He had an MRI result with 2.5 hours of arrival at the ED?! This is really impressively quick even for a large stroke center. These plaintiff experts must be high when they review these cases; they are clearly divorced from reality. This was a case of bad luck for the patient and not bad medical care. They got good care and those doctors were punished despite that.
The time from door to order and door to final report (for CT scan) misses a huge component. When the order is placed, The order has to be received by the radiology technician in the CT scanner, the patient has to be transported to the CT scanner, patient information his to be placed in the radiology information system(RIS). Patient has to be placed in the scanner, images have to be acquired and sent to the PACS (radiology images are a separate system from RIS) system in their entirety (can be 200 images for non contrast head CT up to 3000 for a ct angiogram of head. The images are then interpreted by radiologist. So when goal is 45 min door to CT read, it assumes a lot of things that radiologist has no control over. Their clock should not start until the images are fully acquired and sent to PACS.
Completely agree. A lot of these goals are created by administrators under pressure from national accrediting organizations, with little understanding of how medicine is actually practiced.
This! Going to CT is not a simple/easy process. It’s not like a portable CXR where a tech just shows up and poof, it’s done.
I’m an ICU nurse at a large Level One Trauma Center/teaching facility.
It is nurses’ responsibility to take a pt to CT. (unless the pt is a GCS 15/stable/no monitoring. But if you’re a stable GCS 15 pt it unlikely you need a CT to begin with)
Taking a pt to CT, even if it’s ordered STAT, is pretty complicated, a lot of stars have to align before you can even get the pt to the scanner.
1. The CT machine has to be available. In my facility (approx 700 beds) there is only 1 CT machine. CT tech/machine is often inundated with STAT CT orders. Spoiler alert, there are a shit ton of STAT CT orders at a trauma center.
2. Pt has to be stable enough for transfer. Luckily, I’ve only had 1 pt code in CT but as you could imagine it did not go well. Good luck finding the crash cart and someone to help you run a code when you’re off the unit. Even if you call a code overhead it will take about 5-6 mins for the rapid response team to arrive.
If the pt is unstable or has high FiO2 requirements going to CT may not be worth the risk.
3. An Respiratory Therapist must be available to transport the pt to CT. If the pt is intubated, an RT must be available to got to CT with you as the pt requires a portable vent, the RT can bag the pt but this obviously less desirable.
4. In addition to having an RT& RN available for transport you also need pt transporter.
Transporter to push the bed, RT to handle bagging the pt/ portable vent and the RN to monitor all the vitals signs on a the transport monitor and handle the multiple drips, while making sure the central line/art line/ETT don’t get pulled out accidentally.
5. The radiologist has to be available to read the images.Radiology is also inundated with a ton of STAT orders.
It’s so frustrating to see how out of touch the ppl reviewing these cases actually are.
Can you list the states in which these cases are occurring in? I think it's important to be transparent to medical trainees that the abuse of local malpractice laws by nefarious family members and lawyers are more prominent in certain states. Well informed physicians should do themselves a favor and not choose these states to ever practice in.
That's how he was described by multiple physicians involved. No further details given in the lawsuit... its usually the atypical cases that don't follow the textbook that give rise to these lawsuits!
Good case, lots of delays to care here. It appears this was at a stroke center which makes some of the clinical decisions suspect, no CTA?, no thrombectomy or transfer?
The real reason I'm here is your statement "The utility of tPA in strokes has been called into question recently, with analysis of multiple studies showing that there is probably no benefit, if not harm". Are we still doing this? Even the ACEP agrees at this point in the right structure (ie stroke centers) tPA is beneficial. I have read the point and counterpoint to the data of the early trials and there is risk but clear benefit. The newest data (EXTEND) also shows the early benefit at 24 hours that NINDS and ECASSII lacked but also confirms long term improvement. I think we can put this to bed. tPA works, but comes with risk, in a structure with docs in ED and neurology who examine and determine candidacy quickly and deliver medicine fast the benefits outweigh the risks.
A fair criticism, probably worded in a way that doesn't reflect the data accurately. I think data will look better as we get more specific in figuring out which patients may actually benefit. Thanks for the comment.
I would remove your TPA comment at risk of alienating readers as it is patently false. That line of thinking was unfortunately perpetuated by many a non-neurologist (mostly EM) leading to untold amounts of disability over the years. It's sad really. It's a close cousin of chronic lyme, CCVSI for MS, etc..
He had an MRI result with 2.5 hours of arrival at the ED?! This is really impressively quick even for a large stroke center. These plaintiff experts must be high when they review these cases; they are clearly divorced from reality. This was a case of bad luck for the patient and not bad medical care. They got good care and those doctors were punished despite that.
