Every single stroke coming into your stroke hospital should have a protocol to follow. There is never a stroke that is too good to treat. You never magically recover from a stroke. Your doctor should never have to make a subjective decision. You have an objective damage diagnosis(The NIH Stroke Scale is not objective so we have a problem right from the start.). What should follow directly from that is a stroke protocol to remove the clot or stop the bleeding and then a protocol to stop the neuronal cascade of death or the hemorrhage cascade of death. This is so fucking simple, why can't it be done? Laziness? Incompetence? Or just don't care? No leadership? No strategy? Not my job?
The authors undertook this multicenter United States-based survey to
explore factors that influence intravenous thrombolysis decisions
patients with minor stroke, who constitute a controversial category of
acute ischemic stroke. One hundred ninety-four physicians were across
the United States with 150 vignettes using a variation of the following 7
factors that were agreed on by an expert panel as most likely to
influence tPA (tissue-type plasminogen activator) administration:
National Institutes of Health Stroke Scale (NIHSS) score
(The NIH Stroke Scale is not objective so we have a problem right from the start.), NIHSS area of
deficit with emphasis on 3 levels (visual/language/weakness), baseline
functional status, previous ischemic stroke, previous intracerebral
hemorrhage, recent use of anticoagulation, and temporal pattern of
symptoms in first hour of emergency department care. One hundred
fifty-six physicians returned complete vignettes and were included in
the final analysis, 80% neurologists and 20% emergency department
physicians; nearly 2/3 practiced in academic institutions and
comprehensive stroke centers. On the 2 extremes of the spectrum,
physicians were most likely to treat patients with higher NIHSS, stable
course, and no prior hemorrhage or ischemic stroke and least likely to
consider treatment in those with low NIHSS, preexisting disability, and
recent stroke or hemorrhage. Overall, 4 of the 7 factors weighed heavily
in physician decisions, in descending order: previous intracerebral
hemorrhage, anticoagulation use, NIHSS score, and previous recent
ischemic stroke. However, in a conjoint model, only 25% of the
variability in decision-making was accounted for. The authors also
explored the effect of individual physician characteristics, such as
age, years of practice, sex, and area of training; they found no
significant impact on the probability to use thrombolysis. Overall, a
substantial proportion of the variability in decision-making in minor
stroke remains currently unexplained. See p
1933.
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