Stroke victims are often taken to wrong hospital by EMS

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Stroke victims are often taken to wrong hospital

Monday, May 09, 2005

By Thomas M. Burton, The Wall Street Journal

Christina Mei suffered a stroke just before noon on Sept. 2, 2001. Within eight minutes, an ambulance arrived. Her medical fate may have been sealed by where the ambulance took her. 

Ms. Mei's stroke, caused by a clot blocking blood flow to her brain, occurred while she was driving with her family south of San Francisco. Her car swerved, but she was able to pull over before slumping at the wheel. Paramedics saw the classic signs of a stroke: The 45-year-old driver couldn't speak or move the right side of her body.

Had Ms. Mei's stroke occurred a few miles to the south, she probably would have been taken to Stanford University Medical Center, one of the world's top stroke hospitals. There, a neurologist almost certainly would have seen her quickly and administered an intravenous drug to dissolve the clot. Stanford was 17 miles away, across a county line.

But paramedics, following county ambulance rules that stress proximity, took her 13 miles north, to Kaiser Permanente's South San Francisco Medical Center. There, despite her sudden inability to talk or walk and her facial droop, an emergency-room doctor concluded she was suffering from depression and stress. It was six hours before a neurologist saw her, and she never got the intravenous clot-dissolving drug.

In a legal action brought against Kaiser on Ms. Mei's behalf, an arbitrator found that her care had been negligent, and in some aspects "incomprehensible." Today, Ms. Mei can't dress herself and walks unsteadily, says her lawyer, Richard C. Bennett. The fingers on her right hand are curled closed, and she has had to give up her main avocations: calligraphy, ceramics and other types of art. Kaiser declined to comment beyond saying that it settled the case under confidential terms "based on some concerns raised in the litigation."

Stroke is the nation's No. 1 cause of disability and No. 3 cause of death, killing 164,000 people a year. But far too many stroke victims, like Ms. Mei, get inadequate care thanks to deficient medical training and outdated ambulance rules that don't send patients to the best stroke hospitals.

Over the past decade, American medicine has learned how to save stroke patients' lives and keep them out of nursing homes. New techniques offer a better chance of complete recovery by dissolving blood clots and treating even more lethal strokes caused by burst blood vessels in the brain. But few patients receive this kind of treatment because most hospitals lack specialized staff and knowledge, stroke experts say. State and county rules generally require paramedics to take stroke patients to the nearest emergency room, regardless of that hospital's level of expertise with stroke.

Stroke care is positioned roughly where trauma care was a quarter-century ago. By 1975, surgeons expert at treating victims of car crashes and other major accidents realized that taking severely injured patients to the nearest emergency room could mean death. So the surgeons led a push to make selected regional hospitals into specialized trauma centers and to overhaul ambulance protocols so that paramedics would speed the most severely injured to those centers. Now, in many areas of the U.S., accident victims go quickly to a trauma center, and trauma specialists say this change has saved lives and lessened disability.

Eighty percent or more of the 700,000 strokes that Americans suffer annually are "ischemic," meaning they are caused by blockage of an artery feeding the brain, usually a blood clot. Most of the rest are "hemorrhagic" strokes, resulting from burst blood vessels in or near the brain. Although they have different causes, both result in brain tissue dying by the minute.

Several factors have combined to prevent improvement in stroke care. In some areas, hospitals have resisted movement toward a system of specialized stroke centers because nondesignated institutions could lose business, according to neurologists who favor the changes. In addition, stroke treatment has lacked an organized lobby to galvanize popular and political interest in the ailment.

A big reason for the backwardness of much stroke treatment is that many doctors know little about it. Even emergency physicians and internists likely to see stroke victims tend to receive scant neurology training in their internships and residencies, according to stroke specialists.

"Surprisingly, you could go through your entire internal-medicine rotation without training in neurology, and in emergency medicine it hasn't been emphasized," says James C. Grotta, director of the stroke program at the University of Texas Health Science Center at Houston.

Many hospitals don't have a neurologist ready to deal with emergencies. As a result, strokes aren't treated urgently there, even though short delays increase chances of severe disability or death. Even if doctors do react quickly, recent research has shown that many aren't sure what treatment to provide.

For example, a survey published in 2000 in the journal Stroke showed that 66 percent of hospitals in North Carolina lacked any protocol for treating stroke. About 82 percent couldn't rapidly identify patients with acute stroke.

