Comments on: The drama of using tPA in stroke within the three-hour window

By: Mike Dudley

Mike Dudley — Thu, 24 Sep 2009 21:58:48 +0000

Hemdoc,
You are aware of the considerable risks and limited success when tPA is used, before the intense emergency room/stroke situation. If tPA is still a gamble you’re willing to take, good for you. Frankly, I really hope you never have to worry about it. However, most people do not have that information until they are in an atmosphere that makes it impossible for them to make a rational decision. Maybe if just some of the recourses used to inform the public about the scourge of ED were dedicated to distributing this critical information, more people could have your knowledge when they need it.

By: Hemdoc

Hemdoc — Thu, 24 Sep 2009 19:48:37 +0000

I plan to have “give me tpa if I stroke” tattooed on my forehead. I am not interested in being paralyzed; I prefer to get better or die. By the same token, I have made it clear to my family (yes, I have a living will) that, although I like vegetables, I don’t plan to be one, if a bleed leaves me marginally alive. It sure would have helped Dr. Grumpy’s disposition if his patient had made his wishes known before he couldn’t talk — I try to advise all my patients to do so.

By: Dr. Grumpy

Dr. Grumpy — Mon, 21 Sep 2009 17:43:52 +0000

If the patient is improving, they do not qualify for TPA.

By: cynical

cynical — Mon, 21 Sep 2009 17:41:02 +0000

Mike,

Your situation is tragic. Every doc that administers TPA have to read your story.

Aside, the evidence is not clear. The family/patient has to decide. How can it be any other way? The doc can’t predict the outcome for the patient. But the situation sucks. Very very smart people that study this for a living will disagree. My bias would be to never give it and let the outcome be what it is. In your case, If there was any hint of spontaneous improvement I would use that as an excuse to dismiss TPA asa treatment. option.

I agree with the pharmacist above. Many, in the fire of the moment, side with the “walk or die” philosophy.

By: Mike Dudley

Mike Dudley — Mon, 21 Sep 2009 16:00:01 +0000

NW Hospitalist,
Thanks for demonstrating my comments. A conscientious reader would understand that I am not “vilifying the medical system for giving tPA and having a bad outcome” By the way, if your family’s future hopes and dreams had been swept away, you were financially ruined, and you had to watch your spouse suffer every day until one of you dies, I doubt that you would describe this as simply a “bad outcome”
I am however vilifying the medical system for giving tPA, having a “bad outcome”, and turning their back on the family they destroyed.
A conscientious reader would have noticed that I said “She had improved from an 8 to a 4 and only 1 hour had passed.” and realized that she was quickly improving on her own. Dear God, I wish we had heard PharmNerd’s description of the very real risks vs. the marginally possible benefits!

NW Hospitalist, you seem to say that what happened to us is justified because the medical system is trying to get “more evidence that is free from bias”. Well, we are not lab rats. However, they don’t generate additional profits by destroying lab rats.(sarcasm rooted in the truth)
You said “because it is the patient who is taking that calculated risk with their life, not the doctor – I think that it IS important to have them/family make that decision” WTF? Come on, how often does a patient come into the ER medically qualified to make that decision? Oh yea, and then there is the stroke thing going on as well. Give me a break! According to you, there isn’t enough data for a neurologist unaffected by family attachment to make that decision.

Most days I ask myself, how will we get through this day? Then I realize that I am 53 and my wife is 51. We could potentially have to live like this for another twenty or thirty years. Then I pray that we both die long before that.

By: PharmNerd

PharmNerd — Mon, 21 Sep 2009 12:04:05 +0000

A few people have alluded to this, but it’s very important to lay out the risks & benefits of tPA to the patient/family. At our hospital, it’s myself, the neurologist, and the ED attending who are discussing the risks & benefits with the patients. So, the patient hears it multiple times – often from people with varying viewpoints on the drug’s actual validity (much like you see in these comments).

What I say, in a nutshell: 1 in 3 chance that tPA will probably make you better 3 months down the road. This improvement probably won’t be immediate, and may not be particularly dramatic.

1 in 20 chance that tPA will result in a symptomatic bleed, and you’re worse off (potentially dead). And that’s for the “perfect” patient. Older patients with worse symptoms, for example, probably have quite a bit higher chance of bleed — a risk that’s difficult to predict.

No matter the risk or how serious it’s described to be, patients/family often come to the decision that “I’d rather be dead than live like this, so give the drug.” Explaining that the symptoms could possibly improve over time, even without tPA, rarely dissuades them.

