tPA Malpractice Case: Agree or Disagree?

[Zebra Hunter]

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.

Yup, had an attending in residency do that too. The patient died within about 10 minutes of pushing it. Wrecked the guy for months afterwards.

I had a case in residency with a woman that had sudden onset severe headache. She had severe dysarthria, some expressive aphasia, decreased alertness, a R sided facial droop, although she had a history of a prior CVA but family didn’t come to the ER and EMS didn’t ask if she had a baseline deficits. She was still in severe pain in the ER. CT non con was negative. Neurology said to push tPA. I said I did not feel comfortable doing that and felt that she needed an LP to r/o SAH as the pre-test probability was so high that I could not rule it out with a CT non-con. The neurologist came down and pushed it himself even after my attending urged him not to. About 20 minutes after, I had to intubate the patient as she had become unresponsive and had vomited and aspirated. CT non-con now shows a clear SAH. She was palliatively extubated later that evening.

For the neurology residents and attendings reading this thread, this is why EM docs are frequently so cautious about possible ischemic stroke cases that are atypical. Sure, a benign stroke mimic is unlikely to have adverse outcomes to tPA, but there are numerous ischemic stroke mimics that will kill the patient if tPA is given. Specialists frequently get tunnel vision in acutely ill patients and have a tendency to anchor on diagnoses of their specialty (not saying we EM docs don’t anchor). We went to residency specifically to learn how to manage undifferentiated patients and were taught from day 1 about the importance of avoiding anchoring. We understand y’all’s expertise in strokes, but there is such a wide differential for the acutely altered patient that we are much more familiar with.

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[CliveStaples]

Yup, had an attending in residency do that too. The patient died within about 10 minutes of pushing it. Wrecked the guy for months afterwards.

I had a case in residency with a woman that had sudden onset severe headache. She had severe dysarthria, some expressive aphasia, decreased alertness, a R sided facial droop, although she had a history of a prior CVA but family didn’t come to the ER and EMS didn’t ask if she had a baseline deficits. She was still in severe pain in the ER. CT non con was negative. Neurology said to push tPA. I said I did not feel comfortable doing that and felt that she needed an LP to r/o SAH as the pre-test probability was so high that I could not rule it out with a CT non-con. The neurologist came down and pushed it himself even after my attending urged him not to. About 20 minutes after, I had to intubate the patient as she had become unresponsive and had vomited and aspirated. CT non-con now shows a clear SAH. She was palliatively extubated later that evening.

For the neurology residents and attendings reading this thread, this is why EM docs are frequently so cautious about possible ischemic stroke cases that are atypical. Sure, a benign stroke mimic is unlikely to have adverse outcomes to tPA, but there are numerous ischemic stroke mimics that will kill the patient if tPA is given. Specialists frequently get tunnel vision in acutely ill patients and have a tendency to anchor on diagnoses of their specialty (not saying we EM docs don’t anchor). We went to residency specifically to learn how to manage undifferentiated patients and were taught from day 1 about the importance of avoiding anchoring. We understand y’all’s expertise in strokes, but there is such a wide differential for the acutely altered patient that we are much more familiar with.

That sounds horrifying. "Symptoms suggestive of SAH" is a clear contraindication to TPA. I'd be quite upset too.

 

[deleted547339]

Yup, had an attending in residency do that too. The patient died within about 10 minutes of pushing it. Wrecked the guy for months afterwards.

I had a case in residency with a woman that had sudden onset severe headache. She had severe dysarthria, some expressive aphasia, decreased alertness, a R sided facial droop, although she had a history of a prior CVA but family didn’t come to the ER and EMS didn’t ask if she had a baseline deficits. She was still in severe pain in the ER. CT non con was negative. Neurology said to push tPA. I said I did not feel comfortable doing that and felt that she needed an LP to r/o SAH as the pre-test probability was so high that I could not rule it out with a CT non-con. The neurologist came down and pushed it himself even after my attending urged him not to. About 20 minutes after, I had to intubate the patient as she had become unresponsive and had vomited and aspirated. CT non-con now shows a clear SAH. She was palliatively extubated later that evening.

