You are working in a 15-bed rural hospital with an

You are working in a 15-bed rural hospital with an emergency department. You are the only adult-geriatric provider on this shift, and you are presented with the following case.

A distraught older female brings by personal vehicle her husband of 60 years. This is an 81-year-old male farmer/rancher who was out branding cattle when he experienced new onset headache and difficulty using his right hand. He tried to call his wife on his cellphone but was unable to speak. Instead he blew into the phone and tried to make noises with his mouth. She went to the branding site and transported him to the emergency department.

He is somnolent but will awaken with stimulation. When awake, he is frustrated and tearful. His right hand is flaccid, and he is aphasic. Your facility has a full lab, full x-ray, and CT machine, but no MRI and no neurology consultation service. You are contractually connected with a tertiary care center that is also a stroke center.

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