tPA Malpractice Case: Agree or Disagree?

[bbc586]

Curious on the group's take on this case.

The Expert Witness Newsletter ---> Case #15 (the most recent one posted)

Unresponsive guy found down. Seems like workup moved a little slowly, but tPA ultimately given in the 4.5hr window.

I've gotten varying opinions on whether this is negligent or not.

Would faster workup/tPA have changed the outcome?

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[turkeyjerky]

It was a weird case in my opinion. "found down" isnt' a typical MCA type presentation in my experience. So either this is a case of overzealous lawyering (highly likely) in a confusing presentation, or an inadequate initial eval by the EM doc. The latter seems a little less likely, since they went to the point of getting an MRI prior to administering TPA.

This is, unfortunately, an expected consequence of neurology over-extolling the benefits of TPA.

Also, why the **** are residents allowed to be named in malpractice suits? It is truly disgusting.

 

[wendalltwolf]

Also, why the **** are residents allowed to be named in malpractice suits? It is truly disgusting.

Are residents named so that during discovery they can be deposed for anything valuable to either side, then usually dismissed? Then they have to explain the suit every time they apply for a state license, hospital privileges, insurance paneling, etc. Is that usually what happens?

 

[namethatsmell]

Nope no medmal evident here. At least not on the part of the EM doc. Read the tea leaves in the documents--the plaintiff's witness states the ER doc arrived at a Dx of CVA at 7:56pm. Yet that's also the same time the ER doc is stated to have ordered at head CT. My guess is that this ED is just like the 98.7% of other EDs on earth where you only get a legit super-stat CT head for very specific indications and r/o CVA is the golden ticket for this. So almost certainly the ED doc had to list this as the indication on the CT head scan order to push it through.

From the available documents there's no suggestion that ED doc "knew" that patient had a CVA and raced to get this seemingly undifferentiated patient to a scanner in just a few minutes of arrival...only to then wait ~1.5 hours to call a neurologist to push the care forward.

 

[Zebra Hunter]

Are residents named so that during discovery they can be deposed for anything valuable to either side, then usually dismissed? Then they have to explain the suit every time they apply for a state license, hospital privileges, insurance paneling, etc. Is that usually what happens?

No, residents are named so leeches can leech off their malpractice insurance, as well. I got named in a frivolous suit as a resident, just found out last week that we won our medical review panel unanimously, of course that doesn't stop every leech from proceeding to trial. I guess I probably shouldn't state anymore than that, but once the case is officially dropped, I can post the absolutely absurd review of the case the leech sent us filled with spelling and grammatical errors.

My roommate in residency got sued without his attending being named, lol. Just him and another resident were named, not a single attending. Another frivolous case, as well. In all, I think 8 residents in my graduating class of 15 were named in a suit before we had even graduated. Think long and hard about doing residency in a sue happy state.

 

[thegenius]

I quickly read it.

A few observations:

1) there are only so many diagnoses that can cause someone to literally go from normal to "comatose" in 30 minutes. (if comatose is truly what's going on). Every ER doctor should be able to recite the most common ones immediately without thinking. The list is relatively short
a) hypoglycemia
b) stroke (usually very large ones like brainstem stroke, massive ICH)
c) seizure / post-ictal state / NCSE
d) drugs (GHB, opiates, alcohol, etc),
e) cardiac arrest / major arrhythmia
f) hypercapnia
g) airway obstruction causing hypoxia and letter e above

There are numerous other diagnoses that can cause someone to be comatose but they usually take time to develop like several days.

This guy had an MCA stroke and they are usually not comatose. They are only comatose if it's far enough along that there is brain swelling or herniation or something else going. I see MCA strokes all the time and they are pretty much, umm...duh...unilateral strokes with some available mental status. It's pretty rare that I truly get someone who is comatose. That they literally have no neurologic exam except for breathing.

Who knows what the EM doc thought as we don't have the chart.


2) it should not take ~4 hours to give someone tPA. It matters not it's efficacy...it's now the standard of care. You eval the pt, get FSG, labs, do a good history and physical as best as you can, get the stat CT Head, and decide either by yourself or in concert with a Neurologist to give tPA afterwards. Shouldn't take more than a hour. It doesn't matter whether it would have helped him or not.