For the neurology residents and attendings reading this thread, this is why EM docs are frequently so cautious about possible ischemic stroke cases that are atypical. Sure, a benign stroke mimic is unlikely to have adverse outcomes to tPA, but there are numerous ischemic stroke mimics that will kill the patient if tPA is given. Specialists frequently get tunnel vision in acutely ill patients and have a tendency to anchor on diagnoses of their specialty (not saying we EM docs don’t anchor). We went to residency specifically to learn how to manage undifferentiated patients and were taught from day 1 about the importance of avoiding anchoring. We understand y’all’s expertise in strokes, but there is such a wide differential for the acutely altered patient that we are much more familiar with.

The other big problem is that of social capital. If this patient shows up, most of this time it’s not a SAH. Our system is set up such that we have to expend tremendous social capital to argue with a consultant about this. Most of the time, it doesn’t pay off which subsequently promotes the consultants confirmation bias. Then we may not fight as hard after beating our head against the wall 9 times then this happens. We need to engineer safety in our practice - promoting time to lytics is the opposite of engineering for safety.

 

[Groove]

Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke

An increased emphasis on stroke care has led to a proliferation of specialized stroke teams despite relatively few trials demonstrating their efficacy. Our academic stroke center incorporated a unique setup allowing for the comparison between stroke teams ...

www.ncbi.nlm.nih.gov

In conclusion, despite widely accepted clinical guidelines calling for the rapid treatment of acute ischemic stroke with thrombolysis, debate regarding its efficacy and safety continues.16 When considering institutional practices and processes to decrease door-to-needle times, it is imperative to consider each measure’s evidence and overall effect on patient outcomes. Our study, though limited, suggests that emergency physicians may not be inferior to neurologist-led stroke teams in the evaluation and treatment of acute ischemic stroke. Further prospective, multicenter studies are needed to evaluate the efficacy of and need for neurologist-led stroke teams in the treatment of acute ischemic stroke.

 

[thegenius]

The other big problem is that of social capital. If this patient shows up, most of this time it’s not a SAH. Our system is set up such that we have to expend tremendous social capital to argue with a consultant about this. Most of the time, it doesn’t pay off which subsequently promotes the consultants confirmation bias. Then we may not fight as hard after beating our head against the wall 9 times then this happens. We need to engineer safety in our practice - promoting time to lytics is the opposite of engineering for safety.

That's a very good, prescient point. We have lots of metrics that are time sensitive. Some of them are good, some of them not.

I wonder, at a high level, what gave the right for the attending Neurologist to push tPA on that patient while they were in the ED. Just because you consulted them doesn't mean you have to accept their opinion. Note that I'm not being critical of you at all. I'm not saying you were forced to capitulate.

I remember a time in residency when a pt came to the ED, had a surgical problem and was admitted to surgery. The surgical residents came down wanted to intubate the patient. The chief ER resident went screaming into the room and said "The only docs who INTUBATE in the ED are ER DOCTORS!" LOL. The patient really didn't need to be tubed...but after some discussion that went on longer than it should, the ER tubed the patient and he went to the SICU.

 

[thegenius]

The problem ER doctors face, as you know, is the notion that we may not be the experts in management of medical emergencies in the eyes of most laypeople, especially when a specialist consultant is around. It's a shame, because that's all we do, is recognize, resuscitate, and stabilize emergency medical conditions.

 

[Zebra Hunter]

That's a very good, prescient point. We have lots of metrics that are time sensitive. Some of them are good, some of them not.

I wonder, at a high level, what gave the right for the attending Neurologist to push tPA on that patient while they were in the ED. Just because you consulted them doesn't mean you have to accept their opinion. Note that I'm not being critical of you at all. I'm not saying you were forced to capitulate.

I remember a time in residency when a pt came to the ED, had a surgical problem and was admitted to surgery. The surgical residents came down wanted to intubate the patient. The chief ER resident went screaming into the room and said "The only docs who INTUBATE in the ED are ER DOCTORS!" LOL. The patient really didn't need to be tubed...but after some discussion that went on longer than it should, the ER tubed the patient and he went to the SICU.

Neurology at my residency program were in house and showed up to all stroke activations. When there was a disagreement, typically we tried to hash it out and come to a consensus; however, this one neurology attending was a cowboy and frequently snuck in without talking to the EM attending to push tPA. One of my fellow residents once literally put his body in between the patient and this attending to prevent him from pushing tPA.

 

[BoardingDoc]

The neurologist came down and pushed it himself even after my attending urged him not to.

