The Stroke / TPA Master
Last year academic year I spent one out of every four days working in an inpatient neurology service that mostly cares for stroke patients. I was not The Stroke Master, nor the TPA Master. These were tongue in cheek nick names that we reserved for our most academically venerable and personally inspiring attending who would occasionally attend and supervise the care of stroke patients.
Instead I was a mid level medical lieutenant with faculty above me but also with a junior resident and medical students under my almost always goal oriented direction. When students and interns would join me on rotation, immediately after our first morning teaching conference, I would explain our three main goals as a team: take care of patients, learn (aggressively) and try to have fun in the process. Invariably making the “expectations talk” so short quickly dispatched the worry of the overbearing upper level and always made everyone more at ease. Finally I would add one unofficial but not negligible goal: “get stuff done, and get out on time”.
In retrospect learning, enjoying the camaraderie of the neurology team and even working efficiently proved to be the easiest goals to define and attain. Treating stroke patients on the other hand was a lot more nuanced since the treatment of stroke is a lot more difficult. The only rigorously studied acute treatment for “low blood supply” or ischemic stroke is IV TPA, a very potent clot busting drug. Unfortunately IV TPA can only be given safely within 3 hours of onset of symptoms, and in our center about 90% of patients are outside the window on arrival.
Even with IV TPA, only 12% of patients are one grade functionally better in 3 months. In other words for one patient to be better off from TPA, you have to give the drug to 8.33 stroke patients. Nonetheless the institutional dedication to the management of acute stroke in a typical large American hospital center is dramatic compared to other countries. In my hospital there is a neurology staff member in house 24/7, there are also CT scanners always on call, and finally an ICU bed will be made available for TPA patients whatever the circumstances. The resource mobilization for these patients is not only extraordinary but it is also laudable. A skeptic might point out that TPA patients with their costly work-up and mandatory ICU stay represent a highly lucrative revenue stream with its intrinsic motivations, but nonetheless it takes great organization and hard work to routinely care for these patients.
What about other medical therapies that make you better after a stroke? The overwhelming benefit comes form early and intensive physical and occupational therapy. As from a neurology standpoint there is always a major effort to take steps to prevent another stroke such as taking an aspirin, quiting smoking and lowering blood pressure and among other things.
From my experience on our stroke unit, the relevance of secondary prevention is variable. Recently, I saw a man in his mid 50 who had a small stroke in the setting of astronomic blood pressures and a heavy smoking history. For him the upside of quiting smoking and taking blood pressure medicine is significant. On the other hand I had also seen an octagenerian man, who had a new stroke after having an old stroke on the other side of the brain in the past. Because of the bilateral involvement of the brain his level of consciousness was limited. Yet after the stroke well meaning attendings would round and among other things would prescribe a statin. When I see this on the floor, I whole-heartedly agree with the motivation, but honestly believe its not reasonable medicine. To prevent a stroke with a statin you need to treat 50 patients for 5 years to prevent one stroke. Since statins do have side effects and of course are not free, I do not believe it helps the patient.
So if the treatment of stroke is not highly effective and fraught with grey areas, what are we to do as the next generation of physians to address this large pubic health problem. Certainly funding of the most promising therapy research must be pursued. But we have been doing this and it has not been enough. Beyond more ICUs, CT scanners, and hospital staff what is needed is a transformation and modernization in the way we approach stroke and vascular disease in our society.
Such movement in public perception is not without precedent both in public health and in the public policy arenas. Smoking was a lot more prevalent 20 years ago than it was today in the United States. Greater taxation of cigarettes and stricter marketing rules have been important public health victories. As we speak a palpable shift is occurring in the national consencus about energy policy with more people embracing the importance of conservation as well as the strategic centrality of energy independence.
For the prevention of vascular disease including stroke a similar shit in public opinion is needed. As Americans we need to improve the quality of school lunches, we need to promote and incentivize increased physical activity, and we need preventive care to become more routine and affordable. This tilt of public opinion to embrace prevention as a cornerstone of public health policy will not be easy. But the extraordinary stakes make this the defining challenge for physicians of our time.
Explore posts in the same categories: Hospital LifeTags: acute stroke, medical school, neurology, prevention, public health, residency, TPA
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