tag:blogger.com,1999:blog-5883634615775822475.post6609883203025549276..comments2024-03-18T09:00:31.992-04:00Comments on Doctor Grumpy in the House: TPA- A PlayGrumpy, M.D.http://www.blogger.com/profile/09858110332436246760noreply@blogger.comBlogger53125tag:blogger.com,1999:blog-5883634615775822475.post-25454573240414894422011-01-12T16:06:37.437-05:002011-01-12T16:06:37.437-05:00@Masa with all due respect, what I see is that goo...@Masa with all due respect, what I see is that good clinicians agonize over just how directive to be (or not) and under what circumstances, that this issue is itself carefully studied and debated, and that no consensus has been reached on the "best" approach. I'd say the ideal is much more closely captured in this sentence than in what you write, "Informed decision making requires patients to understand the pros and cons of medical care and to <i>have a say</i> in what happens to them, especially for decisions that involve significant tradeoffs." (emphasis added; source is "Deficits and variations in patients' experience with making 9 common medical decisions: the DECISIONS survey." Zikmund-Fisher BJ, et. al., Med Decis Making. 2010 Sep-Oct;30(5 Suppl):85S-95S.<br /><br />For another example, see "The role of doctor's opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures?" Mazur et. al. Health Expect. 2005 Jun;8(2):97-102 which, to summarize quickly, finds that (of 200 patients studied) 62.5% preferred sharing decision-making with the physician, 22.5% preferred physician-based, and only 15.5% preferred patient-based. More than half of all subjects chose physician opinion as the most important type of information for decision making. <br /><br />If we pause to think through the logic of your assertion, it goes like this: <br />Wife can understand and assess the risks and benefits associated with TPA having just been presented with them for the first time ever in a very stressful situation under time pressure.<br />Yet in that same scenario, wife cannot understand that if she asks Dr. G. "What would you do?" and he replies, "This is such a difficult decision. On the one hand, there's a real risk of ... ; on the other hand, especially given your husband's negative CT, the available evidence suggests that TPA would benefit him. I think if I were in his shoes, I'd use the TPA, and I'd want it done as quickly as possible," that she cannot understand that he has just responded to a hypothetical question that isn't, literally, even a recommendation (much less an instruction).<br /><br />I mean, I get it: what you should do depends on your preferences, and Dr. G's may be entirely different from the patient's. But to suggest that a patient's agent <i>can</i> make the decision about what to do in this case -- something that Dr. G. studied literally for years before he was considered qualified to do it on behalf of others -- but <i>cannot</i> distinguish between (e.g.) a recommendation and an instruction (or a response to a hypothetical and a response) strikes me as simply logically impossible. If she doesn't have the capacity to make that distinction, she doesn't have the capacity to learn and apply information about the risks and benefits associated with TPA.<br /><br />Moreover, do we even know that the patient consented to having his wife act as his agent? I, to be honest, have been astonished by how carefree the medical institutions I interact with are, in this regard (my father has not given me a health care power of attorney, but I am routinely called upon to make medical decisions on his behalf when he is perceived, sometimes correctly and sometimes not, as being incapable of doing so.). Had this patient been delivered in an ambulance with no one else present and unable to communicate his wishes, would Dr. G. have refused to treat him at all (since no one was available to consent), or would he have done his best to make good decisions on the patient's behalf? If there was not in fact a clear directive (about who should make decisions when the patient cannot) did Dr. G. do the patient a service or a disservice in calling upon the wife to assume that role?bogartnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-45702452627367771682011-01-12T03:05:11.047-05:002011-01-12T03:05:11.047-05:00RioRN makes an excellent point. Whenever I get ar...RioRN makes an excellent point. Whenever I get around to writing my advance directives (read: deciding what they actually are), I'll need to include TPA in there somewhere. I wonder if you can place a contingency in advance directives. If the phone a friend you've chosen is unavailable or unable to make a decision, default to care plan A. Don't let anyone else make it. There's some people I'd trust to make this decision. My current next of kin is not one of them.JGhttps://www.blogger.com/profile/11725439942594507383noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-49507246651403963382011-01-11T12:23:32.925-05:002011-01-11T12:23:32.925-05:00Actually, bogart, a doctor is not supposed to tell...Actually, bogart, a doctor is not supposed to tell a patient what they'd do. It amounts to telling a patient what TO do, and that is not informed consent.