What? That isn't how any of this is supposed to work. If there was a lawsuit over this patient's death, this neurologist would be crucified. If I, as the ED attending expressly disagree with a plan for a patient who is under my care, you don't get to push tPA. If you do anyway, not only is it malpractice, but it is also assault.

 

[turkeyjerky]

What? That isn't how any of this is supposed to work. If there was a lawsuit over this patient's death, this neurologist would be crucified. If I, as the ED attending expressly disagree with a plan for a patient who is under my care, you don't get to push tPA. If you do anyway, not only is it malpractice, but it is also assault.

It's unfortunate that many (most?) physicians (both EM and consultants), as well as nurses and administrators, are unaware that we are legally the attending physician of record while patients are in the emergency department.

 

[VA Hopeful Dr]

It's unfortunate that many (most?) physicians (both EM and consultants), as well as nurses and administrators, are unaware that we are legally the attending physician of record while patients are in the emergency department.

So does that mean you're protected malpractice wise for patients that have been admitted but are still physically in the ED?

This is an honest question as that happened a fair bit in residency.

 

[turkeyjerky]

So does that mean you're protected malpractice wise for patients that have been admitted but are still physically in the ED?

This is an honest question as that happened a fair bit in residency.

I don't know the true answer, but I suspect it's a grey area. I have seen some cases published on malpractice newsletters where the ED doc was named (along with medicine) when the patient decompensated after admission, so I suspect it would end up being shared responsibility.

 

[Brigade4Radiant]

If you read the case the ED doctor was dropped from the case. He didn’t really do anything wrong. It is the consultant and the radiologist who have to act on the findings. Also for people saying this is a basal artery occlusion I think you’re using 2020 too much there’s a wire amount of things that could happen such as a subarachnoid hemorrhage or a basilar artery dissection

 

[southerndoc]

So does that mean you're protected malpractice wise for patients that have been admitted but are still physically in the ED?

This is an honest question as that happened a fair bit in residency.

No there was a recent case where a patient in DKA being held in the ER due to lack of inpatient beds had a bad outcome. The physician on-duty -- who didn't even see or know about the patient -- was held liable. I think it was discussed on Greg Henry/Rick Bucatta's podcast.

 

[southerndoc]

If you read the case the ED doctor was dropped from the case. He didn’t really do anything wrong. It is the consultant and the radiologist who have to act on the findings. Also for people saying this is a basal artery occlusion I think you’re using 2020 too much there’s a wire amount of things that could happen such as a subarachnoid hemorrhage or a basilar artery dissection

Even getting dropped from a case can cause a lot of harm. I was sued once for someone else missing something. I came in, figured out what was going on, and appropriately treated the patient. I was dropped after being deposed, but for months I was in agony over it.

 

[VA Hopeful Dr]

No there was a recent case where a patient in DKA being held in the ER due to lack of inpatient beds had a bad outcome. The physician on-duty -- who didn't even see or know about the patient -- was held liable. I think it was discussed on Greg Henry/Rick Bucatta's podcast.

That is unfortunate.

 

[Groove]

I think it likely depends on the state, the institution, the departmental policies and guidelines, etc.. We have ICU pt’s holding in the ED all the time. I’m very clear to nurses that come to me for orders that they are to call the ICU attending who is actively managing the pt. I don’t enter orders, I don’t allow them to document that I gave them a verbal order for anything and it’s very clear when you look at the order screen that the ICU intensivist is actively managing them. I will ask them to physically come down to the ER and evaluate the pt. I think for a case like that...I could produce a pretty solid defense. In the event of a sudden deterioration, I view it like responding to a code. I respond and put out the fire but I call the ICU right away and ask them to come down. I document very clearly that I responded to an ICU pt being actively managed in the ED. That’s very different than a pt being held where you are entering orders every couple of hours for random things and the ICU is clearly taking a hands off approach until they physically show up in the unit.

I had a somewhat related case where I was extremely clear about transition of care to another specialty as well as the hospitalist and a suit was brought against the inpatient team. I was left off but they still deposed me. I didn’t do anything wrong (and they didn’t either to be perfectly honest), but I’m fairly confident that my documentation helped keep me off the original suit.