The time from door to order and door to final report (for CT scan) misses a huge component. When the order is placed, The order has to be received by the radiology technician in the CT scanner, the patient has to be transported to the CT scanner, patient information his to be placed in the radiology information system(RIS). Patient has to be placed in the scanner, images have to be acquired and sent to the PACS (radiology images are a separate system from RIS) system in their entirety (can be 200 images for non contrast head CT up to 3000 for a ct angiogram of head. The images are then interpreted by radiologist. So when goal is 45 min door to CT read, it assumes a lot of things that radiologist has no control over. Their clock should not start until the images are fully acquired and sent to PACS.
Completely agree. A lot of these goals are created by administrators under pressure from national accrediting organizations, with little understanding of how medicine is actually practiced.
This! Going to CT is not a simple/easy process. It’s not like a portable CXR where a tech just shows up and poof, it’s done.
I’m an ICU nurse at a large Level One Trauma Center/teaching facility.
It is nurses’ responsibility to take a pt to CT. (unless the pt is a GCS 15/stable/no monitoring. But if you’re a stable GCS 15 pt it unlikely you need a CT to begin with)
Taking a pt to CT, even if it’s ordered STAT, is pretty complicated, a lot of stars have to align before you can even get the pt to the scanner.
1. The CT machine has to be available. In my facility (approx 700 beds) there is only 1 CT machine. CT tech/machine is often inundated with STAT CT orders. Spoiler alert, there are a shit ton of STAT CT orders at a trauma center.
2. Pt has to be stable enough for transfer. Luckily, I’ve only had 1 pt code in CT but as you could imagine it did not go well. Good luck finding the crash cart and someone to help you run a code when you’re off the unit. Even if you call a code overhead it will take about 5-6 mins for the rapid response team to arrive.
If the pt is unstable or has high FiO2 requirements going to CT may not be worth the risk.
3. An Respiratory Therapist must be available to transport the pt to CT. If the pt is intubated, an RT must be available to got to CT with you as the pt requires a portable vent, the RT can bag the pt but this obviously less desirable.
4. In addition to having an RT& RN available for transport you also need pt transporter.
Transporter to push the bed, RT to handle bagging the pt/ portable vent and the RN to monitor all the vitals signs on a the transport monitor and handle the multiple drips, while making sure the central line/art line/ETT don’t get pulled out accidentally.
5. The radiologist has to be available to read the images.Radiology is also inundated with a ton of STAT orders.
It’s so frustrating to see how out of touch the ppl reviewing these cases actually are.
Can you list the states in which these cases are occurring in? I think it's important to be transparent to medical trainees that the abuse of local malpractice laws by nefarious family members and lawyers are more prominent in certain states. Well informed physicians should do themselves a favor and not choose these states to ever practice in.
100% agree. Those states should be deprived of decent health care providers. Let them live in their self perpetuated disaster
Unresponsive? Describe further. Isolated MCA stroke would not be expected to cause severe alteration in LOC
That's how he was described by multiple physicians involved. No further details given in the lawsuit... its usually the atypical cases that don't follow the textbook that give rise to these lawsuits!
It can come with profound hemispatial neglect though, which looks like unresponsiveness depending on where you're standing. Seen that a few times.
Good case, lots of delays to care here. It appears this was at a stroke center which makes some of the clinical decisions suspect, no CTA?, no thrombectomy or transfer?
The real reason I'm here is your statement "The utility of tPA in strokes has been called into question recently, with analysis of multiple studies showing that there is probably no benefit, if not harm". Are we still doing this? Even the ACEP agrees at this point in the right structure (ie stroke centers) tPA is beneficial. I have read the point and counterpoint to the data of the early trials and there is risk but clear benefit. The newest data (EXTEND) also shows the early benefit at 24 hours that NINDS and ECASSII lacked but also confirms long term improvement. I think we can put this to bed. tPA works, but comes with risk, in a structure with docs in ED and neurology who examine and determine candidacy quickly and deliver medicine fast the benefits outweigh the risks.
A fair criticism, probably worded in a way that doesn't reflect the data accurately. I think data will look better as we get more specific in figuring out which patients may actually benefit. Thanks for the comment.
I would remove your TPA comment at risk of alienating readers as it is patently false. That line of thinking was unfortunately perpetuated by many a non-neurologist (mostly EM) leading to untold amounts of disability over the years. It's sad really. It's a close cousin of chronic lyme, CCVSI for MS, etc..