moment, we simply gazed at each other, breathing in concert.

"Well, Dr. Castaldo, I am grateful that you are here," she finally said. "I know I would rather be dead than paralyzed over half my body." Her deep blue eyes stayed fastened on mine. "I put my faith in you. I know the treatment may be risky, but I am willing to take that chance."

I hesitated a moment, and she leaned closer and motioned for me to put my ear close to her mouth. "Give me the drug," she whispered.

As I straightened back up, trying to process the magnitude of her consent, I again took in the calm, trusting look on Irene's face. I must have been staring because she then gave me a gentle, crooked grin and an exaggerated wink with her right eye.

"CT's ready!" shouted Claranne from outside the exam room. "Gotta go, gotta go, gotta go now!"

"Irene, I'll finish my exam with you in a few moments," I told her. "Right now, we're going to put you into a machine called a CT scanner and take some pictures of your brain."

"Oh, I know what a CT scanner is," she murmured thickly. "Had one for my back years ago and everything turned out fine. Just a pulled muscle. Well, see you later," she said, waving goodbye with her good right hand as Claranne rolled her away.

It was now 60 minutes out from her stroke. By this time, I had put together the key pieces of the puzzle. From taking her pulse, I realized that Irene had developed an abnormal heart rhythm known as atrial fibrillation, which tends to accumulate clots in the left atrial chamber of the heart. After she left the restaurant, for no apparent reason, one of those clots had shot out of her heart and lodged in the right side of her brain, blocking off a critical artery (the right side of the brain being the one that operates the left side

Irene motioned for me to put my ear close to her mouth. "Give me the drug," she whispered. As I straightened back up, trying to process the magnitude of her consent, she gave me an exaggerated wink. "CT's ready," shouted Claranne. "Gotta go, gotta go."

of the body). Half of Irene's brain was dying from lack of oxygen, and the neurologic deficits would be permanent, and possibly fatal, if we didn't act quickly. The only approved treatment for this medical crisis was tPA.

Just then, I was stat paged to CT. It was Claranne. The note on my beeper read: "She's seizing! Get here now!" I raced to the CT room and once there learned that just as the scan of Irene's brain was being completed, she'd suddenly lost consciousness, convulsing helplessly while still in the scanner. After I arrived, her limbs continued to shake as we moved quickly to release her from the machine. Her face was contorted and frothed with blood because she'd bitten her tongue while seizing.

"Give her two milligrams of Ativan stat and let's get one gram of Dilantin rolling," I directed. Ativan is a medication that stops convulsions immediately, but its effects last only a short time. Dilantin acts more slowly but keeps convulsions

from recurring, so using both drugs as a one-two punch is usually very effective. "I've got the Ativan," Joanne announced, biting off the tip of the needle cap and shoving the needle into an IV catheter that was already in Irene's arm. "We need to call Pharmacy for Dilantin," she added. Claranne picked up the phone and ordered the Dilantin as we rolled Irene back to the ED.

"Well, so much for tPA," Claranne said dejectedly. "We all know that seizures mean you can't give tPA, and the patient is 86 to boot."

"Now wait a minute," I said as we rolled Irene down the hallway. "I'm worried about Mrs. Polosky's age, but I'm not worried about the seizure."

"You want to give tPA for stroke after she's had a seizure?" Claranne asked, incredulity clear in her voice.

I understood her concern, but I knew the tPA research literature well. I explained to Claranne that in clinical trials, people who'd suffered seizures were never given tPA because the researchers didn't want to confuse the data they collected to analyze the drug. It wasn't that seizures put patients at greater risk for bleeding, but that seizures can mimic stroke. The researchers wanted to be sure that everyone in the study had truly suffered a stroke. Still, I knew I was treading on thin ice. There was no literature at all on giving tPA after a seizure. I reasoned aloud that it didn't make sense to withhold it once we knew for sure that a large stroke was in progress and that the consequences could be dismal without the drug. I glanced at my watch, recalling once again the time of symptom onset. We still had a little leeway in the three-hour window of efficacy for the drug.

"I am absolutely sure that Irene has had a large stroke and that she might die from it," I said to Claranne.

"CT's normal," called out Joanne. "Just got the call from Radiology." Quickly, I went to the computer and called up the