 

[southerndoc]

Our ER is a little different. We are literally across the street from the main hospital (connected via a sky bridge). We assume more of a role now evaluating boarded patients that are crumping. So when they come to me to evaluate a patient in the ER who is admitted to another service, I go and evaluate them. The nurse still notifies the admitting team, and if the condition warrants, I will communicate with them as well.

 

[deleted547339]

Our ER is a little different. We are literally across the street from the main hospital (connected via a sky bridge). We assume more of a role now evaluating boarded patients that are crumping. So when they come to me to evaluate a patient in the ER who is admitted to another service, I go and evaluate them. The nurse still notifies the admitting team, and if the condition warrants, I will communicate with them as well.

We should give this extra weight as it now comes from a mod ;-)

All joking aside, you can be found liable for boarders. It’s not right, but you can be.

 

[southerndoc]

We should give this extra weight as it now comes from a mod ;-)

Oh dear... I'll have to bite my tongue with some comments now.

My step count doubled when we moved into our new ER because of inpatient holds we aren't following a true pod system like the new ER was designed. 263,000 square feet on two floors. Not sure if any ER in the nation is larger than ours (if it is, I'd be interested to know).

 

[Apollyon]

We should give this extra weight as it now comes from a mod ;-)

All joking aside, you can be found liable for boarders. It’s not right, but you can be.

To be totally clear, I gave this post a "haha" before he edited it.

 

[jw3600]

How do we have a professional discussion about the possibility of self-serving interests of the field of neurology and their obsession with the efficacy and safety of tPA?

 

[The Knife & Gun Club]

Had a great case if depressed mental status come in today. GCS of 9 (eyes 2, verbal 3, motor 4), no clear lateralizing symptoms PERRLA. BP 180/80, HR 65, afebrile.

Stroke alert called. Plain brain negative. Neuro + EM agreed no tPA.

US showed an 11cm AAA with active extravisation into the peritoneum.

Good thing we didn’t give tPA!

 

[Groove]

Had a great case if depressed mental status come in today. GCS of 9 (eyes 2, verbal 3, motor 4), no clear lateralizing symptoms PERRLA. BP 180/80, HR 65, afebrile.

Stroke alert called. Plain brain negative. Neuro + EM agreed no tPA.

US showed an 11cm AAA with active extravisation into the peritoneum.

Good thing we didn’t give tPA!

Yikes! Good call.

 

[thegenius]

Had a great case if depressed mental status come in today. GCS of 9 (eyes 2, verbal 3, motor 4), no clear lateralizing symptoms PERRLA. BP 180/80, HR 65, afebrile.

Stroke alert called. Plain brain negative. Neuro + EM agreed no tPA.

US showed an 11cm AAA with active extravisation into the peritoneum.

Good thing we didn’t give tPA!

Yes very good call.

Did the pt say he had abdominal pain? GCS 9 he might be able to communicate a little. Was the abd tender or distended?

 

[BoardingDoc]

Yes very good call.

Did the pt say he had abdominal pain? GCS 9 he might be able to communicate a little. Was the abd tender or distended?

Yeah, why did you get an abd US? Clearly the right call, but the patient as presented doesn't seem to indicate that workup.

 

[Porfirio]

Yeah, why did you get an abd US? Clearly the right call, but the patient as presented doesn't seem to indicate that workup.

Residency.

 

[The Knife & Gun Club]

Yes very good call.

Did the pt say he had abdominal pain? GCS 9 he might be able to communicate a little. Was the abd tender or distended?

Yeah, why did you get an abd US? Clearly the right call, but the patient as presented doesn't seem to indicate that workup.

Yup. Working with an US attending who said to just throw the probe on and see what’s up.

No abdominal pain. Just “devil” over and over in creole.

So intern dumb luck. 0 skill involved, but still too relevant not to share.

 

[Apollyon]

Yup. Working with an US attending who said to just throw the probe on and see what’s up.

No abdominal pain. Just “devil” over and over in creole.

So intern dumb luck. 0 skill involved, but still too relevant not to share.

Just an aside, but, how do you know it was Creole? For clarity, I speak French, and, when I was prelim, I had a BUNCH of Haitian pts, and, bar none, they all spoke perfect French (when speaking to me), but spoke Creole with their family/friends. We even had consents written in Creole, and they looked like a typewriter threw up on a piece of paper, but, when read aloud, they were intelligible as being related, in some way, to French. That's when I realized that the written form was phonetic. In any case, French for "devil" is diable, pronounced "dee-ahb", whereas the Creole is dyab, pronounced, well, "dee-ahb"!

