The Doctor's Doctor: How To Be An Internist In Five Minutes

Internists are known as the doctor's doctor. The breadth of knowledge for internists is enormous. I often laugh at the computer science folks who do drivebyes on my blog and claim that one day a computer will neatly categorize all illness into neat algorithms and make me expendable. It is simply not possible. As an internist, I manage the whole body. And the evaluation and management I perform on every patient is multi tiered in its breadth and structure. I do this with every patient encounter. All day, every day. If you have five minutes, I'll show you how to do what I do. I interpret my data points across four different organizational structures for every patient, every time. Consistency, consistency, consistency.

• By Organ System. Looking at things by organ system is the first way to conquer disease evaluation and management. Is the disease in the brain? The heart? They thyroid? The lungs? The gallbladder? The bladder? The blood vessels? The blood? The bone marrow? The skin? The neurons? The spinal chord? The colon? The eyes? The hair? The nails? The liver? Disease can affect any organ and an internist's job is to figure out which one.

• By Category of Disease Process. Looking at things by category of disease process is another way an internist must classify the illness. Is it infectious? Is it autoimmune? Is it hormonal? Is it traumatic? Is it genetic? Is it environmental? Is it medication induced? Is it a toxin? Is it allergic? Is it iatrogenic? Is it cancerous? And within each of these categories of disease processes, the internist must ask himself which organ system the disease process is affecting. Is it allergy induced asthma or is it genetic alpha-one antitrypsin induced emphysema. Is it alcohol related cirrhosis or Wilson's disease. Is it myelodysplastic syndrome, a disease of the bone marrow, or is it medication induced pancytopenia. What is the process of the disease?

• Is It Systemic Or Localized? Once you understand the disease process and which organ it affects, you must also know whether the problem is a localized process or a systemic process, and if it is systemic, how else does it present. So much in medicine is lost when you aren't keeping your eyes open. When you focus so strongly on one part of the body and fail to understand the rest. Some infections can be localized in an organ, like an abscess in the liver. Some infections can be systemic and involve multiple organs. Like mononucleosis. Some autoimmune diseases can affect just one organ, like multiple sclerosis and its effect on the neurons of the brain and spinal chord. Other autoimmune diseases, like lupus can span multiple organs, from kidneys and brain to heart and lungs. Lets go back to the cirrhosis example. So it wasn't alcohol related after all. It was hemochromatosis, a genetic disease of iron metabolism that can also affect your skin, joints, pancreas and brain. Is your disease process systemic or localized? Sometimes you find liver disease when your looking for arthritis. It's amazing disease doesn't operate in a cubby hole. And if your disease is a systemic process, you must always be on the look out for its systemic complications.

• Is It Acute Or Chronic? As an internist you want to know if the problem is new or old. Has the patient had heart disease for 25 years, or was it diagnosed last week? Has the patient had diabetes before or is that blood sugar of 350 a new finding? Is that Hgb of 8.9 new or was it there three years ago? Knowing whether something is new or old means all the difference in the world in how you approach it diagnostically. What are you going to do with the information you have in front of you?

What you have here is how I break down every possible illness known to man. Every possible illness can be categorized by organ system, type of disease process, a systemic or localized process and acute or chronic nature. But we aren't done yet. This is just the disease. Full of randomized controlled trials with objective data points. What about the patient? Where do they fall into the loop? Patients don't come to your office complaining of Factor V Leiden. They don't come to your hospital complaining of systemic inflammatory response syndrome. They don't come to your office or hospital complaining of grade II esophageal varices. They come to your office complaining of a swollen leg. They come to your office with dizziness and pain when they pee. They come to your hospital vomiting blood. The goal of all physicians is to try and match the subjective complaints of the patient with the object data points. So you must add in the last component of being an internist

• What Does The Patient Tell You? Are they pointing to one specific point in their belly and saying it hurts right here in my right lower quadrant? Or do they wave their hand over their belly and say it hurts all over? Are they even able to talk? Do they have one complaint? Or a hundred? Do their complaints make sense anatomically? Do they make sense physiologically? Is that pain that jumps from the right leg and makes a right angle turn across the abdomen into the left pinky finger real? Are their complaints believable? Are there too many complaints to believe any of them, the pan positive review of systems? Does mental illness cloud their reality? What the patient tells you can either be diagnostic of a very specific condition or more likely, a generalized constellation of complaints that could be a multitude of disease processes as described above. Great historians are wonderful. Bad historians are painful to work with.

