TPA for Stroke. Have we LOST the Plot? by Mel Herbert, M.D.

Mel Herbert, M.D. EM-Blog August 2009.  To catch more of Dr. Herbert, please visit emrap.tv.

Comments

[Bruce McLeod MD FRCP(C)]

Well stated Mel. I agree totally. Where is the family in this? My advice to them would have been not to give the lytics for all the reasons you stated they presumably they would have taken the advice. My only other suggestion is to move to Canada as the lawyers have not won here yet.

[Mark Boswell]

Based solely on what information you have produced in your video I would not be able to make an informed decision to administer Tpa or not...

Main point: You do not present the pt's physical exam findings; was this a pt with grossly affected motor/speech processes? Or was it just some minor motor/sensory problem?

Another point: I do like your statistic of 2/3 of suits are for "not giving" Tpa, however, I'd like to know how many of those 2/3 are brought successfully (IE: favorably to the plaintiff)... I imagine that during discovery at least some are deemed irrelevant and another venue or settlement is sought.

My personal opinion as to why so many suits are brought for "failure to give Tpa" is probably because the family doesn't feel that the medical community did "everything possible" to save their loved one. They, in their limited joe public thinking" probably think that they were denied some ill-perceived standard of care.

Your point about who deciding what to do or what is right for the patient is well taken. It should be a collaborative and informed decision between the provider, patient, familiy and other involved parties. But I believe, that as of today, without significant tort reform, you cannot completely ignore the potential liability/economic impact of potentially litigenous processes. They should have their respective place in the discussion.

-MB

[Tom Scaletta]

Here is what I have found to be a very useful tool to assist in obtaining informed consent -- http://www.aaem.org/education/tpaedtool-AAEM.pdf. The patient Mel described is a much higher risk (age, CT findings) and so I would let family know that risk for tPA-induced ICB is greater than what is stated on the tool.

[Paul Shahbahrami, MD, FACEP]

(1) Assuming this patient qualified for TPA, should we recommend it? While this patient may not have absolute contraindications for TPA no one knows this particular patient’s true risk of a bad outcome. However one would intuit the risk to be at least moderate if not high.
(2 It is commonplace for physicians to change their practice based on perceived malpractice risks. However, a simple conversation with family would likely satisfy their concern that everything appropriate has been done to care for their loved one. It is amazing to me still after years of practice how even a brief authentic connection with the family can pacify even the most outspoken relatives. Think about the incompetent doctor in your community that no one of you would ever trust with your personal care yet patients will defend him to the death even as they are slowly being killed by him or her. Communication is almost always the key in these situations. I can certainly accept defensive medicine to a degree as in some over ordering of tests. However in this particular case I would not provide a therapy that in my opinion has too many unknown risks for this particular patient based of any perceived threat for malpractice; communicate with your patient and family.

[djbagnoli]

ohio state vs usc, sept 12th 2009
no tpa in columbus... but we will settle it on the field

[Byron Freemyer]

The problem is not the lawyers it is our co-conspirators in medicine. I routinely hear the neurologist say to patients you have a 6 in 100 chance of bleeding, but a 30 % better chance of being normal at 90 days. This is clearly misleading comparing percent change with absolute percentages. I even heard one say if we give this to 100 patients 30 will get better. I am not aware of any studies showing this magnitude of improvement.
TPA is deeply ingrained in the belief system of a number of physicians who are controling what is truth. Take for example the American Heart Associations recommendation to increase the time for iv tpa after one mildly positive study while ignoring previous very negative trials.

[A. J. Auerbach, MD FACEP]

If, as in the case presented, there is an attending present who is willing to admit and assume care, as well as be responsible for the potential complications of the therapy, then absent gross negligence (which I don't think this involves), I wouldn't have a big problem with it. I would sign-off to the admitting attending, and document well who made the decision to administer the TPA, if I wasn't in agreement with the decision.

The problem for most of us who practice outside major teaching hospitals or Stroke Centers, is that we are the ones who frequently have to make the decision on whether to administer TPA or not, frequently with little more than phone advice from a neurologist who may, or may not be responsible for the care of the patient. In that case, as with other potentially hazardous interventions, communication with the patient, family or DPOA, etc. regarding the risk/benefit of the treatment, is paramount.

No one is immune from lawsuits, but documenting your reasoning and communication with patient/family members and consultants can go a long way towards minimizing your risk in these "iffy" cases.

[BW]

The phrase, "its his only chance" at having any kind of function for their remaining years, seems to be popping up quite frequently in our elderly patients suffering from debilitating stroke. Despite that moderate increase in the elderly of hemorrhagic conversion, I don't think this should be ignored. I hate TPA, but I have seen it work in the very elderly. A tactful conversation with family in such situations can really help with decision making when faced with such a situation. If a family can accept the possibility of a poor outcome, Id say give it.