 

[BoardingDoc]

Just an aside, but, how do you know it was Creole? For clarity, I speak French, and, when I was prelim, I had a BUNCH of Haitian pts, and, bar none, they all spoke perfect French (when speaking to me), but spoke Creole with their family/friends. We even had consents written in Creole, and they looked like a typewriter threw up on a piece of paper, but, when read aloud, they were intelligible as being related, in some way, to French. That's when I realized that the written form was phonetic. In any case, French for "devil" is diable, pronounced "dee-ahb", whereas the Creole is dyab, pronounced, well, "dee-ahb"!

Maybe it's location dependent. There are a lot of Haitian Creole speakers among my patient population. I would estimate that only half or so understand me when I speak French, the other half have literally no idea what I'm saying except for the random words that overlap.

In fairness, my French is very basic, so the problem could be on my end and not theirs.

 

[Apollyon]

Maybe it's location dependent. There are a lot of Haitian Creole speakers among my patient population. I would estimate that only half or so understand me when I speak French, the other half have literally no idea what I'm saying except for the random words that overlap.

In fairness, my French is very basic, so the problem could be on my end and not theirs.

Yeah, language is local. What was that quote about the US and the UK, separated by a common language, or some such thing? Watching Line Of Duty, from the UK, I have to turn on the subtitles just to know what everyone is saying! You get a copper from Scotland or Northern Ireland, it's thicker than pea soup!

So, the structure is there, but the bricks (words) are SO variable.

It's like Adam Ant said in Goody Two-shoes "Write it on a pound note". We say "dollar bill". Or, "He took the lift down from the flat, and, opened the bonnet on the lorry, and took the money out of the boot of the car, some 500 quid, maybe a grand. His gaffer wouldn't know ****e, and Bob's your uncle!"

What??

 

[southerndoc]

@Apollyon I got some of that, but can you translate further? He took the elevator down from the apartment, and opened the (door?) on the truck, and took the money out of the (WTH is a boot?) of the car, some 500 pounds, maybe a grand. His (what?) wouldn't know..."

 

[BoardingDoc]

@Apollyon I got some of that, but can you translate further? He took the elevator down from the apartment, and opened the (door?) on the truck, and took the money out of the (WTH is a boot?) of the car, some 500 pounds, maybe a grand. His (what?) wouldn't know..."

Bonnet = hood
Boot = trunk
Gaffer = boss

 

[jw3600]

Yup. Working with an US attending who said to just throw the probe on and see what’s up.

No abdominal pain. Just “devil” over and over in creole.

So intern dumb luck. 0 skill involved, but still too relevant not to share.

Pics or it didn’t happen.

But seriously good case. If you have images we would love to see.

 

[bravotwozero]

Yeah, language is local. What was that quote about the US and the UK, separated by a common language, or some such thing? Watching Line Of Duty, from the UK, I have to turn on the subtitles just to know what everyone is saying! You get a copper from Scotland or Northern Ireland, it's thicker than pea soup!

So, the structure is there, but the bricks (words) are SO variable.

It's like Adam Ant said in Goody Two-shoes "Write it on a pound note". We say "dollar bill". Or, "He took the lift down from the flat, and, opened the bonnet on the lorry, and took the money out of the boot of the car, some 500 quid, maybe a grand. His gaffer wouldn't know ****e, and Bob's your uncle!"

What??

I give you Irish farmers lose their sheep!

 

[The Knife & Gun Club]

Just an aside, but, how do you know it was Creole? For clarity, I speak French, and, when I was prelim, I had a BUNCH of Haitian pts, and, bar none, they all spoke perfect French (when speaking to me), but spoke Creole with their family/friends. We even had consents written in Creole, and they looked like a typewriter threw up on a piece of paper, but, when read aloud, they were intelligible as being related, in some way, to French. That's when I realized that the written form was phonetic. In any case, French for "devil" is diable, pronounced "dee-ahb", whereas the Creole is dyab, pronounced, well, "dee-ahb"!

Maybe it's location dependent. There are a lot of Haitian Creole speakers among my patient population. I would estimate that only half or so understand me when I speak French, the other half have literally no idea what I'm saying except for the random words that overlap.

In fairness, my French is very basic, so the problem could be on my end and not theirs.