And after the patient has talked with you, Dr Internist, it's your job to try and figure it all out, from the top of the their fro to the bottom of their big toe.
It can be very simple

• I'm coughing, short of breath and have fever and an infiltrate on chest xray which turns out to be a simple pneumonia.

Or it can be something much more complex.

• I'm coughing, short of breath and have fever and an infiltrate on chest xray may in fact be Wegener's granulomatosis, an autoimmune process associated with acute renal failure. It may in fact be a post obstructive infiltrate caused by large lung mass and complicated by an empyema. It may in fact be acute lung injury caused by amiodarone toxicity. It may in fact be tuberculosis. It may in fact be an infarct from a pulmonary embolism. It may be a lot of things.

It may be a lot of things. That's what you can expect from your internist. That's why you should want an internist taking care of you. That's how an internist thinks. That's how they were trained. That's how they manage patients every day of the week. That's why internists won't be replaced with computers. That's why they wont be replaced by extenders. In spite of the folks who say we just need more extenders to manage our health care system. They are not trained to do this type of critical thinking. They do not have the medical foundation or the experience to manage illness through these 4 concurrent stages of evaluation. I know this because I did not fully understand it until the end of my seven year journey to my National Board Exam, which certified my as a physician with expertise in his field of knowledge. A knowledge base you want if you ever get sick.
There you are. That's what your internist does. Every day. That's why the world needs us. Because we have the ability to do something nobody else in the world can. And that is to be the doctor's doctor.

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Bisphenol A

Bisphenol A (BPA) is a chemical compound used to create polycarbonate plastic and epoxy resins. BPA-derived plastics, commercially produced since the 1950s, have become ubiquitous because of their shatter resistance, visual clarity, high heat resistance, and electrical resistance. Polycarbonate plastics are found in an enormous range of products, including eyeglass lenses, CDs and DVDs, personal computers, appliances, power tools, sports equipment, medical devices, and food and drink containers. Epoxy resins are easily formed and resist chemicals, which makes them useful in products such as printed circuit boards, paints and adhesives, dental sealants, and coatings for the inside of metal cans.

Over time, the chemical bond connecting the BPA building blocks deteriorates, releasing BPA molecules. The quantity released is typically very low, but the plastics are so widespread—they're in baby bottles, water bottles, metal food cans, food storage containers—that people are regularly exposed. In a 2003-2004 study by the U.S. Centers for Disease Control, nearly 93 percent of the people tested, age six and above, had detectable bisphenol A in their urine; females had slightly higher levels than males.

The health effects of bisphenol A are widely disputed. The amounts that leach into food are well below the safety thresholds set by the U.S. Environmental Protection Agency (EPA) and the European Commission Scientific Committee on Food. The EPA safety level is based on toxicity testing conducted in the 1980s that showed weight loss in rats given 50 milligrams of BPA per kilogram of body weight each day.

Traditional toxicity testing, including the EPA study, relied upon the idea that a chemical would have no detrimental effect below a certain dose. Tests were conducted by using relatively high doses and then either increasing the dose until an adverse effect was seen or decreasing it until the adverse effect was no longer observed. But subsequent research suggests that for some chemicals, including BPA, a second threshold exists below which similar or new adverse effects occur.

These low-dose effects are commonly associated with the endocrine system, the chemical communication system found in humans and most wildlife. While the nervous system is the rapid communication system controlling functions such as heartbeat, breathing, and movement, the endocrine system typically handles long-term functions and processes, including the development of the brain, nervous system, and other organs and tissues; growth and metabolism; and the functioning of the reproductive system. Hormones are the chemical messengers of the endocrine system, and chemical compounds that mimic hormones, affect their production, or prevent them from reaching their target are known as endocrine-disrupting compounds, or EDCs.

