Emergency Medicine Journal Work May 2026

James ran through the ROSIER score: 5 out of 10 – high probability of acute stroke. Crucially, the wife confirmed symptom onset exactly 52 minutes ago. That put Mr. Patel within the 4.5-hour window for thrombolysis, but only if the CT head was clear of haemorrhage and the team moved fast. The stroke team was paged. But the radiology department had just called a “red alarm” – the sole CT scanner was occupied by a major trauma patient with a possible pelvic fracture, and the next slot was 20 minutes away. James faced a decision: wait for CT or consider transfer to a neighbouring hyperacute stroke unit 12 miles away.

James calculated: Door-to-needle time would be 82 minutes if they gave alteplase now. But giving thrombolysis before transfer to thrombectomy carries bleeding risk if the clot doesn’t move. emergency medicine journal

Meanwhile, the nurse recorded a blood pressure of 205/110. James recalled the 2024 EMJ guidelines: BP >185/110 is a relative contraindication to IV alteplase unless rapidly controlled. He ordered IV labetalol 10 mg push. As the labetalol took effect (BP 168/94), Mr. Patel suddenly became agitated. His left arm began jerking rhythmically. The monitor showed tachycardia to 120. Junior doctor Sarah shouted, “Seizure?” James shook his head – the movements were focal, but the patient’s eyes were deviated to the left, and he was unresponsive. James ran through the ROSIER score: 5 out

The decision was shared with Mr. Patel’s wife, who tearfully agreed to both – “Do everything.” Patel within the 4