Yea I’m in Miami. We get maybe the errant French tourist who accidentally gets diverted from south beach, but our county site is tons of hatians speaking creole.

They’re a profoundly underserved group and tend to really avoid western medicine at least around here. By the time they’re presenting to the ED you can see some insanely late disease stages.

 

[The Knife & Gun Club]

Pics or it didn’t happen.

But seriously good case. If you have images we would love to see.

Actually, it ended up being 14 cm!

 

[Apollyon]

I give you Irish farmers lose their sheep!

"Mikey Joe O'Shea"

Oh, and, although I know that you know, RTE is the official news agency of Ireland (the E is "Eireann").

 

[bravotwozero]

"Mikey Joe O'Shea"

Oh, and, although I know that you know, RTE is the official news agency of Ireland (the E is "Eireann").

I bet that's how @GeneralVeers starts talking every time he sees his income tax bill!

Didn't know that about RTE though, interesting.

 

[Apollyon]

Didn't know that about RTE though, interesting.

Yikes! Or, in the words of Velma, jinkies! I looked it up: news is only part - RTE is "Irish Radio Television", a semi-government state broadcaster. The E is still that, though!

 

[Zebra Hunter]

Anyone else been paying more attention to the number of patients with acute onset unresponsiveness since reading this thread?

I’ve seen 3 since first posting on the thread. The first was a herpes encephalitis with non-convulsive status confirmed by EEG, neuro agreed on this one that tPA not indicated after initial negative CT/CTA. The second was a 20 something yr old who appeared to just have a brief onset catatonic episode, or conversion disorder, or a very convincing malingerer (neuro asked that I push tPA on him despite normal CT/CTA, and symmetrical withdraw to pain, I refused). MRI, EEG, LP all normal. He just woke up 5 hours into his ER stay and left AMA after I had already got him admitted. The last was a GHB overdose who I intubated after multiple doses of narcan failed, CT/CTA negative, neuro requested tPA, I refused again, the patient woke up about 2 hours in pulled their tube out and admitted to using GHB.

 

[SpacemanSpifff]

Anyone else been paying more attention to the number of patients with acute onset unresponsiveness since reading this thread?

I’ve seen 3 since first posting on the thread. The first was a herpes encephalitis with non-convulsive status confirmed by EEG, neuro agreed on this one that tPA not indicated after initial negative CT/CTA. The second was a 20 something yr old who appeared to just have a brief onset catatonic episode, or conversion disorder, or a very convincing malingerer (neuro asked that I push tPA on him despite normal CT/CTA, and symmetrical withdraw to pain, I refused). MRI, EEG, LP all normal. He just woke up 5 hours into his ER stay and left AMA after I had already got him admitted. The last was a GHB overdose who I intubated after multiple doses of narcan failed, CT/CTA negative, neuro requested tPA, I refused again, the patient woke up about 2 hours in pulled their tube out and admitted to using GHB.

What lesion was the neurologist concerned about with that clinical picture and a clean CTA?

 

[Zebra Hunter]

What lesion was the neurologist concerned about with that clinical picture and a clean CTA?

I’m still not quite sure. It was our most conservative neurologist both times recommending tPA. He was initially concerned for basilar artery stroke; however, after negative CTA thought there was still the possibility of a basilar occlusion that spontaneously thrombolysed but might still be some micro vascular thrombi. His other reasoning was that they were both young “so it won’t hurt to give it”.

My response was essentially, “yyyyeah I don’t think I’m gonna do that.”

 

[southerndoc]

If you have a negative CTA, you can't have a big enough occlusion to cause unresponsiveness. Unresponsive = NIHSS that's too high to comfortably TPA without some hard evidence of a LVO.

@Zebra Hunter Sounds like you need some better neurologists if they are recommending TPA on unresponsive patients without evidence of LVO.

You mention 3 people who woke up, I can tell you 3 in the past few months who were transferred to us with a negative CT head without a CTA who had a stroke. Also had one that I saw that was a basilar artery occlusion that I identified (in a 25 year old who had COVID 5 weeks earlier).

I think if someone is unresponsive, you should do a CTA unless you have good evidence to think something else is going on. If the CTA is negative on an unresponsive patient, I definitely wouldn't just willy nilly push TPA.