3) It seems so pukish that another radiologist who knows to look for an MCA density finds it while the original radiologist didn't. Seems like there is huge bias there. "Dr. Rads I'm suing someone for missing a stroke. Please review this CT and tell me if you see the hyperdense MCA." LOL



I don't know if there was "gross" negligence in this case but there was some bad doctoring IMO.

 

[bravotwozero]

I'm sorry, I'm supposed to diagnose a friggin MCA stroke on a non contrast head CT, after radiology reads it as normal, with not much on a clinical exam to guide me? Bull crap. If a radiologist read it as normal, and i have no other neuro finding than 'coma', I would start to think something along the lines of metabolic encephalopathy

 

[thegenius]

No you as an EM doc are not qualified to determine if a CT Head non-contrast has a hyperdense MCA. But giving tPA is not dependent on knowing whether there is a hyperdense MCA lesion.

If it is true that the guy was "normal" 30 minutes prior to being found comatose, what on earth could have caused his condition to change? There are only a few things that can do this.

 

[CliveStaples]

Like many lawsuits, this all boils down to documentation. I believe that had the physician documented a complete neurologic examination that indicates the patient did not have any lateralizing symptoms and was simply a presentation of "encephalopathy" then I think a reasonable defense could have been performed that CVA was in fact not in the differential diagnosis any longer and that TPA was not administered after non contrast head CT. Because it seems that documentation of a neurologic exam was not performed, and we know that the MRI afterward indicates that there was a a CVA, it opens up grounds to say that you actually did consider CVA but did not administer the "standard of care" (a whole other discussion).

You have to go all in. The patient's presentation was either concerning for stroke and TPA should have been tossed in after CT ruled out hemorrhage, or the patient's presentation was not consistent with CVA and you document how it's not and why TPA wasn't administered. Instead, there's every indication that CVA was still near a top of a differential diagnosis and then it all looks to come off the rails when you're scrambling after MRI to now treat CVA late.

Notice I'm not trying to get into the absolute insanity that comes with the CT read lawsuit, or the debate over the efficacy of TPA. I also do not believe the ER physician did anything wrong with their medical management. I think they likely had a true encephalopathic patient whose symptoms were not consistent with an ischemic CVA that doesn't at least show evidence of diffuse edema on CT. But their documentation according to deposition does not seem to indicate this.

Chart well. And make sure you chart well when you're giving TPA after MRI because that's a case with a high likelihood of review.

 

[Tenk]

I’m not a big tpa fan at all but there was over an hour delay in getting just a non contrast ct read in someone presenting like that. That’s pretty absurd and if it was any of our family member I’m pretty sure we’d be pissed too.

 

[cyanide12345678]

Also, why the **** are residents allowed to be named in malpractice suits? It is truly disgusting.

I was named in one as a resident when i had minimal to no patient care. Showed up for the coffee blue, cardiology fellow ran the code, nurse ordered one med under my name at some point, i don't know why, they probably just knew my name and ordered it under my name. I signed it.. like i sign pretty much anything lol.

Then a year later I'm named, along with another resident and the cardiology fellow.

I was dismissed 8-9 months ago after 1 year.

Also fun fact: cardiology fellow was thrown under the bus by the interventional cardiology attending.

I don't know what happened to the case once i was dismissed.

 

[southerndoc]

$6 mil? Ridiculous.

We see a lot of basilar artery occlusions that leave people comatose. Seen some outside facilities miss them and transfer them to us very late in the game. I never throw them under the bus to family members. We almost never TPA them as they go directly to the lab for intervention.

Can't say I've seen an MCA territory stroke cause someone to lose consciousness. I wonder if the patient had a seizure from the MCA stroke and had a prolonged postictal state (prolonged because of the already compromised brain due to the stroke).

Nevertheless, *ALL* patients that I see who have unexplained sudden unconsciousness get a non-con head CT and a CT angiogram of the head/neck. As @thegenius pointed out, there aren't many causes of quick onset unconsciousness. A lot of these people have basilar artery occlusions causing brainstem/posterior strokes. I'm not talking about the people with known CO2's of 150, BUN's of 130, known drug users, etc. I'm talking about the normal guy who was talking to family and then suddenly went unconscious without reason.