As with other life-threatening conditions, stroke patients are better off going where doctors have had a lot of practice addressing their ailment. A seven-year analysis of surgery in New York state in the 1990s showed that patients with ruptured blood vessels in the brain were more than twice as likely to die -- 16 percent versus 7 percent -- in hospitals doing few such operations, compared with those doing them regularly. A national study published last year in the Journal of Neurosurgery showed a similar disparity.

Another major shortcoming of most stroke treatment, according to many neurologists, is the failure to use the genetically engineered clot-dissolving drug known as tPA. Short for tissue plasminogen activator, tPA, which is made by Genentech Inc., has been shown to be a powerful treatment that can lessen disability for many patients. A study published in 2004 in The Lancet, a prominent medical journal, showed that the chances of returning to normal are about three times greater among patients getting tPA in the first 90 minutes after suffering a stroke, even after accounting for tPA's potential side effect of cerebral bleeding that can cause death. But several recent medical-journal articles have found that nationally, only 2 percent to 3 percent of strokes caused by clots are treated with tPA, which has no competitor on the market.

Some authors of studies supporting the use of tPA have had consultant or other financial relationships with Genentech. Skeptics of the drug point to these ties and stress tPA's side-effect danger. But among stroke neurologists, there is a strong consensus that the drug is effective.

One reason why many patients don't receive tPA is that they arrive at the hospital more than three hours after a stroke, the time period during which intravenous tPA should be given. But many hospitals and doctors don't use tPA at all, even though it has been available in the U.S. since 1996. The dissolving agent's relatively high cost -- $2,000 or more per patient -- is a barrier. Medicare pays hospitals a flat reimbursement of about $5,700 for stroke treatment, regardless of whether tPA is used.

Glender Shelton of Houston had an ischemic stroke caused by a clot at Los Angeles International Airport on Dec. 30, 2003. In full view of other holiday travelers, Ms. Shelton, then 66, slumped over, and an ambulance was called. It was 4:45 p.m.

By 5:55 p.m., she arrived at what now is called Centinela Freeman Regional Medical Center, four miles away in Marina del Rey. Hospital records show that doctors thought Ms. Shelton had suffered an "acute stroke." But she didn't get a CT scan, a recommended initial step, until 9 p.m. By then, she was already outside the three-hour window for safely administering intravenous tPA. Records also say she didn't receive the drug "due to unavailability of a neurologist until after the patient had been outside the three-hour time window."

Ms. Shelton's daughter, Sandi Shaw, was until recently nurse-manager of the prestigious stroke unit at the University of Texas Health Science Center at Houston. Ms. Shaw says that at her unit, her mother would have had a CT scan within five minutes of arriving, and tPA probably would have been administered 30 or 35 minutes after that.

Today, according to her daughter. Ms. Shelton often can't come up with words or relatives' names, can't take care of her finances, and can't follow certain basic commands in neurological tests.

Kent Shoji, an emergency-room doctor at Centinela Freeman who handled Ms. Shelton's case, says, "She was a possible candidate for tPA," but a CT scan was required first. "The order was put in for a CT scan," Dr. Shoji says. "I can't answer why it took so long."

A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage with our CT scan, and we had to call a technician to come in. That's pretty common with a community hospital." The hospital has since been acquired by a larger health system and now does have 24-hour CT capability.

A hospital-accrediting group has begun designating hospitals as stroke centers, but that is only part of what is needed, stroke experts assert. They say hospitals typically have to come together to create local political momentum to change state or county rules so that ambulances actually take stroke patients to stroke centers, not the nearest ER. New York, Maryland and Massachusetts are moving toward creating stroke-care systems, and Florida recently passed a law creating stroke centers. But in many places, short-term economic interests impede change, some doctors say.

"There are still very parochial interests by hospitals and physicians to keep patients locally even if they're not equipped to handle them," says neurosurgeon Robert A. Solomon of New York-Presbyterian Hospital/Columbia. "Hospitals don't want to give up patients."

The University of California at San Diego runs one of the leading stroke hospitals in the country. It and others in the area that are well prepared to treat stroke patients have sought for a decade to set up a regional system, but there has been little progress, says Patrick D. Lyden, UCSD's chief of neurology. "Some hospitals are resisting losing stroke business," he says. "We have the same political crap as in most communities. Paramedics still take people to the local ER."

