Tuesday, September 28, 2010

Organized push back against TPA for ischemic stroke continues

And again it comes from the house of emergency medicine. The idea is to marshal overwhelming opposition among ER physicians using an on line survey. The problem is, there's only one response you can give---to agree with this statement (my italics):

“Given the controversial evidence that currently exists regarding the efficacy of thrombolytics in ischemic stroke, we the undersigned agree that a decision NOT to administer thrombolytics to a patient with an acute ischemic stroke is reasonable and within the standard of care regardless of the circumstances or the eventual outcome.”

It's a pretty strong statement. Here's the thinking behind the effort:

We get 30,000 emergency physicians to agree that "This is acceptable care. It may not be ideal in all circumstances, but it's not negligent.”

...Our legal system recognizes that a physician's practice will be deemed to be non-negligent if his or her treatment is "what the average physician, who is similarly trained, would do in a similar circumstance."

So if they get enough ER physicians to go on record in agreement with the statement they can, through solidarity and strength in numbers, sway the legal system.

I have mixed feelings about this effort. I hate seeing anything designated as “standard of care” because the whole notion is simplistic and it just gives more fuel to the trial lawyers. On the other hand, if the effort is successful, it will increase the bias against TPA among the very group of providers best positioned to use it effectively. To justify the option not to give TPA regardless of the circumstances is problematic. The findings of NINDS have been reproduced in other studies.

I've opined on TPA in some older posts. Here's my present take:

Strict adherence to exclusion criteria and usage protocol is essential.

Informed consent is important. You need to give patients and families the research data and current recommendations in plain English. This must include explicit information on mortality. That means explaining that the mortality effect is neutral and that this is due to some patients with more severe strokes having just enough improvement in their strokes to stay alive, counterbalanced by some patients dying by a direct effect of TPA induced cerebral bleeds. Families need to understand that some of those deaths may be in direct and dramatic proximity to the administration of TPA.

Consider excluding the very elderly who otherwise meet criteria.

The use of TPA in community hospitals will always be problematic until the system of designated stroke centers is much better developed than what we have now.

Putting aside the issue of TPA for ischemic stroke there's a broader perspective on this effort. While I may disagree with some opinions coming out of emergency medicine I admire their solidarity. Organized emergency medicine seems to recognize that its interests are not inherently conflicted with those of patients. So, it looks after its own. Emergency medicine, unlike hospital medicine, has several professional societies, each of which has put out numerous position statements addressing the professional interests of its members. These statements deal with issues ranging from compensation incentives to boundaries of clinical responsibility and avoidance of areas of liability. Organized hospital medicine has done none of that. In fact, they're doing just the opposite. I think that's a good topic for another post.

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