| December 30, 2005
What do you do when you come across “expert” witness testimony that is so bogus that it makes you sick? Publicize it.
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This transcript is 37 pages long. This site of outrageous testimony picks out less than 1/3 of a page. The doctor lost. Doctor Schroeder (who lost) “remembered” 2 years later that he was worried about a siezure instead of a stroke and that’s why he didn’t administer TpA in the time window. Shouldn’t he be embarassed that it appears that he conveniently “remembered” this detail, not supported by anything in the chart. The supposedly dishonest expert destroys that contention. Also, the doctor had malpractice insurance, but his insurance company went bankrupt due to – wait for it – financial mismanagement (some maybe criminal). This feature at the AAEM site is not about anything other than intimidation. Most doctors won’t testify in a malpractice lawsuit even when the malpractice is clear. Most doctors know an incompetent colleague and will take no action even as limited as talking to that colleague. Spare me the BS.
Dr. Tony, you read the entire transcript. If someone arrived by amulance with the symptoms described and a family that insisted that they thought it was a stroke, how long would you wait before getting the CT scan?
A CT scan would be done as soon as possible. However at my large community hospital it is more than likely that we would be entirely full. That person would be waiting at the ambulance entrance with 4-5 other ambulance patients mixed in with the other 25 patients in the waiting room, all of which think that their problem is the most urgent. The wait for the CT scanner would be 1-2 hours. The good news is that it doesn’t matter. tPA for stroke is one of the biggest treatment frauds ever perpetrated by a drug company and a few advocates. The scientific literature of tPA and stroke is probably argued more than any other topic in emergency medicine, and frankly, most are convinced that the risk/benefit ratio is not in favor of administering. In addition the criteria and barriers that have to be overcome have never been applicable to the emergency department setting.
If Elliot knew anything about this topic he would realize that this physicians testimony os so outrageous and false that he should be stripped of his medical license and the court case declared a mistrial.
That’s BS. You should be stripped of your medical license. tPA has its limitations, but noone is arguing that it should not be administered. It’s use in non-major centers is debatable because it is tricky, but this was a busy urban hospital. It sounds like yours is too.
Elliot, this post, and I presume the AAEM website, was not meant as a discussion of the merits of the case or a defense of the doctor’s actions, but as a comment on the quality of testimony of this expert. Regardless of the merits of the case or how atrocious or not the care was by the ER doc, the testimony by the “expert” was crap.
Here it is, as stark a contrast as you can imagine.
I say with NO medical training that tPA is useful, that it rvolutionized thinking about stroke, that it fostered a national education drive so that stroke symptoms could be recognized early. There are limitations, and perhaps it was overhyped, but tPA should not be withdrawn from the ER.
Anonymous says that the issue is hotly debated and the consensus is that tPA should not be administered. He doesn’t think it is appropriate for the ER setting. He is a working doc supposedly.
VOTE. I really do want to know if this comment board supports my position or Anonymous.
What part was “crap”? He didn’t say that he administers tPA 3-4 times a week. He said that he sees patients 3-4 times a week that may be having a stroke. He sends them for CT scans promptly I assume. He calls tPA a “magic bullet”. For the people it helps, it is. I think that is probably somewhat hype, but it’s really not out of the realm given the revolution in stroke treatment tPA introduced. He doesn’t correct the question about “all available sources”, I think that is a very weak attack. He cites his sources and it is generally true that the available texts at the time and many (if not most) ERs had flowcharts on the wall about when and how to administer. The hospital Dr. Schroeder worked at had tPA and used it. Dr. Schroeder chose not to so I don’t think that this is at all relevant. Finally, you have one factual error about borad pass rates. I think you are wrong. The site is about impugning the testimony and intimidation. It’s relevant that the facts in the other 36 pages of testimony are damning to Dr. Schroeder. It’s relevant that Dr. Schroeder potentially testified to a whole bunch of “crap” in his deposition.
anonymous 1 Elliot 0
The tPA debate has done more harm than good.
