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Preview: Comments on: WSJ on Stroke: TPA is a wonder drug for stroke!

Comments on: WSJ on Stroke: TPA is a wonder drug for stroke!



Ramblings of an Emergency Physician in Texas



Last Build Date: Sat, 02 Dec 2017 13:18:31 +0000

 



By: brandt delhamer

Sat, 11 Jun 2005 02:55:57 +0000

The comments offered here in response to the WSJ piece have demonstrated in spades what we should all already appreciate as EPs-that tPA is an arrow in the EM quiver, to be used judiciously and with serious consideration of the risk/benefit ratio before committing your patient and yourself to this potentially disasterous therapy. Having trained with Dr Grotta I can assure you that his appreciation for the role of EPs in treating stroke is unquestioned and I suspect that his comments to the WSJ author, when taken in full instead of in part, would reflect this attitude. Speaking for my training program specifically we were accustomed to seeing at least one to two stroke patients nearly every day, often outside the window and ineligible for tPA anyway. Many patients did receive the lytic, however, and I have personally seen all of the described outcomes, from complete resolution to partial improvement to no improvement and needing intra-arterial tPA to intracranial bleed causing death. However, this may not be the case at every academic training program, let alone the average community ED. Despite the somewhat abrasive tenor of the article we would all have to admit that, thanks to gruntdoc, we and those whom we have communicated with about the article are all more aware of the way the lay media present the issues; which is to say fairly biased-not that anyone is surprised by this. My 2 cents.



By: Goat Whacker

Fri, 20 May 2005 17:08:12 +0000

ds - Having worked in thatched hut ER's myself yours sounds a little worrisome. Most patients with mild or ambiguous enough symptoms to warrant sitting in the waiting room wouldn't qualify for TPA anyway. If someone with CVA symptoms is sitting watching Desperate Housewives you've got a triage problem, or if you are too busy to see such patients promptly you have a staffing problem. As far as "who pays" if sued, I would guess the lawyers would go after the hospital plus any doctors named on the chart.



By: ds

Fri, 20 May 2005 02:15:18 +0000

So here's the question. The "thatched hut" community hospital I've worked in developed an "institutional policy on tPA for stroke". Thus far, almost every patient that would have qualified since the "institutional policy on tPA for stroke" was instituted has sat in the waiting room so long they no longer qualified. So many Stroke Victims have vague symptoms, and you can only "bring right back" so many chest pains, R/O CVA's and suicidal patients. Welcome to 20th century overwhelmed Emergency Medicine. #1: How do you explain to a family that Grandpa doesn't qualify for TPA cause he was sitting in the WR watching "Desperate Housewives" while time went by, and #2. Who pays? The Hospital or the ED Doc? If its a double coverage ED, do both docs get screwed or just the one that was stupid enough to pick up the chart?



By: A MD

Wed, 18 May 2005 23:00:20 +0000

LOL. You sure know how to ask em, GD. Here's what I think: We'll presume, in addition to the details in your question, the ED doc is the "average" ed doc in a community hospital. Family med residency, seen quite a few strokes, not so many acute strokes, saw tPA given a few times, never given it himself. We'll assume the hospital has no written institutional policy on tPA and stroke. He has not had much of a relationship with the stroke guys at the big academic place, and is not precisely certain what they offer etc. I think this is the scenario you're looking for, right? I would say there is very little he can do, where tPA is concerned. There is now very considerable evidence that giving tPA outside of a formal stroke program (that is able to closely approximate the clinical trial milieu of NINDS) can result in disastrous results. That's the reason why organizations like your ACEP etc have come out strongly saying EM docs should not be faulted for not giving tPA if they are not in an appropritate setting. There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical practice when systems are not in place to ensure that the inclusion/exclusion criteria established by the NINDS guidelines for tPA use in acute stroke are followed. Therefore, the decision for an ED to use intravenous tPA for acute stroke should begin at the institutional level with commitments from hospital administration, the ED, neurology, neurosurgery, radiology, and laboratory services to ensure that the systems necessary for the safe use of fibrinolytic agents are in place. That's the sound of your behinds being covered, guys. Still, this still leaves that nice ol man lying back in Rm 10. What will I do if I were the above doc? Well, I'll first do what all EM docs do better than anyone else. Assess the patient for any emergency and make sure he's stable. I'll get a good HPI. I'll do a solid exam, ie. the usual + making sure that he does seem to have a pronounced neurologic deficit that is referable to a vascular territory that makes sense, and is of a general size/severity as to warrant consideration of lytics. I'll then head back to the nurses desk, and pull out one of those tPA list type things and tick off as many as I can. We'll assume no contraindications on the list (if there are your case ends here). I don't really do the NIHSS, so I skip that bit, and pick up the phone to call Mr. Stroke Guy at Big Hospital. I'll say "I have sitting here Mr. Nice Ol Man, who I think has a stroke. His story is ______. His main findings on exam are _____. Labs _______. I didn't do the NIHSS, but he does have a big stroke. Our hospital doesn't have a policy of offering tPA for stroke. I'm just wondering what you guys might be able to offer? The timing of patints arrival is______, soonest we can get air transport is _____, etc. Do you guys do any 6 hour IA stuff, etc? I just want to know the options before I speak to the fmly." Head back to the Missus. Give her the basic stroke talk. Then talk to her about this "clot busting drug you may have heard about". This part is very important, so I explain very carefully what the data show about its risk:beneit ratio, why its important that this drug not be prescribed simply to anyone who walks in etc. I tell her what options are available, now that there is approx 1:45 minutes left on the clock. She will ask why cant I "just give the tPA here". I'll explain that this drug is an uncommon, complicated treatment. The company ads on tv tend to stress only one side, but every single one of the studies have shown that there is a bad side in increased brain bleed risk. Becuase the balance is quite fine, it is best for the drug only to be administered by a special team who have experience in optimising the treatment. We do n[...]