 

[xaelia]

Looks like they dropped the ED doc – good.

Almost guaranteed the documentation in this case is "garbage". But, frankly, a lot of charts I review – especially for docs who have been practicing for 20+ years – is "garbage" compared to the macro- and checkbox-facile documentation of recent grads. Maybe the ED doc came off well in his deposition; juries don't like to convict nice docs.

I'll happily argue causation for time-to-tPA. What % disability changes per minute? Prove it, show work. It's not obvious the year of this case, but you can get the neurologist for not pursuing endovascular options and the rest is just window dressing to make him/her look incompetent. Proximal MCA isn't a great lesion for lytics, and recognizing a large vessel occlusion in this day and age can be profoundly important.

 

[Brigade4Radiant]

The ED doctor was IM trained was removed from the lawsuit. There was nothing really wrong with the care from an ED perspective

Also for the people ordering the CT Angio when this guy is comatose You can also argue that if you weren’t given TPA while the CTA was being read that you were outside the standard of care.

In most circumstances you’re better off just documenting a normal physical exam

 

[gro2001]

There aren’t enough details in the expert witness statements to judge for sure, but in my reading between the lines, I am actually not super sympathetic to the actions of the ED doc. Even discounting for lapses in documentation which we all know can happen when things get busy. The timeline doesn’t really hold up.

You have a patient that was recently completely normal, that suddenly isn’t, and with a “GCS of 8”. I suspect that it’s one of those cases that screams ICH. Either way, this is something that is definitely big bad. This is not the patient you just put some orders in and wait for the radiologist report to act on. This is the patient you follow to the CT scanner (or push the stretcher yourself if you have to) both so you can see the bleed and because with a ”GCS of 8’’, even accounting for inaccuracy in GCS calculation, this patient sounds like they might be close to losing their airway. I am not expecting ED docs to see a dense MCA sign (which who knows if this case truly even had). I am, however, expecting them to see if there is a big bleed or not. And once there isn’t, the alarm bells shouldn’t silence. You should do something. Call the radiologist to double check the read. Call the neurologist to look at the images. Yet nothing was done till half an hour after the images were read, an hour and a half after the CT was ordered. Given that in the subsequent half an hour they were able to get an MRI done and read, it doesn’t seem like this is an under resourceD critical access type hospital.

Even with the gaps in documentation and limited information we have, it really seems like for some reason alarm bells that should have been going off were not. For some reason they didn’t see what was going on as an immediate and time sensitive life threat or didn’t feel the urgency to go full court press. My bias on reading this is to suspect that perhaps the IM background of the attending led them astray, but this is of course even more speculative than everything above.

 

[bravotwozero]

The only time i'll get MRIs, or wait for them is if it's a TIA (deficits resolved), or deficits are not significant enough to merit tpa, or I think it's total BS. That way with a negative MRI I can more or less exclude things.

 

[Porfirio]

Sorry from what I see, what failed here? Radiologist reading ct head that has MCA sign?

 

[gro2001]

The problem with being hypercritical of the timeline is that no one else knows what else was going on in the department at that time. Was the physician also running a rode, reducing a fracture with neurovascular compromise, placing a central line in a septic shock patient, taking care of a STEMI, seeing a level 1 trauma patient, intubating a pediatric drowning patient or all of the above at once with a full waiting room and 8-12 active patients requiring intermittent doffing PPE for Ebola or SARS-CoV-2 patients while reading EKGs, taking transfer calls, giving EMS medical direction, answering lined up nurses with questions and a million other distractions? The legal system never cares and we’ll never know. We’ve all been there though.

I get it. As I said, not enough info. However, it seems clear that judging from timeline that the ball was dropped. Whether it was the doc who did the dropping, who knows. Maybe it was the middle of all ****storms. But its hard to imagine a scenario where there aren’t a few minutes to look at the images of a head CT for a patient that went from normal to “GCS 8”. Go to the scanner with them. Send a resident. Heck, call the CT tech and ask them if there was a big bleed.