Ignoring the fact that the preceding six thrombolytic stroke trials were negetive (harmful), subanalysis of the landmark NINDS data showed that most of the benefit was for those in which treatment could be initiated within 90 minutes (which makes you wonder what proportion are TIA’s and would get better with nothing). Their data showed that giving it within protocol showed about 12% chance of improvement over placebo with a 6% chance of hemmorhage which is often fatal.
In the NINDS protocol patients were analyzed by a stroke team and CT scans were read by a neuroradiologist. This is impractical. I work at a very busy community hospital with over 80,000 patient visits/year and we can not even come close to meeting the criteria. In seven years of practice I have administered it zero times. The 3 hour window can rarely be met. The neurologists have not bought into it and will not participate in the ER panel call (liability risk?) and the scans are not read by dedicated neuroradilogists.
I am surprised at you elliot. You are always harping about economics. What is economical about promoting a very expensive drug, that for the most part is impractical or impossible to deliver and has little, (if any or even harmful)proven benefit when aplied to the population and medical practice. Good stroke care to prevent long term morbidity and mortality is basic stuff — optimizing oxygenation, blood sugar levels, appropriate work up for etiology, risk factor modification, cheap aspirin, rehabilitation, swallowing evaluations, etc…….
I am not saying that I would never find its use appropriate but I would much rather face a lawsuit for not giving it, rather than giving it, based on the available data and current practice settings and limitations. You have fallen for the hype.
Well said jerry
Elliot you are an idiot. Stick to law. As someone who has SEEN the effects of TPA (not just for CVA’s but for hemodynamically unstable saddle PE’s) I can safely say that I would be hard pressed to use it again. I also work in a large community hospital and can say with the window, to get a stat read by a neuroradiologist and a neuro opinion within the window is difficult at best.
Elliot 0“Anonymice” 2
“I say with NO medical training that tPA is useful, that it rvolutionized thinking about stroke, that it fostered a national education drive so that stroke symptoms could be recognized early. There are limitations, and perhaps it was overhyped, but tPA should not be withdrawn from the ER.”
“VOTE. I really do want to know if this comment board supports my position or Anonymous.”
I wonder how much genentech has paid to infiltrate and lobby the American Heart Asociation?? Even though I am a board certified ER doc the contract we have with the hospital requires us to keep a certification in ACLS. I was flabbergasted at how they have successfully infiltrated the chapter on stroke when I took the last certification course.
What pipe dreams and false hope preached as gospel.
Elliot 0, anonymous 3
Wow! I am surprised to find not one doc stepping up for tPA. I truly did not realize it was so controversial. Perhaps I was taken in by the hype, but, on the other hand there appears to be a bit of an intramural fight between ER docs and the AHA. I found particularly interesting the follow-up study from Cleveland recently published that shows that you can be taught if you would just try.
I have given tPA twice only this past 10 years just because the ER and Dept of Neurology have the protocol and the agreement to administer it. I was not a doctor who prayed, but I prayed and hoped that they would not be the ones to die with the complication of brain hemorrhage. As expected, there was no improvement in the outcome in these 2 cases both male and in their 40′s. My VOTE is NO.
Elliot are you talking about the recent study done by neurologists at three hospitals? Certainly community neurologists have not done enough on this. Could it be because they understand it is more hype than hope or a desire to remain asleep at night and not be on ER call panels.
Or are you talking about the Cleveland 29 hospital study in 2000 that was quite dismal, in fact alarming? No control group, 15% incidence of ICH (half fatal), lots of protocol violations. Majority of patients probably done at the larger teaching hospitals within the group, etc….
It is quite amazing how people keep viewing this as a “magic bullet” when a mountain of evidence says otherwise.
Regarding the AHA. No doubt good intentions are involved, but you would be very naive to think that sponsorship money has not influenced its outlook. Medicine should be practiced based upon objective scientific evidence that is available. The twisted evidence and hype around tPA use in stroke is mind boggling in face of the evidence when it is viewed objectively.