Among the opponents of the stroke-center concept during the 1990s was Richard Stennes, then ER director at Paradise Valley Hospital south of San Diego. In various public debates, Dr. Stennes recalls, he argued that many apparent stroke patients would be siphoned away from community hospitals even if they didn't turn out to have strokes. Also, he argued that tPA might cause more injury than it prevents. And then there was the economic issue: "Those hospitals without all the equipment and stroke experts," he says, "would be concerned about all the patients going to a stroke center and taking the patients away from us." Dr. Stennes has since retired.

"All hospitals and clinicians try to deliver the right care to patients, especially those with urgent medical needs," says Nancy E. Foster, vice president for quality of the American Hospital Association, which represents both large and small hospitals. "Community hospitals may be equally good at delivering stroke care, and it would be important for patients to know how well prepared their local hospital is."

Stroke experts aren't proposing that every hospital needs to specialize in stroke care but instead that in every population center there should be at least one that does. In Atlanta, Emory University's neuro-intensive care unit illustrates the special skills that make for top care. Owen B. Samuels, director of the unit, estimates that 20 percent to 30 percent of patients it treats received poor initial medical care before arriving at Emory, jeopardizing their futures or even lives. Brain hemorrhages, for example, are commonly misdiagnosed, even in patients who repeatedly showed up at emergency rooms with unusually severe headaches, Dr. Samuels says.

The Emory unit has 30 staff members, including two neuro-critical care doctors and five nurse practitioners. A team is on duty 24 hours a day. The unit handles about two dozen patients most days, keeping the staff busy. On the ward, nearly all patients are unconscious or sedated, so it's eerily silent. Patients generally need to rest their brains as they recover from stroke or surgery.

After a hemorrhagic stroke, blood pressure in the cranium builds as blood continues to seep out of the ruptured vessel. Pressure can be deadly, cutting off oxygen to the brain. Or escaped blood can cause a "vasospasm," days after the original stroke, in which the brain reacts violently to seeped-out blood. In the worst case, the brain herniates, or squeezes out the base of the skull, causing death. To avoid this, nurses at Emory constantly monitor brain pressure and temperatures. They put in drain lines. They infuse medicines to dehydrate, depressurize and stop bleeding.

Since Emory launched the neuro-intensive unit seven years ago, 42 percent of patients with hemorrhagic strokes have become well enough to go home, compared with 27 percent before. Fewer need rehabilitation -- 31 percent versus 40 percent -- and the death rate is down.

Damica Townsend-Head, 33, gave the Emory team a scare. After surgery last fall for a hemorrhagic stroke, her brain swelling was "really out of control," Dr. Samuels says, raising questions about whether she would survive. The staff put a "cooling catheter" into a blood vessel, which allowed the circulation of ice water to bring down the temperature in her blood and brain. They intentionally dehydrated her brain to lower pressure. A month later, she woke up and recovered with minimal disability. She still walks with a cane and tires easily, but her speech is normal and she hopes to return soon to work. "I consider her what we're in business for," Dr. Samuels says.

The public's low awareness of stroke symptoms -- and the need to respond immediately -- can also hinder proper care. Ischemic strokes, those caused by clots or other artery blockage, cause symptoms such as muscle weakness or paralysis on one side, slurred speech, facial droop, severe dizziness, unstable gait and vision loss. People with this kind of stroke are sometimes mistaken for being drunk. In addition to intense head pain, a hemorrhagic stroke often leads to nausea, vomiting or loss of balance or consciousness. Still, many people with some of these symptoms merely go to bed in hopes of improving overnight, doctors say. Instead, they should go immediately to a hospital and demand a CT scan as a first diagnostic step.

The well-funded American Heart Association, established in 1924, has made many people aware of heart attack symptoms and thereby saved many lives. In contrast, the American Stroke Association was started only in 1998 as a subsidiary of the heart association. The stroke association spent $162 million last year out of the heart association's $561 million overall budget.

Justin Zivin, another University of California at San Diego stroke expert, says the stroke association "is a terribly ineffective bunch. When it comes to actual public education, I haven't seen anything."