To be honest, I suspect that the patient did have lateralizing signs but no one did even a cursory neuro exam. I see it often enough. A resident will walk over to evaluate a patient who is not responsive or not cooperating with exam. They will try to get them to follow a command and look in their pupils, but get thrown off by inability to follow commands. They conclude there is nothing focal. I pinch extremities x 4 and find the patient withdrawing on one side and doing nothing on the other.

 

[The Knife & Gun Club]

What constitutes documenting a “full” Neuro exam in this case?

Guys in a coma - so just “GCS 3, CN 2-12 unable to assess, sensory unable to assess, motor unable to assess?”

Or more flowery than that?

 

[bravotwozero]

Why even bother with the MRI if it’s a TIA and the deficits are resolved?

If i'm admitting these patients, you can then skip the ct. you have an MRI to start off with, and the admit team can worry about mra/cta/dopplers etc

 

[Postictal Raiden]

What constitutes documenting a “full” Neuro exam in this case?

Guys in a coma - so just “GCS 3, CN 2-12 unable to assess, sensory unable to assess, motor unable to assess?”

Or more flowery than that?

You can assess most of the CNs on a comatose pt. You can assess for lateralized muscle rigidity and brisk reflexes.

You can get a lot out of your neurological exam if performed properly, but that is something for us, neurologists, to do. I wouldn’t expect that from other physicians.

 

[Postictal Raiden]

I’m a Neurology resident, and at my institution, this patient would’ve gotten tPA within 30mins or arrival to the ED.

Stroke alert would be called the minute he’s wheeled in and the on call neurologists would’ve been notified. He would be taken straight to the CT scanner. After ruling out ICH and ensuring no contraindications (if family available), he’d receive tPA.

I’ve seen numerous of LMCA strokes present as coma.

 

[deleted547339]

I’m a Neurology resident, and at my institution, this patient would’ve gotten tPA within 30mins or arrival to the ED.

Stroke alert would be called the minute he’s wheeled in and the on call neurologists would’ve been notified. He would be taken straight to the CT scanner. After ruling out ICH and ensuring no contraindications (if family available), he’d receive tPA.

I’ve seen numerous of LMCA strokes present as coma.

You have no idea what you’re talking about. You know only about the patients on whom a stroke is called. Your obvious lack of understanding of selection bias and gross overconfidence reeks of a junior resident who just was promoted a year.

 

[Postictal Raiden]

You have no idea what you’re talking about. You know only about the patients on whom a stroke is called. Your obvious lack of understanding of selection bias and gross overconfidence reeks of a junior resident who just was promoted a year.

Why don’t you enlighten me since you sound like someone who has seen and treated hundreds of strokes?

 

[deleted547339]

Why don’t you enlighten me since you sound like someone who has seen and treated hundreds of strokes?

Ha. I’m not going to get baited by you. Although I likely have treated more stokes than you between EM residency, CCM fellowship heavy in NICU and now attending in an ER and ICU.

Lookup dunning Kruger effect. It would be like me telling you what should happen in the MS clinic because I see patients with MS in the ER.

 

[Postictal Raiden]

Ha. I’m not going to get baited by you. Although I likely have treated more stokes than you between EM residency, CCM fellowship heavy in NICU and now attending in an ER and ICU.

Lookup dunning Kruger effect. It would be like me telling you what should happen in the MS clinic because I see patients with MS in the ER.

Alright Mr double boarded. Instead of this condescending tone, why not elaborate and explain why my comment was wrong.

 

[Fox800]

You have no idea what you’re talking about. You know only about the patients on whom a stroke is called. Your obvious lack of understanding of selection bias and gross overconfidence reeks of a junior resident who just was promoted a year.

Totally out of touch, agreed.

Homeslice, we aren't checking reflexes in the resuscitation bay on arrival. Our algorithm would be BGL, decide about a tube, draw labs, +/-ECG, then to the scanner. You're way out of your element here. We so many other things that present as "unresponsive" that you never even hear about...

 

[Fox800]

Alright Mr double boarded. Instead of this condescending tone, why not elaborate and explain why my comment was wrong.

You should skedaddle out of here and back to the neurology forums.