 

[Zebra Hunter]

This is the problem with being forced to consult neuro by institutional policy for all stroke activations. None of my neurologists are in house after hours, so many of the more conservative neurologists will err on pushing tPA in patients that continue to display neuro abnormalities since they can’t evaluate the patient themselves. I’d much prefer never having to consult them given that their input is rarely useful when they haven’t seen the patient.

 

[BoardingDoc]

Our tele-neurologists are a little cavalier with tPA as well. I agree that part of this may be related to them not being at bedside, but also partly due to their over confidence in the ‘miracle’ of tPA overemphasizing the benefit over the risk despite less than amazing outcome data, and also them having less familiarity with undifferentiated encephalopathic patients in comparison to us as EPs.

I worry that there might be a wave of litigation related to tele-neurology use. When our group inquired with our malpractice carrier they told us that you are much more likely to be sued for not giving tPA than giving it. I’m concerned there are going to be cases where EPs for appropriate reasons do not give tPA despite tele-neurologist’s recommendations with subsequent bad outcomes that may or may not even be related to acute CVAs, leading to litigation against EPs. If I have strong suspicion for a non-CVA etiology where tPA might cause major harm, I tend to not activate or cancel a stroke alert from the start. I think I’d rather have to defend that decision than to defend going against a neurologist by not giving tPA upon their recommendation.

Agree completely with this. If I am confident that the patient is altered for a reason other than a stroke, I almost never consult neurology precisely because if they recommend tPA when I've already decided not to give it, I either open myself to a lawsuit or am forced into doing something I don't want to do.

 

[GeneralVeers]

This is the problem with being forced to consult neuro by institutional policy for all stroke activations. None of my neurologists are in house after hours, so many of the more conservative neurologists will err on pushing tPA in patients that continue to display neuro abnormalities since they can’t evaluate the patient themselves. I’d much prefer never having to consult them given that their input is rarely useful when they haven’t seen the patient.

I'd rather consult on all the stroke patients. This gives me CYA peace of mind. I can easily forsee a situation where I don't give TPA, then the Monday Morning Neurologist comes in and questions why we didn't give it.

Now I document the discussion with the neurologist, and recommendations (TPA, no TPA) and there's not much anyone can say.

 

[thegenius]

I'd rather consult on all the stroke patients. This gives me CYA peace of mind. I can easily forsee a situation where I don't give TPA, then the Monday Morning Neurologist comes in and questions why we didn't give it.

Now I document the discussion with the neurologist, and recommendations (TPA, no TPA) and there's not much anyone can say.

I as well have mostly stopped questioning Neurologists and just document what they want me to do. But our Neurologists are pretty reasonable, as they usually do not recommend tPA for the young 32 yo comatose pt is unlikely to have a brainstem stroke or the pt with new onset tingling in 1/2 the forearm.

Unless it's an egregious call I do as they say.

 

[GeneralVeers]

The problem with potentially blindly following a specialist’s recommendations in all cases is that if there is a bad outcome, they won’t just hold the specialist liable. I have no doubt that the neurologist would try to argue that they weren’t present at the bedside like you were and that they were just a consultant. I’m sure if there was a seemingly egregious recommendation for tPA you would likely question the decision, but it also puts you in a tough spot.

I wouldn't say blindly. Before I call the neurologist, I know whether I want to give tPA or not. My call starts with: "Dr. XXX I have a patient who I don't think needs thrombolytics, but I'm required to call you on.....". Most of the time they agree with me and I can document that.

I'm not worried about malpractice concerns, it's more the retrospective case evaluation once the neurologist sees the patient the next day.

 

[thegenius]

The problem with potentially blindly following a specialist’s recommendations in all cases is that if there is a bad outcome, they won’t just hold the specialist liable. I have no doubt that the neurologist would try to argue that they weren’t present at the bedside like you were and that they were just a consultant. I’m sure if there was a seemingly egregious recommendation for tPA you would likely question the decision, but it also puts you in a tough spot.

You can be damned if you do, damned if you don't. The point of my comment is that I am no longer an activist in the camp of "tPA doesn't work". As long as it's not abused, I give it.

 

[GeneralVeers]

You can be damned if you do, damned if you don't. The point of my comment is that I am no longer an activist in the camp of "tPA doesn't work". As long as it's not abused, I give it.

I used to fight the same fight over tPA, but there simply was no benefit to me and only grief by fighting it.