Here’s a sure way to get sued:

Use TPA on 100 patients. That’s all it takes. 100 times, statistically, and it’s off to the courts.

TPA is a pretty cool drug because it is the only one that actually breaks up blood clots. Effectively Drain-O for the body, TPA drills through plugs holding blood from crucial areas of the brain. Ostensibly, it could be used for clots in other areas like the heart and the legs, but it usually isn’t. In fact, there are EXTREMELY strict guidelines for exactly when to prescribe the drug. Roughly, those rules claim that you can only use it within about 3 hours after a person exhibits classic symptoms of a stroke. An ischemic stroke, by the way, not a hemorrhagic one.

Why so many rules? Wouldn’t a drug like that be the answer to the world’s medical problems? Think of how many people die every day because of clots forming in our vasculature that shouldn’t be there. This is why docs are so obsessed with cholesterol, for example. It contributes to clogging up coronary arteries. Arteries get blocked, heart muscle doesn’t get oxygen…heart attack. Pretty simple, really. So this drug should save the world. Maybe we should all take it on a regular basis, just to keep things thinned out.

The problem is that the drug works incompletely. It does, in fact, break up clots, but sorta like a photon torpedo from the Star Trek Enterprise would break it up (it must be quite cool to watch). You end up with bujillions of little clots in your blood stream. If they’re small enough, they will pass through even the smallest capillaries and not clog anything up. But usually, all those clots will lodge somewhere else and cause more problems…like mini-strokes, mini-heart attacks etc.

But the legal problem with the drug is that approximately 1 in 100 patients will end up with a brain bleed as a result of the drug. The reason is because after a clot forms, holes open up in the artery downstream from the clot as things dry up. The holes are basically caused by shrinkage like anything shrinks after it dries out. Then the TPA comes along and busts up the clot. Blood starts flowing again, and viola! it rushes across the newly-formed holes and pours into the brain.

“My doc gave me a hemorrhagic stroke.” Defend THAT mister docta man.

There is no incentive in our system to NOT bring litigation against doctors or anyone else. Sure, most lawyers don’t want to waste their time, but when there is a basic complaint as glaring as “my doctor caused my brain to bleed”, most will give it a whirl. Think about it: Plaintiff attorneys have a 50-50 chance of winning on the basic charge alone. Some poor patient gets on the witness stand, drooling and drooping and describing what their life was like before Dr. Flamethrower over there pasted him with that terrible medicine. But even if the case loses, most lawyers make money. Bringing charges…brings charges. Trial lawyers bring cases with big pay off potential (most stroke cases fit this bill), settlement potential, or when the patient can pay up-front.

I think there should be a litigation approval process where complaints can’t be filed unless approved by a board of medical professionals. The proper use of TPA should never lead to litigation – bleeding or otherwise, if the risks of using it are described to the patient, or the patient’s family if the patient is incapacitated.  In many situations, TPA is the patient’s only hope of salvaging some brain tissue.

But this isn’t how things work in this country. A person can sue for any reason – rational or not, understandable or not. Fortunately for me, family docs don’t often use TPA. Use of the drug is left to ER docs and neurologists. With this kind of involvement of the un-trained legal profession in the medical world however, more and more docs of all specialties are taking a hard look at that 100th patient who could use TPA. Statistically, the lawsuit is virtually assured.