You aren't going to gain any traction here, and an off-service resident picking a fight with staff doesn't make you look smart.

We'll call you if we want you to bring down that weird torture device looking wheeled toy (Wartenberg wheel).

 

[Postictal Raiden]

[QUOTE="Fox800, post: 22059559, member: 112800" We so many other things that present as "unresponsive" that you never even hear about...
[/QUOTE]

None of which would be a major contraindication to giving tPA given a negative CT

 

[deleted547339]

Alright Mr double boarded. Instead of this condescending tone, why not elaborate and explain why my comment was wrong.

You’re getting the condescending tone because of your extreme arrogance. You think you know enough to state what is or isn’t malpractice for a different specialty as a resident? What do you think is appropriate to respond to that level of arrogance? You say something like that in my department, and you’re quickly getting asked to leave and a call to your chair. That sort of attitude is hard to deal with and dangerous. You can dislike what I say, but I’m right.

As above, you are out of your element. We see plenty of obtunded patients, only a small subset (if I had to guess, maybe 10%) ever see you - of those that do, probably fewer than half have concern for ischemic stroke, even fewer are eligible for tPA (which has at most minimal effect). The differential on that is broad, and we would likely kill people if we treated them all as a stroke. You have your hypoglycemia, hyponatremia, HHNK, status, hypercapnea, hypoxia, conversion disorder, numerous drug ODs (single vs poly, intentional vs unintentional), alcohol intoxication, heat stroke, anoxic injury following cardiac arrhythmia, SDH, hemorrhagic stroke, dissection extending north, etc. This is just what comes to mind rapidly, there are many more. If every patient above was treated as a stroke, many would die. To be cavalier in a room full of specialities declaring what they should have done or to presume to know what is done is arrogant.

 

[Dr Tapatio]

Ha. I’m not going to get baited by you. Although I likely have treated more stokes than you between EM residency, CCM fellowship heavy in NICU and now attending in an ER and ICU.

Lookup dunning Kruger effect. It would be like me telling you what should happen in the MS clinic because I see patients with MS in the ER.

How sad. You get called out and instead of being a man about it and saying "I was wrong" or "this is how it should be" you go "BUT I IS ATTENDING WITH BOARDZ. DUNNING-KRUGER DUR DUR" as if some appeal to (self)authority convinces anyone with an IQ of 80 or greater. Congrats, you played yourself and showed us you're what the NPC meme is all about

 

[Fox800]

You’re getting the condescending tone because of your extreme arrogance. You think you know enough to state what is or isn’t malpractice for a different specialty as a resident? What do you think is appropriate to respond to that level of arrogance? You say something like that in my department, and you’re quickly getting asked to leave and a call to your chair. That sort of attitude is hard to deal with and dangerous. You can dislike what I say, but I’m right.

As above, you are out of your element. We see plenty of obtunded patients, only a small subset (if I had to guess, maybe 10%) ever see you - of those that do, probably fewer than half have concern for ischemic stroke, even fewer are eligible for tPA (which has at most minimal effect). The differential on that is broad, and we would likely kill people if we treated them all as a stroke. You have your hypoglycemia, hyponatremia, HHNK, status, hypercapnea, hypoxia, conversion disorder, numerous drug ODs (single vs poly, intentional vs unintentional), alcohol intoxication, heat stroke, anoxic injury following cardiac arrhythmia, SDH, hemorrhagic stroke, dissection extending north, etc. This is just what comes to mind rapidly, there are many more. If every patient above was treated as a stroke, many would die. To be cavalier in a room full of specialities declaring what they should have done or to presume to know what is done is arrogant.

Amen.

None of which would be a major contraindication to giving tPA given a negative CT

Um, I'm pretty sure that MANY of the causes of coma besides ischemic CVA are a contraindication to tPA.
Head trauma. Seizure. Hypoglycemia. Overdose.
Pls go.

 

[Postictal Raiden]

You’re getting the condescending tone because of your extreme arrogance. You think you know enough to state what is or isn’t malpractice for a different specialty as a resident? What do you think is appropriate to respond to that level of arrogance? You say something like that in my department, and you’re quickly getting asked to leave and a call to your chair. That sort of attitude is hard to deal with and dangerous. You can dislike what I say, but I’m right.