The stroke association counters that it is buying television and radio ads promoting awareness, similar to ones produced in 2003 and 2004. The group also sponsors research and education, including an annual international stroke-medicine conference.

It's not just the general public that fails to recognize stroke symptoms. Often, emergency-room doctors and nurses don't, either. Gretchen Thiele of suburban Detroit began having horrible headaches last May, for the first time in her life. "She wasn't one to complain, but she said, 'I can't even lift my head off the pillow,' " recalls her daughter, Erika Mazero. Ms. Thiele, 57, nearly passed out from the pain one night and suffered blurred vision. When the pain recurred in the morning, she went to the emergency room at nearby St. Joseph's Mercy of Macomb Hospital. Ms. Mazero says that during the six hours her mother spent there, she was given a CT scan, but not a spinal tap, which could definitively have shown she had a leaking brain aneurysm, meaning a ballooned and weakened artery in her brain. After the CT, Ms. Thiele was given a muscle relaxant and pain medicine and sent home, her daughter says.

Two months later, the blood vessel burst. Neurosurgeons at William Beaumont Hospital in Royal Oak, Mich., did emergency surgery, but Ms. Thiele suffered massive bleeding and died. Ali Bydon, one of the neurosurgeons at Beaumont, says a CT scan often is inadequate and that her condition could have been detected earlier with a spinal tap, also called a lumbar puncture. "Had she had a lumbar puncture and perhaps an operation earlier, it might have saved her life," says Dr. Bydon. "In general, a person who tells you, 'I usually don't get headaches, and this is the worst headache of my life,' is something that should alarm you."

In addition, he says Ms. Thiele "absolutely" was experiencing smaller-scale bleeding in May that foreshadowed a more serious rupture. If doctors identify this kind of bleeding early, he says, chances of death are "minimal." But when a rupture occurs, he says, "25 percent of patients never make it to the hospital, 25 percent die in the hospital and 25 percent are severely disabled."

A St. Joseph's hospital spokeswoman says the hospital has "very aggressive standards for treatment, and we met this standard," declining to elaborate.

Paramedics did the right thing after Chuck Toeniskoetter's stroke, but only because of some extraordinary intervention. Mr. Toeniskoetter, then 55, was on a ski trip Dec. 23, 2000, at Bear Valley, near Los Angeles. He had just finished a run at 3:30 p.m. when, in the snowmobile shop, he began slurring his words and nearly fell over. Kathy Snyder, the nurse in the ski area's first-aid room, quickly diagnosed stroke. She called a helicopter and an ambulance.

Ms. Snyder says she knew the closest hospital with a stroke team was Sutter Roseville Medical Center in Roseville, Calif. The helicopter pilot was planning to take Mr. Toeniskoetter to a closer ER, but Ms. Snyder says she stood on the helicopter runners, demanding the patient go to Sutter. The pilot eventually relented. Mr. Toeniskoetter went to Sutter, where he promptly received tPA. Today, he has no disability and is back running a real estate-development business in the San Jose area. "Trauma patients go to trauma centers, not the nearest hospital," he says. "Stroke victims, too, require a real specialized sort of care."

One-third of all strokes are suffered by people under 60, and hemorrhagic strokes in particular often strike young adults and children. Vance Bowers of Orlando, Fla., was 9 when he woke up screaming that his eyes hurt, shortly after 1 a.m. on Jan. 8, 2001. Malformed blood vessels in his brain were bleeding. He was in a coma by the time an ambulance delivered him at 1:57 a.m. to the nearest emergency room, at Florida Hospital East Orlando.

Emergency-room doctors soon realized Vance had a hemorrhagic stroke. But neurosurgery isn't performed at that hospital. A sister hospital-- minutes away by ambulance, Florida Hospital Orlando, did have neurosurgical capability. But in part because of administrative tangles, Vance didn't get to the second hospital until 4:37 a.m., more than two hours after his arrival. Surgery began at 6:18 a.m. "This delay may have cost this young man the possibility of a functional survival," Paul D. Sawin, the neurosurgeon who operated on Vance, said in a letter to the hospitals' joint administration.

Florida Hospital, an emergency-medicine group and an ER doctor recently agreed to settle a lawsuit filed against them in Orange County, Fla., Circuit Court by the Bowers family. The defendants agreed to pay a total of $800,000, court records show. Monica Reed, senior medical officer of the hospital, says the care Vance received was "stellar" and that any delays weren't medically significant. Vance's stroke, not the care he received, caused his injuries, she said.

