Sunday, January 01, 2006

In an earlier post, I mentioned the AAEM's beginning a Remarkable Testimony project. The first case listed was with regard to the testimony of Dr. Tarlow who made some real woppers. On another blog, I called his testimony "crap" and was asked what I meant by that. Here are further comments:

  • Page 7: "And, in fact, half the people practicing ER medicine are not board-certified." He doesn't support this statement and I certainly doubt it. Almost every doctor I've ever been associated with in an ER has been board certified. Maybe not in emergency medicine, but board certified.

  • Page 7: "The American Medical Association really mandates people take examinations every few years." We all know that the AMA has nothing to do with board examinations and some boards do not require recertification.

  • Page 12: "...people with seizures don't develop seizures at age 50, okay, unless there's a tumor or aneurysm or something bad. People who have seizures at 40 or 50 typically have had them for many, many years, generally as an adolescent." It is certainly less common for older patients to develop seizures, but not so uncommon as to say it doesn't happen.

  • Page 14: Fast heart rate and fast respiratory rate are very non-specific and would not be useful to rule-in or rule-out a seizure. Most of the patients I see who are post-ictal are not tachycardic or tachypneic.

  • Page 15: Indicated that if a patient doesn't have incontinence of urine or stool, tachycardia, tachypnea, no history of seizure disorder and negative blood tests, she didn't have a seizure. What blood tests rule out a seizure? None that I know of. It is certainly possible that a patient could have none of the above and still have a seizure.

  • Page 16: "Facial droop. That's a seventh nerve palsy." Facial droop can certainly be a sign of a stroke, but not if it is a seventh nerve palsy, but rather an upper motor neuron lesion. If he felt it was a seventh nerve palsy, how did he rule out Bell's Palsy?

  • Page 16: "...in fact, she has all these symptoms" One of the symptoms he had just referenced was "sudden loss of bowels" but had indicated earlier that she had not had bowel incontinence which would have been a sign of a seizure.

  • Page 17: "If a person really thinks a patient has a seizure, they really, really, really think they have a seizure, the medication is clear. It's Valium IV push, Dilantin, and phenobarbital. No question about it. That's the therapy, period. Okay?" Well, no, Dr. Tarlow, not OK. ER docs see patients every day who they feel really, really, really have had a seizure and may not use any of those drugs. Personally, if a patient is seizing in front of me, I might use Ativan, not Valium. I might not use Dilantin if it had failed for that patient in the past, or if she was allergic to it. I use phenobarbital, but rarely.

  • Page 18: "We'll give them Valium until they become unconscious, intubate them, and load into that--load in the Dilantin and the phenobarb, if you really think they had a seizure." WHAT THE HELL???? Dr. Tarlow, are you suggesting that every patient you see in the ER who you believe had a seizure gets intubated? And you induce with Valium alone? The incredible vast majority of seizure patients get treated without intubation.

  • Page 18: "The patient didn't get any of these medications, so I don't believe the doctor thought at this time it was a seizure at all." Many patients who present to the ER with c/o seizure, who aren't actively seizing, may not receive any treatment in the ER at all. Especially if it is a first seizure.

  • Page 18: "If a person has a stroke or a TIA, then depending on what's involved, you're going to get tPA--which is that special magic bullet drug called tissue plasminogen activator--within three hours, or heparin or coumadin..." Just not true. If a patient presents to the ER with symptoms of a TIA, either resolved or rapidly resolving, you may do nothing. Certainly, the diagnosis of TIA is an absolute contraindication to use of tPA.

  • Page 22: Stated that you don't give tPA in a patient with a seizure because the seizure may have been secondary to a bleed or a tumor and these would be contraindications to use of tPA. Stated "If the head is normal, despite the fact the patient really had a seizure, it doesn't matter." Yes it does, Dr. Tarlow. If you suspect the presentation is secondary to a seizure, even with a normal CAT scan, you don't use tPA. Not because of the possibility of another condition, but because you don't treat seizures with tPA. Pretty basic.

  • Page 22: "...even with a seizure...you'll still give them tPA." A seizure at the onset of a stroke is one of the exclusion criteria for the use of tPA in stroke. See this.

  • Page 23: "It's a very classic--if you've ever seen a seizure, there's no way you would not--miss that diagnosis." Other than Dr. Tarlow, I've never heard of a doctor claiming that he could never miss any diagnosis, especially one as complicated as seizure.

  • Page 24: Indicated that the NINDS study and the NIH have established the standard of care for stroke treatment. "That's why we have the National Institutes of Health..." This is an unfounded claim. Neither the NINDS nor the NIH establish SOC. Specifically, the American Academy of Emergency Medicine has written:
    It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke.

  • On Page 25, he indicated that frequent checks should be recorded and that "It doesn't have to be the doctor..." Then, on page 26, he criticized the doctor because his next notation was 2 hours later.

  • Page 26: "...one needs to check that every 15 minutes, maybe 30 minutes..." This is an unreasonable standard, especially for a busy ER. Has anyone out there seen this as a SOC?

  • Page 33: In response to a question about whether the administration of tPA would have saved her life, he answered, "There's no question it would have." This is unfounded. There have been no studies demonstrating that use of tPA in stroke decreases mortality.

  • Page 34: "The Food and Drug Administration in very conservative. They will not approve a drug unless it is both safe and effective." Right, safe in the proper context and when the benefits outweigh the risk. However, tPA is not safe or effective in every patient. We all know that there have been drugs approved for use by the FDA that were later recalled. Vioxx, anyone?

  • Page 35: "...it [tPA] saves people's lives." Again, there is no evidence that tPA used to treat strokes decreases mortality from strokes.
This is commentary on Dr. Tarlow's testimony. I haven't read a transcript of the whole trial or the defendant's testimony. I can't comment on the merits of the trial or whether the defendant did or did not commit malpractice. So, Elliot, don't get on that train again. The testimony of Dr. Tarlow was full of errors and should not have gone to the jury.