Critics of BPA cite the potential effects of low doses as a cause for concern. Research has shown that BPA mimics estrogen, a naturally occurring hormone, and therefore can affect the body's endocrine system. BPA's effects are often most pronounced when humans are in stages of rapid development, such as in the womb or during childhood. Laboratory studies conducted since the 1990s have noted that low-dose BPA exposure may be connected to abnormal penis development in males, early sexual maturation in females, an increase in neurobehavioral problems such as attention deficit hyperactivity disorder (ADHD) and autism, an increase in childhood and adult obesity and type 2 diabetes, and an increase in hormonally mediated cancers, such as prostate and breast cancers.

As concerns over the potential health effects of BPA exposure have become publicized, manufacturers, consumers, and governments have taken steps to reduce BPA use and exposure. In April 2008 Canadian regulators announced a ban on the use of BPA plastics in baby bottles. As a result, the European Food Safety Authority is now considering whether to take a similar step, and U.S. lawmakers have introduced a bill to ban its use in children's products. In the meantime, manufacturers and consumers have already begun taking steps to reduce BPA use. Many people are now exchangingBPA-containing plastics—including hard-plastic water bottles and baby bottles—for other plastics, glass, or stainless steel containers. Additionally, retailers such as Wal-Mart and Toys "R" Us have announced that they'll remove BPA-containing baby bottles from their stores. Still, the U.S. Food and Drug Administration released a statement in April 2008 that it isn't recommending that anyone discontinue using products with BPA while it continues to assess the risk.

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Beta Blockers Worsen Blood Sugar--May Cause Diabetes

 

Many people know that it is a bad idea for anyone who takes insulin or a sulfonylurea drug to take a beta blocker. This is because it has long been known that these drugs block the counter-regulatory response that prevents a dangerous hypo or--if it cannot prevent the hypo--at least gives the victim some warning that one is coming by causing shakes and pounding pulse.

Now evidence from a huge study of almost 20,000 people has learned that beta blockers are dangerous to anyone with any blood sugar abnormality. The study is Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA,). It was published in Diabetes Care in May.

Determinants of new-onset diabetes among 19,257 hypertensive patients randomized in the Anglo-Scandinavian Cardiac Outcomes Trial--Blood Pressure Lowering Arm and the relative influence of antihypertensive medication.

It concluded: "Baseline FPG >5 mmol/l, BMI, and use of anatenolol +/- diuretic regimen were among the major determinants of NOD [Non-insulin dependent diabetes i.e. Type 2] in hypertensive patients."

An analysis of the study (which is still only available as an abstract to non-subscribers) published in Irish Medical News explains "Hypertensive patients allocated to amlodipine and perindopril were found 34% less likely to develop NOD [Type 2] compared with those allocated to the β-blocker/diuretic combination."

Diabetes in Control adds the following: "Says Dr Anoop Misra, director and head (diabetes and metabolic diseases) Fortis Hospitals: "In patients with hypertension, beta blocker drugs are no longer frontline therapy. These drugs may not only increase blood sugar levels in those who don't have diabetes, but may worsen sugar control in those with diabetes and also blunt warning symptoms when low sugar occurs."

My mail suggests that American doctors are not aware of the negative impact of beta blockers on the blood sugar of their patients as many people with Type 2 who contact me are taking these drugs. My own doctors have also prescribed beta blockers for me in the past.

