Usually I don't think poster's level of training should impact a scientific discussion. We should be able to adjudicate based on facts and logic, not titles. This is a special case, however, as we're arguing what the standard of care was in Florida in 2015. With an area of medicine changing as rapidly as thrombectomy over the last decade having the experience of having practiced 6+ years ago does actually matter when discussing something so variable as standard of care.
I completely agree with you that the we should be able to “adjudicate based on facts and logic”, I disagree with you that this case is any different, and you certainly do not need to work in Florida in 2015 to understand why, all that is required is some knowledge of stroke care.
According to the ED physician that evaluated the patient, they were “seen immediately and stroke alerted”, implying that the patient was evaluated quickly and initial work-up (blood work, CT) should have been obtained anywhere from 30-60 minutes from arrival. Unfortunately, the CTA was incorrectly cancelled and there was a significant delay in obtaining another CTA leading ultimately to a delay in initiating mechanical thrombectomy (MT), witch was started at the
same centre 3 hours after the patient was initially evaluated, suggesting the ‘error’ caused a 2-2.5 hour delay.
How do we know what the ‘standard’ of care was in Florida and in that particular centre in 2015?
The very fact that the centre was offering mechanical thrombectomy (MT). We have known for decades that earlier time to recanalization is a very important factor associated with better outcome, hence the mantra of ‘time is brain’. No credible centre would offer MT and accept unreasonable delays, you would be exposing the patient to the risks of the procedure and possible harm, without the benefit, and we know the centre is credible as it was enrolling patients into RCTs.
Was the 2-2.5 hour delay in obtaining the CTA reasonable? Should someone have followed up sooner to re-order the CTA? There was a reason that the neuro-interventionalist who worked in the centre in 2015 was not pleased with the situation, they understood that a major error occurred that was not within the ‘standard’ of care. It should be noted, I am not condoning blaming other physicians in front of patients as was described, or I am not casting blame on any single physician, but we should not deny facts.
Read the AHA/ASA guidelines from 2013:
“As with intravenous fibrinolytic therapy,
reduced time from symptom onset to reperfusion with intra-arterial therapies is highly correlated with
better clinical outcomes, and all efforts must be undertaken to
minimize delays to definitive therapy
(Class I; Level of Evidence B).”
“Intra-arterial treatment requires the patient to be at an experienced stroke center with
rapid access to cerebral angiography and qualified interventionalists.
An emphasis on expeditious assessment and treatment should be made. (Class I; Level of Evidence C).”
What did we know in 2014-2015?
So far my argument has relied on information from 2013 and prior, however new evidence emerged from 2014-2015.
Take a look at the timeline:
-October 2014 - positive results of MR CLEAN presented at the World Stroke Conference.
-December 2014 - the results of MR CLEAN published online in NEJM.
-February 2015 - three positive trials (ESCAPE, EXTEND-IA, and SWIFT-PRIME) presented in the International Stroke Conference, and ESCAPE and EXTEND-IA were published online in the NEJM.
-June 2015 - new AHA/ASA guidelines published recommending MT for all patients that meet criteria.
Given what was already known and the
new evidence from 2014-2015, significant delays to MT would definitely not be within the ‘standard’ of care in Florida in 2015.
My initial comment was pertaining to post that stated: " the fact that neurointervention was performed within
3 hours which is hardly a delay" Besides the harm to the patient, believing that MT started within 3 hours after initial assessment is “hardly a delay”, and it appears some of you do, may result in future unnecessary lawsuits. A lack of timely treatment with MT is already a high risk of litigation and will likely increase in frequency in the coming years, and ED physicians are the most likely group to get sued, some possibly due to holding beliefs like the one I am trying to correct.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.025352
I feel like I have to stay it every post because there will be multiple accusation that I am blaming the ED physician, I never have. Don’t misconstrue correcting misinformation as blaming individuals, and I of course agree with the poster ‘namethatsmell’ that we should “create enduring safeguards against medical errors”, and to do that we need start with the facts!