Vance, now 13, survived but is mentally handicapped and suffers daily seizures, his mother, Brenda Bowers, says. Once a star baseball player, he goes by wheelchair to a class for disabled children. He speaks very slowly but not in a way that many people can understand. "He remembers playing baseball with all of his friends," his mother says, but they rarely come around any more. "He really misses all that."

By the Numbers

How many : 700,000 strokes a year in the U.S., 164,000 of them fatal

Rankings: No. 1 cause of disability, No. 3 cause of death

Types: 80 percent or more caused by artery blockage, up to 20 percent by burst blood vessels

Death rate: About 1 in 10 clot-caused strokes results in death within 30 days, compared with 1 in 3 hemorrhagic strokes

Warning signs:-- percent of people who have strokes or "mini-strokes" have another within one year

Sources: American Stroke Association; WSJ research

Emergency Treatment

Too often, stroke victims are taken to the closest hospital rather than one with the ability to treat stroke effectively. This increases the chances of death, brain damage or paralysis. Common stroke symptoms and treatments:

STROKE TYPES

Ischemic

Cause

Blockage of an artery feeding the brain, usually a blood clot.

Symptoms

Muscle weakness or paralysis on one side

Slurred speech

Facial droop

Severe dizziness

Vision loss

Hemorrhagic

Cause

Burst blood vessels in or near the brain. Tissue dies by the minute

Symptoms

Massive, sudden headache

Nausea, vomiting

Loss of balance or consciousness

Facial pain, double vision

GET SCANNED

A CT, MRI or other imaging scan should be performed immediately, largely to rule out a hemorrhagic stroke, though clots may not be visible. The scan can show the area and extent of the hemorrhage.

TREATMENT

tPA, the clot-dissolving drug, is administered intravenously to selected patients.

Doctors may try to retrieve the clot with a device snaked through artery, or increase blood flow by increasing blood pressure and fluids.

Medications lower blood pressure and reduce brain swelling

Surgery to repair burst artery and/or remove blood is often necessary.

Sources: WSJ reporting; Merck Manual; Stanford Stroke Center

[Guest NYTruckie]

No hospital in Westchester Co. is a Stoke center, White Plains is the closest to getting certified. I think they are on the fourth step or so, Northern Westchester was doing the paperwork for the first step. From what I understand the city has stroke centers and the remac may already have protocols about transporting to them (Not sure City mac expired 2 years ago). But once you go north from New York City I think the next Stroke Center is north of Albany. This info is from a CME about three weeks ago.

[ny10570 745]

AS far as I've been told, White Plains has the best Neurology dept. in the county. Anyone have any facts or to confirm or correct this?

[WAS967 97]

NWHC being a stroke center is news to me. The fact of the matter is there is no set protocol by REMAC or otherwise stating that we are to transport Stroke patients to a particular hospital. Same with Cardiac patients (although we all know thats coming eventually). It's good to get the word out via CMEs and the like, but if they are going to take this to the next level, then a protocol needs to be drawn up and put into place. Until then, they (patients) go to the closest hospital as per standing state and local protocol unless directed otherwise by medical control.

[Guest alsfirefighter]

Good points WAS. Protocols dealing with taking patients to specialized hospitals will be coming.

The biggest thing I see with stroke patients through QA/QI is way too much time on scene by both BLS and ALS. Oxygen isn't gonna solve the problem, a line isn't gonna solve the problem, saving time is. There are many systems in the country who treat stroke much like trauma cases and want them off the scene within 10 mins.

[Guest]

There are many systems in the country who treat stroke much like trauma cases and want them off the scene within 10 mins.

NYC already does this, any call 911 determines to be a CVA is routed to a BLS unit. They do this with trauma as well, BLS only for shooting, stabbings, and MVAs unless the patient is unconscious or in cardiac arrest.

Anyway, so far the only state designated stroke centers are in Brooklyn and Queens.