<br /><br />And no, the wife did not make a decision. She told dr. Grumpy to decide. And he cannot do that.Mašahttps://www.blogger.com/profile/18023082635905872067noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-30863143208459291552011-01-11T11:40:52.568-05:002011-01-11T11:40:52.568-05:00I don't know. I do get that this play does no...I don't know. I do get that this play does not represent the ideal of informed medical decision making, even by an agent, even under stress and time pressure.<br /><br />But come on. The "best" choice wasn't known. The wife had, presumably unexpectedly and with no advance preparation or information, to make a decision. Her seeking to inform their children and seek their input seems to me entirely appropriate (conceptually, if not practically). Dr. G., you yourself admits you don't know what the right answer was, but that you'd probably have chosen TPA. Could you have conveyed this more clearly to the patient's wife? She did make a decision, it wasn't (it seems) the one you'd have made, and if her mechanisms for making it seem less than perfect (and they do), well, it was a tough situation to be in.<br /><br />In 2005 I was in the ER with my dad after he'd had a stroke and got the pros and cons of TPA. My dad was conscious, coherent, and able to communicate, but I had repeatedly to remind the resident that the decision was my dad's, not mine. In fact, we all agreed that TPA made sense and my dad took it; I assume it helped his recovery (it certainly didn't kill him, that much is clear). <br /><br />Personally I'd say both based on my own experience and Dr. G's description that there's responsibility on both sides here ... the patient's (or agent's) to make a decision and the doctor to provide sufficient guidance to the person who has to make the decision. What's sufficient is going to vary widely depending on the people involved and I don't for a minute doubt that it's horrifically difficult, but still.bogartnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-39347523190267585542011-01-11T10:47:54.556-05:002011-01-11T10:47:54.556-05:00...so what if during the previous 35 years of marr......so what if during the previous 35 years of marriage, he had scolded and ridiculed her for every decision she had ever made? <b>...how would that change how you feel?</b>Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-52042518921887296612010-04-19T19:00:51.161-04:002010-04-19T19:00:51.161-04:00That was nerve-wrecking.That was nerve-wrecking.Unknownhttps://www.blogger.com/profile/08409721871393658453noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-63045498716266633892009-09-04T22:50:29.668-04:002009-09-04T22:50:29.668-04:00omg omg omg
i just wanted to punch that stupid wom...omg omg omg<br />i just wanted to punch that stupid woman in the head. what a dope. <br /><br />if this guy had it together, would have had all this squared away before he got sick, because i'm sure his wife was criminally stupid the whole time they were married.whiteknucklesnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-79671544509883528492009-08-27T13:25:26.760-04:002009-08-27T13:25:26.760-04:00I would take it only if I was not a complete gork ...I would take it only if I was not a complete gork already and if I was like under 1.5 hours max.ERPhttps://www.blogger.com/profile/15973334581468131595noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-32441752808120728142009-08-27T10:42:56.727-04:002009-08-27T10:42:56.727-04:00They have TPA there, too.They have TPA there, too.Grumpy, M.D.https://www.blogger.com/profile/09858110332436246760noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-26384007254998100852009-08-27T10:41:42.680-04:002009-08-27T10:41:42.680-04:00I would, but we don't have half the drugs you ...I would, but we don't have half the drugs you have over here. I got my husband to read it, and he looked really grim, and said at least we knew we know what the other wanted - but whether we'd be offered it is a different matter...Fiznoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-35105695827875141792009-08-27T07:55:05.968-04:002009-08-27T07:55:05.968-04:00Good question Richard. Very tough call in all thes...Good question Richard. Very tough call in all these cases.