Here is a list of commonly prescribed beta blockers:

Generic name/Brand Name

cebutolol- Sectral

Atenolol (G)- Tenormin

Betaxolol- Kerlone

Bisoprolol fumarate- Zebeta

Carteolol hydrochloride- Cartrol

Metoprolol tartrate (G)- Lopressor

Metoprolol succinate- Toprol-XL

Nadolol (G)- Corgard

Penbutolol sulfate- Levatol

Pindolol (G)- Visken

Propranolol hydrochloride (G)- Inderal, Inderal LA

Timolol maleate (G)- Blocadren

CAUTION! Do NOT Stop These Drugs Without Help from Your Doctor

One of the nastier problems with Beta Blockers is that if you are taking one and stop it suddenly you raise the risk of having a heart attack. So if you are taking a beta blocker, you MUST contact your doctor and ask for guidance as to the safe way of getting off of it and onto a drug that is safer for people with diabetes.

There are alternatives to Beta Blockers. ACE inhibitors like Lisinopril do not raise blood sugar and also appear to have some kidney-protective qualities. Those who cannot tolerate ACE inhibitors usually do well on ARB drugs which include Diovan (Valsartan) and Avapro (Irbesartan). ARB drugs besides lowering blood pressure, also lower insulin resistance slightly. Though this effect is not usually detectable in people who are severely insulin resistant, I see an immediate impact on my own blood sugar when I take a dose of Diovan after not having used it in a while.

HCTZ (Hydrocholorothiazide, often abbreviated HCT) is a diuretic which is prescribed alone or combined in pills containing other blood pressure drugs. It has been shown to raise blood sugar. This may be because as a diuretic it eliminates water from the blood stream and this concentrates the glucose that is left. Whatever the explanation, if you can control your blood pressure with medications that do not contain HCT do so. Your blood sugar will thank you. Many doctors immediately prescribe the combination pills that contain this diuretic as a first line treatment, rather than prescribing the other drug alone. But if you cannot get adequate control with just the one pill, HCT may help. Just make sure you drink a lot of water with it.

Blood pressure control is as important as blood sugar control in preventing heart disease and stroke and it is thought that the overall improvement in stroke and heart attack statistics over the past decade are due to patients having better blood pressure control. So don't let this news make you avoid doing something about high blood pressure. Just make sure that the drugs you take to control your blood pressure are ones that are safe for people with pre- and full fledged diabetes.

Other ways to lower blood pressure are:

1. Cut way down on carbohydrates. Many people, though not all, will see dramatic drops in their blood pressure when they cut down on their carbohydrate intake.

2. Exercise.

3. Lose weight.

4. Eliminate salt from your diet. Whether this works depends on your genetic make up. For people whose genes make them salt sensitive, cutting salt causes a dramatic improvement in blood pressure. For others it has no effect.

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Xylitol May Prevent Early Childhood Tooth Decay

 

Photo courtesy of iStockphoto, Craig Veltri

In a recent clinical trial, researchers report a significant reduction of tooth decay in toddlerstreated with the topical syrupxylitol, a naturally occurring non-cavity-causing sweetener.

Researchers reported that nearly 76% of the children in the group who received xylitol were free of tooth decay by the end of the study, compared with 48% of the children in the group that did not receive the substance.

Xylitol is FDA approved as a food additive, and is classified as safe. For the purpose reported here, it can be administered in the form of chewing gum, lozenges, or syrup.

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New Tuberculosis Vaccine Goes Into Clinical Trials

After 80 years, a new live vaccine against tuberculosis enters clinical trials this week. The new vaccine, VPM1002, is based on a vaccine that has been in use since 1921, and has been genetically engineered to prevent infection with tuberculosis bacteria much more effectively than its predecessor.

"The BCG tuberculosis vaccine, which was developed by French researchers, is the most frequently administered live vaccine in the world," says Kaufmann. However, BCG (short for the bacterium Bacillus Calmette-Guérind) is now frequently ineffective. The immunologist continues: "BCG has become a blunt weapon. We wanted to use genetic engineering to sharpen it so that, rather than hiding from the human immune system, it would stimulate it as much as possible."
"The vaccine bacteria are taken up by the scavenger cells of the human immune system and end up in their digestion chambers. The genetically engineered modification allows them to escape from the chambers and arm the immune system against the tuberculosis pathogens."

The new vaccine has been developed at the Max Planck Institute for Infection Biology. In 2004, the vaccine was licensed to the Hanover-based VPN, which expedited the clinical study.

