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.

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.

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.

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.

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

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.

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.

The original study:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10703777&dopt=Abstract

The follow up:

http://www.ingentaconnect.com/content/jcaho/jcjqs/2005/00000031/00000008/art00003

including several of the original authors.

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.

“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, 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.

“BTW. Ariel Sharon received the drug for his recent stroke.”

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)