“It is unclear why he was not considered a TPA candidate.”
That sentence grabbed my attention when I read it in a neurologist’s report about our client. Let’s call him Rigo.
What is TPA?
TPA, or tissue plasminogen activator, is a drug that physicians can order for eligible patients who are having an ischemic stroke. Most strokes are ischemic, meaning they’re caused when a clot forms, dislodges, and blocks a blood vessel to the brain. TPA is basically a clot-busting medication.
Rigo is dealing with the fallout from a massive ischemic stroke. He was at the hospital emergency room (ER) within 30 minutes of his sudden stroke symptoms that included facial droop (asymmetry), aphasia (abnormal speech), nausea, vomiting, extreme headache, and dizziness (room spinning).
So why wasn’t Rigo considered a TPA candidate?
When he got to the hospital, the ER team got him into the CT scanner within a few minutes. That part of his care was impressive. For a stroke protocol CT scan of the head and brain, a negative result doesn’t necessarily mean the patient isn’t having a stroke. It just means that the patient doesn’t have acute intracranial bleeding (a brain bleed) which would be a reason not to give TPA.
Stroke symptoms
Rigo’s ER doctor ordered a CT scan under the stroke protocol, noting the reason for the scan was aphasia. His CT scan was negative, so that wasn’t a reason to withhold TPA. The physician also noted his exam findings that Rigo had some facial asymmetry. These two findings alone are classic signs of a stroke.
So why wasn’t Rigo considered a TPA candidate?
Questionable NIH Stroke Scale
Around the same time as the CT scan, an ER nurse did an NIH Stroke Scale assessment of Rigo. She scored him a 0. That doesn’t make any sense based on the ER doctor’s reasoning for ordering the CT scan, or his finding of facial asymmetry/droop.
Unfortunately, the ER nurse and ER doctor didn’t sort out their different evaluations. In fact, after the nurse’s 0 NIH Stroke Scale score and negative CT scan findings, nothing happened. For hours. And hours.
Eventually, a new ER doctor started his shift and reassessed Rigo. He ordered a teleconsult with a neurologist. By this time, Rigo was way outside the TPA treatment window. The next morning, Rigo was transferred by ambulance to a larger hospital.
That’s where the neurologist documented his confusion over why Rigo wasn’t considered a TPA candidate. Follow-up scans at the new hospital revealed Rigo’s massive stroke.
Mild but disabling stroke symptoms and TPA
We consulted with a stroke neurologist about the care at the first hospital and discussed important guidelines put out by the American Heart Association/American Stroke Association for the early management of acute ischemic stroke. You can read them here.
Under the guidelines, if a patient has mild but disabling stroke symptoms and it’s within three hours of the initial development of the symptoms (last known well), then it’s appropriate to give TPA. That’s provided, of course, that no contraindication or problem would otherwise render the patient ineligible to receive TPA.
The expert commented that he would consider the aphasia, or speech disturbance, alone to be a disabling stroke symptom for this patient who was in his 40s. He explained that he would have recommended the treatment to this patient for whom TPA had a low risk.
If you were in that situation, would you want to receive TPA? Or would you prefer to absorb the risk of having a life-long problem of being unable to communicate normally? Would you want your physician to at least talk to you about the TPA treatment option? Rigo didn’t even get that.
Stroke cases are notoriously challenging under current legal standards. Some courts have noted, in some cases, that it’s simply impossible to pursue a stroke medical malpractice case. In others, though, our firm has been successful.
If you’ve been seriously injured because of poor stroke care in Texas, then contact a top-rated, experienced Texas medical malpractice attorney for a free strategy session about your potential case.