By: Goat Whacker

Tue, 17 May 2005 23:51:26 +0000

I did a little poking around - it looks like this is still the current position statement from the AAEM: It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke. An interesting point/counterpoint on the issue: http://www.mja.com.au/public/issues/180_03_020204/letters_020204_fm-6.html and another, this looks a bit older: http://www.emedhome.com/features_archive-detail.cfm?FID=29 Feel free to clean up my links, I'm not good at them



By: DrTony

Tue, 17 May 2005 22:33:29 +0000

I wrote these posts (here and here) before I saw this post by GruntDoc. How well they match up. Great job GD.



By: GruntDoc

Tue, 17 May 2005 06:00:05 +0000

A MD points out, correctly, that all drugs have downsides. Granted. Aspirin can cause GI bleeds, can contribute to excessive and sometimes life-threatening bleeding. However, it's one thing to prescribe a cheap drug with known but acceptable side effects (rare is the ASA induced lethal GI bleed) but it's entirely another to push a drug with a 6-9% (at best) complication rate. I suspect we could go over this forever, and agree on separate points but not agree it's a terrific drug. I am entirely OK with that. An aspect of stroke treatment I'd like to engage you in, though, is the 'Stroke Center', and whatever to do where a lot of America lives not near a 'Stroke center', in the Hinterland. What should the EM doc, alone in an already busy ED, do with a 'Classic Witnessed Stroke' (no complications, let's make this fairly straightforward) who arrives in the ED 45 minutes after onset? A CT can be obtained within 30 minutes (after blood drawn) and is read by teleradiology within 10 minutes of completion with a faxed report within 15 minutes. (No info about the rads quals, just like most docs practice). It's two hours to get the patient transferred to a 'big center' by helo, minimum. No neurologist on staff, but several IM docs who are helpful, and you could get one to come in if called to help. So, what to do? Forgo the TPA because transfer takes too long? Go a it John Wayne and do your own exam, history, and give TPA while readying the transfer? Explain to the family that there's a drug they'll sue the ED doc for not giving, but as you cannot get to a Stroke Center in time, so they aren't eligible? This is where many ED docs live and work, and their patients arrive. What to do?



By: A MD

Tue, 17 May 2005 03:39:35 +0000

PS. GD, I may be missing something, but it seems to me that you and Greg don't have to agree to disagree, because you both agree. You're both saying candidate patients should be encouraged to make an informed decision. (Except when it comes to parents, LOL).



By: A MD

Tue, 17 May 2005 03:32:16 +0000

Gruntdoc: Good post. What you say about why EM docs do not like TPA is very true, and I commented on that sentiment in my first post. I remember being a bit puzzled about it very early on, because their objections seemed rather more earnest than you'd expect from a disagreement about interpreting the data. But if you go down to the ER and stand in an EM doc's shoes, you begin to see things from their perspective very quickly indeed. It can be very difficult to prescribe a drug which you usually see either doing nothing or else killing your patient, even if you intellectually understand that the overall mortality is unchanged etc, etc. The argument that there is a difference between giving a drug that directly kills (which, make no mistake folks, is exactly what TPA can potentially do) as opposed to letting a patient die of his stroke, also has something going for it. However, with this particular argument, one has to thread lightly - for aren't most of our drugs that way? Aspirin can directly kill some people too. The difference with tPA of course lies both in the numbers (the frequency with which this happens), and in the dramatic way in which it happens - but no one should mistake that tPA alone behaves like a double-edged sword. Far from it. I am a strong advocate of letting docs on the front lines - whoever they are, EMdocs or neurointensivists or stroke specialists - decide on their own whether they are going to give tPA in a given patient. No lawsuit that you read about in the papers annoys me as much as some of the tPA related ones. It takes a great deal of hubris to argue that papa would have lived "if only Dr. EM had given him tPA". Now, I do think that each stroke patient deserves consideration (of whether tPA should be given), ie. I have a problem, based on the data, with a prospective decision to not ever consider the use of tPA in any patient, but once a decision is reached, second guessing the guy in the trenches is very poor form. Lastly, about the numbers used in the first post. These are the numbers found in the original NINDS paper for the Barthel index. As most of you know, the NINDS trial used four different methods to measure outcomes - I like to use the Barthel figures because they are easier for most folks to understand (as compared with, say, talking to them about the NIHSS scores). However, do note that if you employ the summary estimates from meta-analyses (the most important is Wardlaw's Cochrane review), your figures are going to be lower (because the other thrombolytic trials did not have outcomes as good as NINDS). I have no argument with using the NINDS data as the basis for my decisions as opposed to summary data from meta-analyses (which is what I think should usually be done), because there is clear heterogeneity between the trials - the other trials used stroptokinase, or enrolled up to 6 hours post, for example. The validity of the NINDS result was, IMO, affirmed by the Ingall/O'Fallon reanalysis.



By: GruntDoc

Tue, 17 May 2005 02:46:23 +0000

Greg, We'll have to agree to disagree. I have had the chat with BOTH my patients who were candidates, and explained it all. I didn't bias it, and we made a gropu, informed decision. And, when it's my parent, I know. No TPA.