<br /><br />With a negative CT and early enough in the window, I'd likely go with TPA.Grumpy, M.D.https://www.blogger.com/profile/09858110332436246760noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-31918809114455894502009-08-27T03:56:27.519-04:002009-08-27T03:56:27.519-04:00I am curious, Dr. Grumpy. If you were the patient...I am curious, Dr. Grumpy. If you were the patient inthis play, what would you want your decision maker to decide - TPA or no TPA?<br /><br />I have to admit that I am up inthe air on this one.Richardhttps://www.blogger.com/profile/00687617840747530626noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-24561717118781203752009-08-26T09:26:48.494-04:002009-08-26T09:26:48.494-04:00I think that the NINDS trial created one of the wo...I think that the NINDS trial created one of the worst situations we as docs (and patients and their families) have to deal with. The study is not well done (and the new one that is now going to push the time frame to 4.5 hours is even weaker), and the in the years since I have been giving TpA, I am never really sure if the improvement patients had was due to the drug or just tinture of time (since many symptoms DO improve on their own), I DO however, remember the times patients have acutely bled and died! Add this to the fact that TpA issues are now one of the BIGGEST causes of lawsuits against ER docs and neurologists ("Why didn't you give it!" "Why did you give it!!") and I can tell you nothing makes us groan more than when the triage nurse yells "Acute CVA!!!" I actually often cross my fingers that the window has already closed.ERPhttps://www.blogger.com/profile/15973334581468131595noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-87033943989449538462009-08-26T03:35:24.341-04:002009-08-26T03:35:24.341-04:00Give me TpA. If the CT is down and you don't k...Give me TpA. If the CT is down and you don't know if it's wet or dry still give me TpA. If it has been less then 4, yes 4, hours give me TpA. <br /><br />And I hope to all things holy that my family calls 911. Paramedics, scoop and run and give me 8 L NRB en route!Pod Ahttp://talesfromthepods.blogspot.comnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-90394469528198854602009-08-26T00:59:25.051-04:002009-08-26T00:59:25.051-04:00I happen to work at the one of the facilities, whe...I happen to work at the one of the facilities, where Dr Grumpy works. I work nights. I have Dr Grumpy on speed dial on my cell phone...just in case. I trust Dr Grumpy. <br /><br />Signed, mmAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-90217329897960643022009-08-25T23:13:00.170-04:002009-08-25T23:13:00.170-04:00Mom and I wanted the doctors at my local, small, r...Mom and I wanted the doctors at my local, small, rural, county hospital to give my Dad the Clot Buster drug for his stroke. Instead, they wheeled him to a remote corner, and left him completely alone, to wait until the window of opportunity had passed before they would do anything at all, like a CAT scan. Then they said with impunity, "Oh, its to late for that."<br /><br />If they had administered it when he first arrived at the hospital, three blocks away from our house, like Mom and I wanted them to; then Dad might still be alive.<br /><br />They should have at least air lifted him to a larger hospital, that actually had a neurologist availiable for consultation, or on staff.<br /><br />He had his stroke on Monday afternoon and died early Thursday morning, three years ago.<br /><br />RSDSRSDSnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-69951352917159429482009-08-25T22:31:20.931-04:002009-08-25T22:31:20.931-04:00And in the end she still did not make a decision -...And in the end she still did not make a decision - "she wants to do whatever Dr. Grumpy thinks she should do." That is the part that kills me! I get that ALL THE TIME as a health care professional - informed consent does not mean I make the decision for you! YOU have to make the choice and deal with the consequences!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-27351424791614913682009-08-25T14:47:58.357-04:002009-08-25T14:47:58.357-04:00Nice! Add in the extra 8+ min it takes the pharmac...Nice! Add in the extra 8+ min it takes the pharmacy to thaw the pre-made, sub zero frozen, TPA (which can be several if the patient is a big one)under their armpits or handing a syringe to everyone with hot hands! Loved the Jeopardy song over head idea. New to your blog...very amusing, indeed!