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Medical Mystery: Only One Person Has Survived Rabies without Vaccine--But How?

RABIES SURVIVOR: Jeanna Giese plays with her dog Maggie in her yard last summer in Fond du Lac, Wisc. The medical marvel survived rabies without vaccination.
AP Photo/Morry Gash

Four years after she nearly died from rabies, Jeanna Giese is being heralded as the first person known to have survived the virus without receiving a preventative vaccine. But Giese (pronounced Gee-See) says she would gladly share that honor with others if only doctors could show that the treatment used to save her could spare other victims as well. "They shouldn't stop 'till it's perfected," said Giese, now 19, during a recent interview about physicians' quest to refine the technique that may have kept her alive.
Giese's wish may come true. Another young girl infected with rabies is still alive more than a month after doctors induced a coma to put her symptoms on hold, just as they did with Giese. Yolanda Caicedo, an infectious disease specialist at Hospital Universitario del Valle in Cali, Colombia, who is treating the latest survivor, confirmed reports in the Colombian newspaper El País that the victim is an eight-year-old girl who came down with symptoms in August, about a month after she was bitten by an apparently rabid cat. Caicedo said that the family had sought treatment for the bite in Bolivar, at a hospital about three hours by foot from their rural home, but that the child, Nelsy Gomez, did not receive the series of vaccines that can prevent the virus from turning into full-blown rabies.
The five shots contain minute amounts of the dead rabies virus and are designed to nudge the body into developing antibodies to fight it. Patients are also given a shot of immunoglobulin (in this case a synthesized rabies antibody) to protect them while their immune systems produce antibodies to the vaccine virus. But the combination is only effective within six days of infection, before symptoms show up; when Gomez developed signs of the disease, it was too late for the shots. With no other options available, doctors induced a coma.
Caicedo is hopeful, but indicated that Gomez will face a long, slow recovery. She would not say how long Gomez was comatose but told ScientificAmerican.com that she had been awake for "a few days" and is stable. The child can move her fingers but cannot walk or eat on her own, and her eyes are open but she cannot speak yet and physicians are not sure if she can see, Caicedo says.
Giese, informed of the case, says that she "hopes and prays" that Gomez will survive.
Giese was the keynote speaker at a conference last week in Atlanta, where scientists gathered to discuss the latest research being conducted on ways to battle the deadly disease. During her talk, she urged physicians to continue efforts to pin down treatments that work.
Giese was 15 when she was infected after being bitten by a rabid bat she had picked up outside her church in her hometown of Fond du Lac, Wisc.

Her parents cleaned the superficial wound and she says they did not believe it was necessary to seek further medical treatment. "We never thought of rabies," she says. By the time Giese began displaying signs of rabies three weeks later—fatigue, double vision, vomiting and tingling in her left arm—it was too late for the antirabies vaccine cocktail.
Instead of giving her up for dead, the doctors decided to "shut the brain down and wait for the cavalry to come" by inducing a coma to give her own immune system time to build up antibodies against the virus, says Rodney Willoughby, an infectious disease specialist who treated Giese at the Children's Hospital of Wisconsin in Milwaukee. Willoughby devised the treatment credited with saving Giese there, which has since become known as the Milwaukee protocol.
Rabies kills by compromising the brain's ability to regulate breathing, salivation and heartbeat; ultimately, victims drown in their own spit or blood, or cannot breathe because of muscle spasms in their diaphragms. One fifth die from fatal heart arrhythmia. Doctors believed that Giese might survive if they suppressed her brain function by sedating her while her immune system attacked the rabies virus.
This was the first time the therapy was attempted, and doctors had no clue if it would work or, if it did, whether it would leave her brain damaged. But Willoughby says it was the only chance doctors had of saving her.
When she arrived at the hospital, Giese couldn't talk, sit or stand and fell in and out of consciousness—she also needed to be intubated to help her breathe. "She was critically ill," Willoughby recalls, "and looked as if she might die within the day."
In addition to inducing the coma, doctors also gave her the antivirals ribavarin and amantadine. They tapered off the anesthetics after about a week, when tests showed that Giese's immune system was battling the virus. For about six months after awakening from the coma, physicians also gave her a compound called tetrahydrobiopterin that is chemically similar to the B-complex vitamin folic acid, which may have improved her speech and ability to eat, Willoughby says.
He notes that physicians gave her the supplement after tests showed that she had a deficiency of the compound, which is known to boost production of serotonin and dopamine neurotransmitters needed to perform motor, speech and other routine bodily functions.

