Comments on: http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html medical blog Sun, 22 Nov 2009 14:15:05 -0500 http://wordpress.org/?v=2.8.4 hourly 1 By: freddy http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58172 freddy Sun, 01 Jan 2006 20:12:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58172 Busted. Genentech and the AHA<br/><br/>http://www.mindfully.org/Industry/Genentech-AHA-Connection.htm Busted. Genentech and the AHA

http://www.mindfully.org/Industry/Genentech-AHA-Connection.htm

]]> By: Anonymous http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58171 Anonymous Sun, 01 Jan 2006 18:38:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58171 "BTW. Ariel Sharon received the drug for his recent stroke."<br/><br/>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) “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)

]]> By: Anonymous http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58167 Anonymous Sun, 01 Jan 2006 02:11:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58167 "BTW. Ariel Sharon received the drug for his recent stroke."<br/><br/>Maybe his doctor was from Hamas. “BTW. Ariel Sharon received the drug for his recent stroke.”

Maybe his doctor was from Hamas.

]]> By: jerry http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58165 jerry Sun, 01 Jan 2006 00:13:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58165 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.<br/><br/>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. 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.

]]> By: Anonymous http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58159 Anonymous Sat, 31 Dec 2005 19:44:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58159 Elliot, I'll be happy to administer tPA to you when you check in for stroke. We sure will miss you. Elliot, I’ll be happy to administer tPA to you when you check in for stroke. We sure will miss you.

]]> By: Anonymous http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58158 Anonymous Sat, 31 Dec 2005 19:28:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58158 "BTW. Ariel Sharon received the drug for his recent stroke."<br/><br/>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. “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.

]]> By: Anonymous http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58156 Anonymous Sat, 31 Dec 2005 17:41:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58156 "On the other hand, it works (when appropriately administered)." Elliot on TPA<br/><br/>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. “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.

]]> By: Elliott http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58153 Elliott Sat, 31 Dec 2005 14:18:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58153 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.<br/><br/>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. <br/><br/>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. <br/><br/>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.<br/><br/>BTW. Ariel Sharon received the drug for his recent stroke. 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.

]]> By: Anonymous http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58152 Anonymous Sat, 31 Dec 2005 13:04:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58152 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. 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.

]]> By: Elliott http://www.kevinmd.com/blog/2005/12/what-do-you-do-when-you-come-across.html/comment-page-1#comment-58149 Elliott Sat, 31 Dec 2005 10:47:00 +0000 http://clients.emmense.com/kevinmd/2005/12/19702.html#comment-58149 The original study:<br/><br/>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10703777&dopt=Abstract<br/><br/>The follow up:<br/><br/>http://www.ingentaconnect.com/content/jcaho/jcjqs/2005/00000031/00000008/art00003<br/><br/>including several of the original authors. 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.

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