Of course study after study is now showing PCI to be superior over thrombolytic in acute MI so genentech needs to peddle its drug and influence somewhere else.
Elliott said, “I had not realized it was so controversial.” That’s because it isn’t. None of the practicing ER docs I know are supportive of using TPA for stroke. NONE. Not controversial.
I’m sure the fact that Genetech payed for a new building on the AHA campus didn’t affect their decision. Hmmmm.
I will have further comments regarding the “crap” in the testimony.
The original study:
The follow up:
including several of the original authors.
I abhor TPA. I too am a Board Certified ER Doc. Now if a patient comes in having an acute stroke, I can be sued for giving TPA (“He didn’t explain the risks well enough”) I can be sued for delayed treatment with TPA (“We Don’t care if there were 75 patients in the ER, that’s Irrelevant”) and I can be sued for withholding TPA (especially since most insurance companies would prefer settling out of court when the outcome in question is a life changing stroke). I’ve never seen it work, I saw it kill the Fire Chief of my city (He bled to death in his brain, in front of his entire department). What really pisses me off about TPA for stroke is it makes us ER docs call Neurologists for EVERY mild Neuro symptom, so in case it turns out to be a stroke, we can make them share the blame and legal responsibility. (I find myself and my colleagues calling Neurology for patients with vertigo, “in case” it’s a cerebellar stroke) We never used to do this, and it adds to the clogging of our ER’s. All because that “clotbuster” is on our shelf.
Illuminating discussion. Thank you. I can see where ER docs hate the drug. It’s a burden. There’s a risk of lawsuit. The brain bleeds happen right in front of you if it’s going to happen. The 3 hour window is oppressive.
On the other hand, it works (when appropriately administered). It absolutely changed the way people thought/think about stroke. It has opened up new avenues of research to expand the 3 hour window.
Regarding Dr. Tarlow’s testimony, I don’t think it any more remarkable than Dr. Schroeder’s and certainly does not deserve the level of scorn directed at it, but I can see how it would anger the ER docs here.
Perhaps further research will render the question moot, but I hope that the ER docs will think more in terms of how to improve outcomes than saving their butt from a lawsuit. Why? (like a broken record) only improved outcomes will decrease your overall lawsuit risk. I think that means doing triage better, having a protocol, and better education.
BTW. Ariel Sharon received the drug for his recent stroke.
“On the other hand, it works (when appropriately administered).” Elliot on TPA
The message we’re trying to tell you, Elliot, is that the study that Genentech is touting is flawed. And this drug kills. Every ER doc has seen a “CVA” patient who recovers without this drug in a few hours.
“BTW. Ariel Sharon received the drug for his recent stroke.”
Your point, Elliott? Maybe he got the drug BECAUSE he’s Ariel Sharon, not because it was appropriate. From what I read, he had a TIA, not a stroke.
Elliot, I’ll be happy to administer tPA to you when you check in for stroke. We sure will miss you.
Elliot, this is the last time I will ever waste time on you. Your links are to the study that was absolutely abysmal in regard to outcome. The follow up link is to an abstract that shows that they decreased ICH rate and protocol violations but does not prove that it worked.
It has not been shown to improve outcomes, that is why we don’t use it. Stop with the “fear of lawsuit” “don’t want to try” “protocol” bullshit.
Maybe his doctor was from Hamas.
I doubt it. News reports said that he was improving prior to arrival and shortly thereafter. They said he recieved blood thinners (I would assume aspirin and/or plavix?) The reports I read made a generic statement about tpa saying that “doctors generally have a 3 hour window in which to administer it” but do not report that he was actually given it. Someone who is improving rapidly in front of your eyes is not the person you would adminster tpa to and risk an ICH. In the case of Ariel Sharon that would be called an assasination attempt, for other folks that would be just plain attempted murder. On the other hand you might have to be the Prime Minister or President in order to feasibly get a work up within 90 minutes. (NINDS data showed most of the improvements were in those patients treated within 90 minutes — perhaps because many were really only TIA’s to begin with)
Busted. Genentech and the AHA
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