Remarkably, Giese survived. She recovered most of her cognitive functions within a few months, and other skills within a year, Willoughby says. She got her driver's license and is now a sophomore at Marian University in Fond du Lac, where she is majoring in biology. There are lingering signs of her illness: Giese, once an avid athlete, says she now lists to one side when she runs and walks and no longer plays volleyball, basketball and softball as she once did. She also speaks more slowly and sometimes not as clearly as before her illness, but Willoughby says these effects may fade over time.
Giese is "pretty much normal," says Willoughby, an associate professor of pediatrics at the Medical College of Wisconsin in Milwaukee. "She continues to get better, counter to conventional medical thinking."
Rabies has an incubation period of two weeks to three months and kills within a week of the symptoms showing up. The vaccine series and other immune therapies are useless at this point and may even speed up and increase the severity of the symptoms. Usually, patients are made as comfortable as possible in the hospital or, in countries without sophisticated health care, sent home to die an agonizing death.
Antiviral drugs and immune therapies including steroids, disease-fighting interferon-alpha and poly IC (which stimulates the body's own production of interferon-alpha) have been tried, but none have been shown to be lifesaving on their own, Willoughby says.
Over the past four years, the Milwaukee protocol to differing degrees has been used a dozen times, but until now Giese was the sole survivor. Exactly why she lived—and the others died—is still a mystery.
In a 2005 report on her case in The New England Journal of Medicine, Willoughby speculated that she may have been infected with a rare, weakened version of the virus. Today, he chalks Giese's survival up to aggressive intensive care, the decision to sedate her "and 10 percent sheer luck." Which element of that combination made the difference, and whether the antivirals she was given helped save her is unknown.
"In all honesty, we were probably just pretty lucky," he says. Only another survivor, and then animal and clinical trials, will show if the therapy works, and why, he says. The U.S. Centers for Disease Control and Prevention (CDC) plans to test the protocol on rabies-infected ferrets; Thai and Canadian doctors, who unsuccessfully treated a 33-year-old man with rabies with the Milwaukee protocol, recommended in the Journal of NeuroVirology two years ago that physicians exercise "caution" in using the treatment, because it is too expensive and lacks " a clear scientific rationale." Willoughby says it cost about $800,000 to treat Giese.

Rabies is 100 percent preventable with vaccinations if patients receive them before the onset of symptoms, including hallucinations, delirium, muscle spasms, paralysis and hydrophobia. Yet an estimated 55,000  people, mostly in Asia and Africa, die from it annually because of misdiagnosis or because the illness is not recognized until it has taken hold, according to the journal Neurologic Clinics. Often, patients dismiss the potential seriousness of bites, cannot afford follow-up medical treatment or, in some situations, are unaware they've been bitten, as was the case of a 13-year-old Connecticut girl who died of rabies in 1995.
Vaccine shortages as one manufacturer, Bridgewater, N.J.–based sanofi–aventis, upgrades its factory to meet U.S. Food and Drug Administration requirements, and chronic shortfalls of immunoglobulin also play a role in the fatalities. The vaccine-immunoglobulin regimen costs $1,200 to $2,000 in industrialized nations and $100 to $300 in developing countries—an out-of-reach sum for many people, Willoughby says.
Though it's promising that Gomez is still alive, "The hope that the outcome will necessarily be the same as with Jeanna, particularly in a developing country, is expecting a bit much," laments Charles Rupprecht, chief of the CDC's Rabies Program
Willoughby acknowledges that even if Giese's success is reproducible—and the Milwaukee protocol perfected—it likely will only be available for use in 10 percent of cases, because of limited medical facilities in developing countries.
"Re-creating that in a place stricken with poverty, you get into ethical issues of whether we should do this when we should be about prevention; and does that society have the ability to rehabilitate a patient who may survive but with severe [side effects]?" Rupprecht says. "Jeanna created several ethical issues for all of us to deal with this bug."
Giese says that the fourth-year anniversary of her illness has brought up some bitter memories that she'll probably never shake, but she's glad to be alive—and doing as well as she is.
"It takes some getting used to, but I've kind of come to terms with the fact that I'm the only…[survivor]," she says. "At 15, I never would have thought that anything like this would ever happen, and that I lived is just amazing."
An animal lover who owns a dog, two rabbits and six birds, she hopes to one day open a sanctuary in Fond du Lac for endangered animals, including "big predators like lions and tigers and wolves," and maybe even bats, too.
"I'm not scared of them at all," Giese says of bats. "I'm more passionate about animals than I was before. Animals are my happiness and reason for living."