By: NW Hospitalist

NW Hospitalist — Sun, 20 Sep 2009 21:47:59 +0000

Oops,
Should say:
What I find most interesting in this discussion is that there is one post villifying the medical system for giving tPA and having a bad outcome and another for NOT giving it and having a bad outcome.

By: NW Hospitalist

NW Hospitalist — Sun, 20 Sep 2009 21:47:09 +0000

What I find most interesting in this discussion is that there is one post villifying the medical system for giving tPA and having a bad outcome and another for giving it and having a bad outcome.

Medicine is just not so black and white, is it?

We need more evidence that is free from bias (due to funding, statistical design, etc.) in order to make the best decisions. And we need to understand that nothing (except) death is 100% and that will NEVER know what would have happened had we made a different choice. Yes, the hemorrhage following tPA is terrible and I am sorry for your loss, but you don’t know that she would have had a better outcome without it. Maybe she would have survived at all. Everything is a calculated risk – and because it is the patient who is taking that calculated risk with their life, not the doctor – I think that it IS important to have them/family make that decision with the physician providing as much guidance as possible.

By: cynical

cynical — Sun, 20 Sep 2009 03:25:09 +0000

Mike,

I am so sorry. This promotion of tpa is one of the most flabbergasting things I have seen outside of undercover ACORN videos. I don’t know how? I don’t know why? Genentech money?? Neurologist zeal to want to try and treat a devastating disease?? The press for promoting some type of magic treatment??

One neurologist in one of our community hospitals went gung ho on this initially and a third of the ICU became brain dead patients on vents.

It is very hard for the truth to get traction. And in the meantime ER docs are getting sued on both treatment sides.

By: Mike Dudley

Mike Dudley — Sat, 19 Sep 2009 19:07:47 +0000

My 50 year old Wife had a stroke while getting ready for work about 18 months ago. I called 911 and she was in the stroke clinic very quickly. Unfortunatly, the Neurologist recommended that they give her tPA to speed her recovery. Both her and I were scared and of course said yes to the treatment. She had improved from an 8 to a 4 and only 1 hour had passed. After they gave her the tPA, they sent her to critical care for obsevation. It’s a long story, but briefly, she was moving both arms and legs when she got the tPA and as the day progressed, I noticed she was getting worse. I kept telling the nurses she was getting worse. They said it was just the resut of her getting tired. Late that night I went home for a little sleep. Soon after I fell asleep, I was woke up by the police telling me that I need to get to the hospital, they need my consent to do emergency brain surgery on my wife. The tPA had cused her to bleed in her brain and the pressure was killing her. I made it there and the surgery to stop the bleeding was succesful. Now, after 18 long months of therapy, 500,000.00 dollars worth of medical bills and constant depression, crying, and the realization that our lives are over, my Wife is parilyzed on her left side, she has left side neglect, left side vision split, and short term memory problems. Because she got tPA, our lives have been ruined forever! I am sick of reading about how great tPA is! Check the facts. Many of the people that get tPA for stroke, recover no better than they would have without it, and it causes about 6 percent to bleed like my wife. Roughly half of the people that bleed die. My wife often says she wishes it would have killed her instead of having to live like this. It makes no sence for the doctor to ask for your consent to give tPA, you are most likely not even close to being qualified to make that decision, especially in the crtical and emotional situation you are in. It is absolutly agonizing for me to see my wife suffering like this. Except to help my wife dress, bath, eat, go to the bathroom, etc, I really feel like I have nothing to live for anymore. My grandchildren? Not really, the kids, like everyone else, avoid us whenever possible. I love my wife so much and, in my opinion, we had a perfect marrage. Now, not only have my wife and I lost everything that we had together in terms of our marrage. I lost my job. I worked for a small company that has a self insured health care benifit. Yes, the economy slowed down, but during the slow down, they implemented rotating layoffs. I was not part of that. My position was eliminated. In the last benefit meeting I attended, they showed the medical claims paid out for last year. Our claims were huge in comparison. I can’t prove anything, but I worked there for over 30 years and I know how things work around there. Recent new management has a very comprehensive profit plan and the CEO is always talking about health insurance. The slow down made it easier for them. The list of problems that tPA has caused goes on and on. Many in the health care system are quick to endorse this very expensive and highly controversial drug. However, when they destroy an entire family with a single dose, they are quick to turn their back on them while they reap the huge additional profits the resulting carnage has generated. They seem to be saying that because tPA has helped a few people, the total devistation that we have suffered is justified. If this had happened to their wife and their family, I believe they would have a much differnt opinion. I would never allow anyone I love to recieve tPA again, NEVER!