As above, you are out of your element. We see plenty of obtunded patients, only a small subset (if I had to guess, maybe 10%) ever see you - of those that do, probably fewer than half have concern for ischemic stroke, even fewer are eligible for tPA (which has at most minimal effect). The differential on that is broad, and we would likely kill people if we treated them all as a stroke. You have your hypoglycemia, hyponatremia, HHNK, status, hypercapnea, hypoxia, conversion disorder, numerous drug ODs (single vs poly, intentional vs unintentional), alcohol intoxication, heat stroke, anoxic injury following cardiac arrhythmia, SDH, hemorrhagic stroke, dissection extending north, etc. This is just what comes to mind rapidly, there are many more. If every patient above was treated as a stroke, many would die. To be cavalier in a room full of specialities declaring what they should have done or to presume to know what is done is arrogant.

Ok thank you for the explanation.

And you’re right, I don’t agree with you. However I’ll take your advice and stop here.

 

[deleted547339]

[QUOTE="Fox800, post: 22059559, member: 112800" We so many other things that present as "unresponsive" that you never even hear about...

None of which would be a major contraindication to giving tPA given a negative CT
[/QUOTE]

You need an indication before you consider a contra-indication.

 

[Fox800]

How sad. You get called out and instead of being a man about it and saying "I was wrong" or "this is how it should be" you go "BUT I IS ATTENDING WITH BOARDZ. DUNNING-KRUGER DUR DUR" as if some appeal to (self)authority convinces anyone with an IQ of 80 or greater. Congrats, you played yourself and showed us you're what the NPC meme is all about

I guess the neuro troll brigade is here. This is karma for me making fun of those neurology tool fanny packs/satchels in residency.
I'm done. Time to go get enchiladas.

 

[deleted547339]

How sad. You get called out and instead of being a man about it and saying "I was wrong" or "this is how it should be" you go "BUT I IS ATTENDING WITH BOARDZ. DUNNING-KRUGER DUR DUR" as if some appeal to (self)authority convinces anyone with an IQ of 80 or greater. Congrats, you played yourself and showed us you're what the NPC meme is all about

You’re right, board certification means nothing.

 

[Fox800]

 

[Dr Tapatio]

You’re getting the condescending tone because of your extreme arrogance. You think you know enough to state what is or isn’t malpractice for a different specialty as a resident? What do you think is appropriate to respond to that level of arrogance? You say something like that in my department, and you’re quickly getting asked to leave and a call to your chair. That sort of attitude is hard to deal with and dangerous. You can dislike what I say, but I’m right.

Translation: "I'M GOING TO TELL THE TEACHER!!!"

You’re right, board certification means nothing.

Because nobody with board certification has made a mistake or gotten sued. Rock solid logic you're bringing here, bro

 

[Fox800]

You’re right, board certification means nothing.

We can't take ABEM oral boards due to COVID, so no one can become board-certified at this point.
Thus, obviously, EM BC means nothing. Lolz

 

[deleted547339]

Translation: "I'M GOING TO TELL THE TEACHER!!!"


Because nobody with board certification has made a mistake or gotten sued. Rock solid logic you're bringing here, bro

No, translation: your douchebag resident is going to cause massive problems for your departments reputation if you don’t reign him in before it’s too late.

 

[Dr Tapatio]

No, translation: your douchebag resident is going to cause massive problems for your departments reputation if you don’t reign him in before it’s too late.

He simply shared his experience of how things are done at his institution. You reacted by telling him he doesn't know what he's talking about and acting like a neurologist doesn't even know what the differential for stroke mimicking is. You're the type of arrogant person that steps on those below you for questioning you. The least of problems is the reputation of a department. The real problem is someone like you that has anointed himself infallible because he finished residency/fellowship

 

[deleted547339]

He simply shared his experience of how things are done at his institution. You reacted by telling him you don't know what he's talking about and acting like a neurologist doesn't even know what the differential for stroke mimicking is. You're the type of arrogant person that steps on those below you for questioning you. The least of problems is the reputation of a department. The real problem is someone like you that has anointed himself infallible because he finished residency/fellowship

You’re oblivious. I was pointing out that he only has a small view of patients and that he over-stepped. He thinks he knows what goes on at his institution, but he doesn’t - not any more than I know what happens at the MS clinic. I gave him a list of other potential diagnoses because he asked about it.

