a look here," I replied.

As I examined Irene, I discovered that her face was densely paralyzed on the left side and that she was blind in her right eye. Her left arm and leg were also paralyzed, and she was unable to feel anything on the left side of her face and torso, or in her left arm and leg. When I asked her to move her right side, she did so easily. But when I asked her to move her left arm, she lifted her right arm. "Like this?" she asked.

"No," I replied. "Try moving this hand." Gently, I picked up her left arm and put it on her belly.

"Why, that's not my arm," she replied, slightly indignant.

"Whose arm is it then, Irene?" I asked.

"Why, Dr. Castaldo, you're playing games with me," she slurred. "That's your arm."

Carefully, I turned her head so she could follow her arm back to where it joined her body. "Irene," I asked, "can you see now that it's your arm?"

"Why, I guess it must be mine then . . ." She trailed off, confused.

"Okay," I replied. "Now that you see it's yours, can you move it?"

"Well, certainly." She nodded confidently.

"Okay," I said. "Show me."

With that, Irene picked up her left arm with her good right hand and moved it up and down to verify that it worked just fine.

The left arm dangled from her right hand like a dead fish on a line.

I knew then, beyond a shadow of a doubt, that Irene had suffered a stroke, caused by a blood clot that had somehow torn loose from her heart and clogged one of the arteries to her brain. Only a stroke can cause the kind of sudden, disabling loss of motor function on one side of the body that Irene was suffering.

My eye was on the clock. We were now 45 minutes into her stroke and our window of opportunity to treat it was quickly burning away. I imagined her right brain dying from lack of blood, while we conversed about her symptoms. I felt an overwhelming sense of time pressure. If I was going to save Irene, I needed to act fast.

I crouched down so I could talk with her at eye level, pondering how to explain "the problem" in lay terms. "Mrs. Polosky, you have a blood clot causing a stroke of the brain, and I believe it's a life- threatening problem," I said, striving for the right mix of urgency and unflappability.

"The stroke has paralyzed the entire left side of your body," I went on, "and has created a condition known as anosognosia, which keeps you from even recognizing your degree of paralysis." I took a deep breath and then made my pitch. "There is a drug that may be able to break up the clot," I told her. "But the truth is, using it is risky. It might cause a massive brain hemorrhage in the process of trying to help you. This drug, which is called tPA, is generally only given to younger patients who have had a stroke."

I looked down at my patient's open, trusting face. I owed it to her to be completely honest. "Irene," I said, "I'm worried about giving this medicine to you."

Irene looked me straight in the eye. I could see a sense of calm come over her, and at the same time, strangely, a sense of peace entered me as well. For a