<br />~PharmagirlAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-24146475819446716222009-08-25T14:12:02.678-04:002009-08-25T14:12:02.678-04:00That is an amazing story, but not atypical I'm...That is an amazing story, but not atypical I'm sure. My thoughts are<br />(1) everybody get off your goddamm cell phones and pay attention to what's going on around you, (2) advance directives and living wills have been strongly recommended for years and all of a sudden it's become this ridiculous political football, and (3) I'm still waiting to see some intelligent panel discussions on health care reform -- perhaps featuring people like yourself who actually WORK in the trenches of health care and not some goofy ex-governors or radio talk show hosts.<br />Oh, the frustration.... !!!!Frantic Pharmacisthttps://www.blogger.com/profile/15804872250102867314noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-45304296484576793012009-08-25T10:17:46.628-04:002009-08-25T10:17:46.628-04:00As usual, "Masterpiece Theater" at its f...As usual, "Masterpiece Theater" at its finest, Dr. Grumpy. <br /><br />I'm a nurse, so I sympathize with the wife and my heart aches for the husband. Life and death decisions on a timer are difficult at best and disastrous at worse. But that's life....how sad we in the medical field must harden our hearts d/t ignorance. <br /><br />This type of procedure should be added to advance directives, in my opinion.RioRNnoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-42602765484856890692009-08-25T08:04:12.366-04:002009-08-25T08:04:12.366-04:00I can see a pretty good ad for Starbucks in this s...I can see a pretty good ad for Starbucks in this story.<br /><br />You know, emergency room, husband sitting there in a semi-paralyzed state, frantic-looking doctors and nurses telling the wife, "Hurry up! You have just 5 minutes to decide whether to give this life-saving medication(*) to your husband!" <br /><br />Suddenly, she sniffs the air a couple of times, looks around. The voices around her fade and become indistinct as she looks through a window and sees a Starbucks across the street. She gets up and follows the delicious smell of coffee to the Starbucks.<br /><br />Final shot is of her back in the emergency room, blissfully drinking a Caramel Frappuccino, as her husband is toe-tagged and wheeled away.The Brick Mannoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-64370590748681707132009-08-25T00:07:26.636-04:002009-08-25T00:07:26.636-04:00Wow. It's sad and amazing that people are rea...Wow. It's sad and amazing that people are really as ignorant as this woman. I'm a nurse and never thought to discuss stroke treatment with my husband or kids....so now I'm sure going to!<br /><br />Thanks for the cautionary tale.Liznoreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-19910618830377087992009-08-24T22:46:42.849-04:002009-08-24T22:46:42.849-04:00People don't think about this stuff when they ...People don't think about this stuff when they get married, do they? The wedding officiants should ask, Do you trust this person to make decisions on your behalf when you're too sick to speak?<br /><br />Her indecisiveness probable drove him crazy for decades, too.Deodandhttps://www.blogger.com/profile/14252076084306247100noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-68683972839842183822009-08-24T22:11:19.655-04:002009-08-24T22:11:19.655-04:00Wow...another Dr. Grumpy masterpiece.
Patient&#...Wow...another Dr. Grumpy masterpiece. <br /><br />Patient's wife can't make critical decision, can't find anyone to make it for her, can't deal with the gravity of the situation so she finds something meaningless like coffee, and then it's all too late.<br />(plus Dr. Grumpy humour)<br /><br />Excellently done. I am a forever fan. (but I'm pretty sure you knew that).Lipstickhttps://www.blogger.com/profile/04346441046070223404noreply@blogger.comtag:blogger.com,1999:blog-5883634615775822475.post-44940040723449457682009-08-24T21:26:29.730-04:002009-08-24T21:26:29.730-04:00Who knows, maybe the TPA would've killed him, ...Who knows, maybe the TPA would've killed him, and her seemingly selfish actions saved his life?<br /><br />Granted, that's the ONLY silver lining here.<br /><br />Hindsight is 20/20.<br /><br />But she's a complete idiot anyway. Going to get coffee while your husband is status post stroke? *shakes head*.Cap'n Cakezhttps://www.blogger.com/profile/11984241653911245545noreply@blogger.com