I’m done.

 

[Dr Tapatio]

You’re oblivious. I was pointing out that he only has a small view of patients and that he over-stepped. He thinks he knows what goes on at his institution, but he doesn’t - not any more than I know what happens at the MS clinic. I gave him a list of other potential diagnoses because he asked about it.

I’m done.

Again, the inability to self-reflect "you don't know what you're talking about" and "you're oblivious" would not be interpreted by anyone as fussy and rainbows. Don't try to gaslight me by saying "I was only points out..." BS and we both know it

Bye felicia

 

[CliveStaples]

Hurt feelings aside, this brings up a good point.

At my Ivory Tower training institution, a patient presenting with new onset reduced GCS without focal neurologic deficit on exam would not have triggered a "Stroke Alert" and would not have triggered a neurology consultation. The ER would evaluate the patient for neurologic, metabolic, infectious, toxicologic, etc. causes of altered mental status including a stat CTH but not always with CTAs (sort of a dealer's choice depending on your clinical suspicion).

I agree that based on the patient's final diagnosis, I suspect that a more careful neurologic exam would have determined that the patient did in fact have lateralizing neurologic deficits and the absence of such documentation is going to open up the ER physician to such scrutiny.

But if you do a real exam on this patient and it's truly just a presentation of encephalopathy, that would not trigger a Stroke Alert at my old institution and Neurology would be none the wiser to this patient's existence, just like they were unaware of all the AMS from suspected respiratory failure, intoxication, hepatic encephalopathy, etc. This is the "spectrum bias" that we are referring to when we state that blanket statements such as "this patient would have received TPA within 30 minutes" from a Neurology resident comes across as narrow sighted.

 

[Porfirio]

In a related case, I knew a doc who had a comatose patient like this. TPA was given within 30 mins as per stroke protocol.

Patient bled out from a ruptured aortic dissection.

Sad day.

 

[southerndoc]

Fair enough. I send most TIAs home with a low-moderate ABCD2 score (most seem to be), which our neurologists strongly prefer and have a protocol in place for. They just request a CT/CTA prior to discharge, which is a lot faster for me to obtain than a MRI. The CT to evaluate for causes of symptoms other than TIA/CVA and the CTA to help speed up the outpatient workup.

Per ACEP Clinical Policy, you're supposed to get an MRI of the brain and some sort of imaging of the carotids before discharging the TIA. Not many ED's follow that, but it's policy AFAIK. Just waiting for the first lawsuit over that...

 

[Arch Guillotti]

I unlocked the thread but please keep it professional please. Thanks.

 

[xaelia]

In a related case, I knew a doc who had a comatose patient like this. TPA was given within 30 mins as per stroke protocol.

Patient bled out from a ruptured aortic dissection.

Sad day.

Seen that, too. Had to shoo away the stroke fellow repeatedly during acute evaluation. Got patient to the OR with vascular with a pericardiocentesis.

Moot anyway from multiple infarcts secondary to the dissection.

Probably similar ultimate outcome in this case, expedited by tPA.

 

[Apollyon]

Seen that, too. Had to shoo away the stroke fellow repeatedly during acute evaluation. Got patient to the OR with vascular with a pericardiocentesis.

Moot anyway from multiple infarcts secondary to the dissection.

Probably similar ultimate outcome in this case, expedited by tPA.

I can't exactly say why, but, your post sounds like, kinda, somehow, a haiku.

 

[Groove]

Seen that, too. Had to shoo away the stroke fellow repeatedly during acute evaluation. Got patient to the OR with vascular with a pericardiocentesis.

Moot anyway from multiple infarcts secondary to the dissection.

Probably similar ultimate outcome in this case, expedited by tPA.

Same here, this one was not even that long ago. It was a transfer from an outside hospital and the doc pushed TPA right after the non contrasted CT Head and before the CTA only to find out they had a gigantic Type A dissection extending up the carotid. Needless to say, it did not end well for the pt.