Tuesday, May 29, 2007

Some ER docs are gonna be hopping mad

….about this New York Times article on tPA for stroke. It’s full of distortions and misstatements although it makes one interesting (and controversial) assertion, which is that defensive medicine is a significant reason for under treatment of patients:

Dr. Richard Burgess, a member of Dr. Warach’s stroke team, explained the situation: There is no particular penalty for not giving tPA. Doctors are unlikely to be sued if the patient dies or is left with brain damage that could have been avoided. But there is a penalty for giving tPA to someone who is not having a stroke. If that patient bleeds into the brain, the drug not only caused a tragic outcome but the doctor could also be sued. Few emergency room doctors want to take that chance.

Through several dramatic stroke anecdotes the piece, with little apparent regard for perspective or accuracy, paints tPA as some sort of miracle drug. Here are some of the distortions.

Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator. The only drug shown to make a real difference? Wrong. Aspirin is associated with improved outcomes and reduced mortality in the first few weeks. This, in fact, is more than can be said for tPA, which does not reduce mortality.


Although tPA was shown in 1996 to save lives and prevent brain damage… Since the article contains no citations to back up its assertions I can only guess that this statement refers to the NINDS study, even though that study was published in 1995, not 1996. The study, the only large randomized trial to show benefit from tPA, showed no statistically significant reduction in mortality. The title of the NYT piece, Lost Chances for Survival, Before and After Stroke, also deceptively implies that tPA is life saving.

Concerning the evaluation of patients for tPA treatment, the article says Many hospitals say they cannot afford to have neurologists on call to diagnose strokes, and cannot afford to have M.R.I. scanners, the most accurate way to diagnose strokes, for the emergency room. Nonsense. The widely accepted guidelines for the use of tPA, which are based on clinical assessment and CT imaging, mention no role for MRI scans.

There’s more. Although the New York Times is widely regarded as a reputable source of medical news this particular NYT piece is yet another example of how scientific issues are distorted when discussed in popular media.

4 comments:

DGL said...

I read the article and I agree that there are some problems with it. But the quote that you rely on to illustrate the problem is a statement made by those working in hospitals about why they don't want to provide tPA - because they don't have MRI scanners or neurologists on call. While this may or may not be a true statement, it's not the job of the NY Times to disabuse their interviewees of their ideas. It's to report them. And that, it seems to me, is what they're doing.
To me, what's really going on is that people are reluctant to give a drug that has a rather robust potential for a potent short term downside in exchange for a long-term benefit. But I don't think withholding the drug when indicated will stave off lawsuits as one of the docs in the article suggests. The case law on this involves allegations of improper withholding and improper administration.
DGL

RoseAG said...

I wondered about aspirin when I read that article.

My thought was whether they skipped mentioning aspirin because it's something someone might take at home hoping it would all go away, and not head for the ER as they ought to.

R. W. Donnell said...

dgl,
While the NYT shouldn't have to disabuse their interviewees of misleading ideas neither should they quote them uncritically and without perspective, in a manner that misleads.

Anonymous said...

You weren't wrong about at least one EM doc:
http://gruntdoc.com/2007/05/tpa-and-stroke-2.html

GruntDoc

PS: Why the 8 digit check code?