"There is a fracture. I need to fix it."

That's our new go-to phrase in the NCCU when dealing with any other service. Those of you who don't know where it came from, watch this, and then read on. (Note: the video will only take three minutes and twenty-two seconds of your life, and you won't regret it.)

The new patient came in late in the evening, after I'd left, from an outside ED. The folks at the ED had done everything right, from a stat CT to offering TPA for his stroke symptoms (which he and his family refused) to doing a 12-lead EKG. It was the 12-lead EKG that caused the trouble: without TPA, there was nothing our services could do but watch and wait to be sure his stroke symptoms didn't get worse, but he was also having a heart attack.

Oops. Well, crud. That's below the clavicle.

So we transferred him to cardiology, because, well, you don't want neurologists and neurosurgeons managing your myocardium. I mean, I'll happily give you all the oxygen and aspirin you can suck down, but I'm really not a heart kind of gal.

A few hours after he'd left my unit and gone to the CVCCU, I got a call from the resident.

Heart Gal: Hey, I'm the resident in the CVCCU, and I had a question about Mr. Jones. How do you know he had a stroke?

Me: Beg pardon?

Heart Gal: Well, you know, he never got an MRI. How do you know he had an acute infarct?

Me: Symptoms.

Heart Gal: But he never had an MRI. How do you know he had a stroke?

Me: His left side went weak and his speech got slurred and his palate wasn't elevating equally. His stroke scale score was 5.

Heart Gal: But...but...without an MRI, how do you know there was an infarct? I mean, how can you tell that there was a stroke without an MRI?

Me: One quick question for you: have his symptoms resolved, or is he still weak and ataxic on that left side?

Heart Gal: He's still weak and ataxic, yeah. But I don't see what that has to do with it. He didn't have an MRI, so you can't tell if he had a stroke, right?

Me: Um. (thinking hard, trying to figure out how to explain this to HG, who's a very nice person as well as an excellent cardiologist) Well, y'know, we don't generally *do* MRIs on people who present with symptoms of an embolic stroke. They take a long time, so we go by symptoms so we don't lose any time in treating with TPA. And Mr. Jones and his family didn't want TPA, so we figured we'd do an MRI once he was stablized. How's his heart, by the way?

Heart Gal: His heart?

Me: Yeah, his heart. We sent him over there with a troponin of 3; how's his heart?

Heart Gal: Oh, it's fine. I'm just trying to figure out how you knew he had a stroke.

et finis