Journal article: Start making stroke treatment decisions in the ambulance

As a Houston, Texas medical malpractice lawyer, I have had the opportunity to represent several clients in lawsuits over the misdiagnosis and delayed treatment of strokes.

While it is always a good idea for an injured patient to hire a competent medical malpractice lawyer (rather than an attorney who has a dozen different practice areas), when it comes to strokes, there are even more reasons why that is the case. Here are a few.

Most of the time, strokes are misdiagnosed in a hospital emergency room. Under Texas law, healthcare provider decision-making in a hospital emergency room setting is reviewed under a gross negligence (willful and wanton negligence) standard, which is much higher than the typical general negligence standard. In short, for gross negligence, a medical negligence plaintiff must prove that the defendant had actual, subjective knowledge of findings and then consciously disregarded them, putting the patient at risk.

Another legal challenge for stroke lawsuit plaintiffs comes into play when there is a question about whether an appropriate medication, like the clot-busting drug tPA, was given timely. Under the peer-reviewed, scientific literature, there is a fairly-broad time window in which doctors should give tPA. Under Texas law, though, courts only allow experts to testify that the drug would have likely been effective to treat a patient for a sliver of the time period referenced in the literature.

One of the positive developments that I have seen over the past several years is the development of different types of stroke centers, including acute stroke-ready hospitals, primary stroke centers, and comprehensive stroke centers. Hospitals must go through a vigorous process to obtain accreditation as a primary or comprehensive stroke center, which is awarded by accrediting organizations like The Joint Commission and DNV Healthcare.

Unfortunately, from my direct experience in handling stroke lawsuits, some stroke center-designated hospitals in the Houston area have repeatedly missed the mark. Yet, I still find this type of accreditation to be useful because the process forces hospitals to devote training and effort to meet standards that continuously get more strenuous each year.

For example, I was very interested to read an article in the medical journal JAMA Neurology about how pre-hospital triage of stroke patients is getting attention. Interestingly, comprehensive stroke center standards require accredited hospitals to train ambulance emergency medical technician (EMT) crews on how to triage (figure out and prioritize what is going on with patients) stroke patients.

For anyone interested in the history of how stroke treatment has undergone a sea-change over the past two decades, this article is worth reading. Many physicians used to think that strokes were untreatable, but, in 1996, the medication alteplase (tPA) came along. Now it is the standard of care when it comes to treating ischemic strokes within three hours (4.5 hours in some circumstances) of the beginning of stroke symptoms.

Now, research is pointing to a surgical procedure called thrombectomy (a mechanical surgical procedure to remove a blood clot blocking a blood vessel), particularly in large vessel occlusion (LVO) strokes. Many stroke experts believe that thrombectomy protocols for LVO strokes will be the next game-changer, like tPA, in stroke treatment.

As the saying goes “time is brain” and every minute matters when it comes to stroke. Getting an appropriate stroke patient into the operating room for a thrombectomy is no different.

The JAMA Neurology authors are making some novel and potentially-powerful recommendations. They propose creating a decision model algorithm for ambulance EMT crews when a patient is recognized to have an LVO stroke. It would take significant training for EMTs but could certainly be done. The model would have ambulances bypass nearby hospitals that have alteplase/tPA treatment only, in favor of a somewhat farther destination hospital that is thrombectomy-capable.

As a stroke attorney, I am continuously keeping up with the medical literature and legal standards. In my view, these are some recommendations worth considering and watching.

We are here to help

If you or a loved one has been seriously injured—perhaps with a permanent brain injury—by stroke misdiagnosis and delayed treatment, then the experienced medical malpractice attorneys at Painter Law Firm, in Houston, Texas, are here to help. Click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.

All consultations are free and, because we only represent clients on a contingency fee, you will owe us nothing unless we win your case. We handle cases in the Houston area and all over Texas. We are currently working on medical malpractice lawsuits in Houston, The Woodlands, Sugar Land, Conroe, Dallas, Austin, San Antonio, Corpus Christi, Bryan/College Station, and Waco.


Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.