tPA ... it's a cookbook, like making pork roast
Initial Correspondence from Dr. Lynn Jensen
My name is Lynn Jensen. I have practiced Emergency Medicine for 30 years, and I am faculty in the EM residency at York Hospital. My resident Eric Salib, our employer York Hospital, and myself have recently successfully defended a malpractice suit in which the plaintiff, xxxxxxxx, claimed that we failed to meet the standard of care by not giving her tPA for a stroke, thereby denying her a chance of recovery. I would like to submit the testimony of the plaintiff's Emergency Medicine expert, Ira Mehlman M.D., as remarkable.
Mrs. xxxxxxxx presented to the York Hospital ED in October of 2002 at about 0903 hrs., with a complaint of left sided weakness and slurred speech, accompanied by substantial right sided headache. She had a history of atrial fibrillation and reported that she had taken Coumadin in the past, but could not remember exactly when she had stopped it.
Headache had been present for about four days. She reported to us that the onset of the left sided weakness was 0700 hours. We evaluated her immediately, finding dense left hemiparesis, mild dysarthria, right lateral gaze, and an irregular heart beat, with monitor showing a-fib.
We ordered Priority 1 studies (i.e., "STAT") including PT/INR and an unenhanced head CT. The studies were negative, and the CT report was faxed to us at 1037 hours, placing her outside the three hour window for tPA. In my deposition I was asked the hypothetical question whether or not I would have given her tPA had she been within the 3 hour window, and I answered "no", citing that we still had some concern about bleeding and the possibility of a false negative CT, given the presence of significant headache. This concern was later echoed by the neurologist who saw her in house, who withheld anticoagulation for the a-fib until after the patient had a second CT and an MRI. In addition, I cited that tPA for stroke was controversial in the field of EM.
The plaintiff claimed that the symptoms started at 0800 hours, based on reports from the medic unit (which arrived to us hours later) that the patient slumped over at 0800 hours, and that therefore the stroke started at 0800, placing her within the 3 hour window. We contended that this report was not necessarily in conflict with the patient's report of onset of weakness at 0700, since many strokes have a gradual or stuttering onset, and many patients do not report their symptoms to family or others immediately. Our defense had several layers: 1) the patient was not a candidate for tPA given the time window; 2) she had the additional contraindication that we had a clinical concern about the possibility of SAH; 3) tPA for stroke was not standard of care in Emergency Medicine in that significant controversy existed -- and of course we quoted position statements from AAEM, SAEM, ACEP to support this.
Dr. Mehlman's testimony was in my opinion egregious. I have attached it in entirety, but here are some of the highlights (I paraphrase some):
p. 41 -- "Even patients who have a bleed have better survival than the untreated group."
p. 41-42 -- "It's the only chance they have to get better" (this ignores the significant chance of spontaneous recovery).
p. 43 -- "It's a cook book"
p. 48 -- "It's the standard of care"
p. 51 -- "If you eliminate the chance of complications..."
p. 52 -- "My neurologists tell me I'm crazy to get consent -- I don't need informed consent, it's the standard of care."
p. 52 -- "If they are told that they don't have any risks, and that the alternative is that they will be paralyzed for life, ....."
p.52 -- "tPA is on the shelf in every ER -- it's a cookbook, like making pork roast".
p. 53 -- "5 to 6 minutes maximum from the decision to use tPA to the administration". (ignores mixing time, re-evaluating the patient, consent).
p. 64 -- "brain bleeds are not typically associated with focal findings"
p. 67 -- regarding SAH: -- "They are in deep coma"
p. 71 -- "Dr. Jensen did not have the right to deny her a chance of recovery".
p. 77 -- "yeah, tPA is dangerous -- so is too much water".
p. 105-109 -- summarizing, he basically says that AAEM and SAEM are wrong and he is right regarding tPA as standard of care.
p. 125 -- "even patients who get a complication do better than if they had not been treated with tPA".
p.126 -- "there are no studies that don't support the fact that tPA is good treatment".
p. 139-140 -- He very clearly implies that we lied about the time of onset.
p. 156-58 -- summarizing, he basically denies that gradual or stuttering onset was a possibility in this case.
Dr. Mehlman is a board certified Emergency Physician practicing in Nyack NY (Nyack Hospital). He trained in Internal Medicine and Endocrinology. He has published nothing in the field of Emergency Medicine, he has never been involved in an EM residency, and he has never been invited to speak at other institutions or state or national EM assemblies. But he does testify a lot.
If you need links to the entire court proceeding or other data, you might try contacting our attorney Chris Stump at email@example.com.
Please feel free to email me or call if you need clarification or if I can provide further documents.
I truly appreciate the service you provide allowing a venue to air remarkable testimony.
Lynn S. Jensen MD