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Will More Stroke Patients Receive Thrombolytics Now?

According to this article in the September 25th edition of the New England Journal of Medicine, alteplase improves the outcomes in stroke patients up to 4.5 hours after symptom onset. Previously, the “window” of effectiveness was only three hours. The clinical trial criteria are here.

The percentage of patients having a favorable outcome at 90 days in this study wasn’t huge, but was statistically significant - 52% of patients receiving alteplase had good outcomes compared with 45% of patients who received placebo. At the same time 27% of patients had some type of bleeding after receiving thrombolytics compared with only 17% of patients who had bleeding after receiving placebo. The rate ofsymptomatic bleeding in the brain was 2.4% for thrombolytics versus 0.2% for placebo.

So while you may have an overall improvement in your outcome at 90 days if you get the medication, more than 1 in 4 patients who receive the medication will have bleeding and 1 in 40 patients will have symptomatic bleeding.

Is it worth the risk?

In the editorial article accompanying the study, one of the study authors states that “one cannot help wondering why thrombolytic therapy has traveled such a long, difficult path to wider clinical use.”

I can help wondering.

Thrombolytics are one of the few things that physicians can give that will have an immediate and significant harm on patients. Sure, patients may occasionally have bad outcomes from allergic events or they may have undesirable side effects from some medications. But 2.4% of patients will havesymptomatic bleeding in their brains when they get thrombolytics. Some of those patients will die. Bad outcomes in this society are a plaintiff attorney’s dream.

No health care provider wants to risk their life savings even if there is a “small” chance that they could be sued.

So the choice is …
1. Let patient continue with the stroke symptoms they have already presented with and follow the doctrine of “primum non nocere.” After all, even this study shows that if doctors do nothing, 45% of the patients will get better on their own.
-or-
2. Give a medication that may improve clinical outcome in 7% more of the patients … at the risk of getting dragged through 3-5 years of litigation and losing your life savings if the patient has a bad outcome from the medication.

What would you choose?

Want a simple way to immediately expand the use of thrombolytic therapy?

Grant blanket immunity from liability if thrombolytics are given according to the established guidelines. Create a checklist at “guidelines.gov” and let all healthcare providers download it. If the guidelines are followed, the healthcare providers can’t be sued or have any professional actions taken against them. Period.

If an emergency physician gets a CT report from a radiologist that says “no bleed,” the patient meets the criteria for thrombolytic therapy and doesn’t have any exclusion criteria, then the emergency personnel cannot be held liable for any bad outcomes for giving thrombolytics.

There will still be some docs that philosophically disagree with giving patients a medication that could kill them. Nevertheless, there would be an instant spike in thrombolytic use. I guarantee it.

Plaintiff attorneys will stomp up and down at the thought of this idea.

Then again, 7% more of the stroke victims in this country - some of them attorneys - might be able to stomp up and down if docs weren’t so afraid to give thrombolytics for strokes.

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