Years ago I sat in a room full of doctors with an unsolvable problem.
The emergency department physicians were tasked with shaving time off their already fast and furious stroke response. For those like me who got their M.D. from watching medical dramas on television instead of attending medical school, a stroke is when blood flow to the brain is interrupted. This can happen for one of two reasons — some sort of blockage (this is called an ischemic stroke and it’s most often caused by a clot) or a brain bleed (called a hemorrhagic stroke).
The symptoms of ischemic and hemorrhagic strokes are identical, but the treatment is vastly different. For an ischemic stroke, the patient may be given a drug called tPA which breaks up the clot and restores blood flow to the brain. However tPA is the last thing you would give a patient with a hemorrhagic stroke, as it would cause increased bleeding and make the situation much, much worse.
Fortunately for these doctors, their hospital had exactly the resources needed to tell the difference between the two — a head CT to spot bleeding in the brain and something called a CT angiogram to find any clots.
Enter the radiologists with the bad news.
A CT angiogram requires injecting the patient with an iodine-based material called contrast. Most patients tolerate it just fine — a little poke, maybe a strange metallic taste, and that’s about it. For anyone on the verge of renal failure, though, contrast could fry their kidneys. It just so happens that the population most at risk of kidney failure — the elderly — is also the population most at risk of stroke.
There is a blood test that indicates if a patient’s kidneys are at risk, but the emergency physicians could not spare the precious time it took to get the lab results — not when every second counts. The radiologists, aware of the urgency, could not sign off on something that could potentially go against every physician’s credo to do no harm.
The discussion went around and around, each side making impassioned arguments and no one budging. Finally someone exclaimed in frustration, “I don’t know how we’re going to solve this when we’re both right.”
It was as though the room turned into a CT scanner and you could see the mental gears start turning. With that comment the group realized all at once they had been trying to solve the wrong problem. This wasn’t a question of either treating the stroke or saving the kidneys; they needed to figure out how to do both. They agreed to get the CT angiogram for stroke patients and to vigilantly monitor for kidney damage and treat that, too, when appropriate.
Last year our area K-12 schools made some tough calls. With little information and almost no guidance at the state and federal level, they had to determine whether it was safe to hold in-person classes during a global pandemic.
They knew upending routine and minimizing socialization could cause our children emotional and psychological harm. But the risk of an untreated stroke was greater than an overloaded kidney, so many of the schools closed or limited access to in-person learning.
Addressing the most urgent need first was the right call. But doing the right thing came with a price, and we now have an obligation to address the repercussions. So far we have failed to provide comprehensive mental health screening and services to our kids — in part because we have always failed in that arena due to a scarcity of resources nationwide. We didn’t help our situation, though, by spending so dang much time arguing whether the virus or the mental health was the real emergency.
We didn’t monitor the kidneys during the unpopular but necessary shut downs. Now we’re facing our children’s reentry into the big, scary world which will be just as jarring and potentially even more difficult for them. We have got to get on the same page and come up with a plan to get them through it.
After all, this was never an either/or problem — it has always been both.
Jade Stellmon set sail for athree-hour tour on the Palouse in 2001. She is now happily marooned in Moscow with her spouse and five children.