Kings County

* Brookdale University Hospital

* Long Island College Hospital

* Lutheran Medical Center

* New York Methodist

* University Hospital of Brooklyn - SUNY University Downstate

* Wyckoff

* Kings County Hospital

* Victory

* Coney Island

* North Shore Forest Hills

Queens County

* Elmhurst Hospital

* Flushing Hospital

* Jamaica

* Long Island Jewish

* Mt. Sinai Queens

* NY Hospital Medical Center

* North Shore University Hospital

* Parkway

* Peninsula Hospital

[roeems87 0]

I just want to point out a little fact in the protocol. The time frame as the protocol stands now (for BLS, and note this has been changed in the last few years) is within TWO (2) hours of KNOWN onset of symptoms, you take to the nearest APPROPRIATE FACILITY. That does not mean the closest. Doctors will tell you (those involved in EMS and the protocols, if you have been to any of these conferences) that if you are within the window where getting tPA in less than 3 hours is possible, you should get them to that hospital as soon as possible. If that means traveling to NYC, and it's possible for you, then it's the best option for the patient. It sounds a little abstract because that's not the common practice, but maybe it should be. Time (as in minutes) is not really the issue here. Time (as in hours) is more important, and getting to the appropriate facility, for the best treatment is 100% necessary.

On a side note, making stroke centers, like we have trauma centers is just a great idea. It's making a specialized facility for a specific medical issue available. Just like if trauma is too serious or not serious enough, you go to the closest hospital, stroke centers would be the same way. It's a good dynamic to have.

[LCFD994 8]

Well if thats true about No. Westchester, I guess they better get used to alot more patients coming from up north, unless Putnam Hospital gets approval as well.

I know they get pretty snippy as it is when we come down that way now..

[TRUCK6018 50]

No hospital in Westchester Co. is a Stoke center, White Plains is the closest to getting certified.

NWHC being a stroke center is news to me.

Well if thats true about No. Westchester..

I think what is meant is that no hospital in Westcheser is a stroke center ,not "No(rthern Westchester) Hospital".

[Guest]

If that means traveling to NYC, and it's possible for you, then it's the best option for the patient.

The state designated stroke centers are only in Brooklyn and Queens because they are testing them at this point to see if it would be feasible to expand it to the rest of the state. This does not mean you should bypass all the hospitals in Westchester, Putnam, Connecticut, the Bronx and Manhattan to take them to an otherwise crappy hospital in Queens. I believe the major requirements to be a stroke center are 24/7 CT-scan, 24/7 neurology and a plan to expedite treatment when CVA patients are identified.

At Jamaica Hospital, you call in a stroke notification. When you arrive at the hospital, a neurologist very quickly evaluates the patient, decides whether your assessment was a good one, then sets the wheels in motion with the overhead PA system anouncement and everything starts to get done (emergent CT scan, tPA, etc...)

Theoretically, any hospital with CT scanner capabilities should be able to do this and all of the "good" hospitals already are, regardless of whether the state says they are a Stroke Center.

[Guest NYTruckie]

No hospital in Westchester Co. is a Stoke center, White Plains is the closest to getting certified.

NWHC being a stroke center is news to me.

Well if thats true about No. Westchester..

I think what is meant is that no hospital in Westcheser is a stroke center ,not "No(rthern Westchester) Hospital".

Yes sorry if not Clear it was NO (Not Northern) Hospital in Westcheser. Not only does the TPA have to be given in 3 hours (most doctors will say from the last time the patient was normal) but the sooner (within) the three hour window the better outcome for the patient.

[Guest alsfirefighter]

The availability of anticoagulation medication is exactly the reason why EMS providers must do all they can to limit on scene time. The earlier the window the better the outcome, and if your in that inbetween time, every minute can count. I've witnessed a few cases when working in the ER of the window closing by the time the assessment was done, CT scan completed and getting consent. Lucky for us, most hospitals in our area have CT scanners and tPA.

[WAS967 97]

The problem too is that despite popular belief, tPA is NOT the "standard of care" for patients in acute CVA, even inside the 3 hour window. Brian Bledsoe did an interesting article in JEMS on that a while back. I think the biggest potential comes from the newer techniques of mechanical thrombectomy devices like the Amplatz system. Even after three hours a patient can make close to 100% recovery. It has recieved a lot of exposure PR-wise, even being featured on a recent episode of ER.

[Guest NYTruckie]

The problem too is that despite popular belief, tPA is NOT the "standard of care" for patients in acute CVA, even inside the 3 hour window. Brian Bledsoe did an interesting article in JEMS on that a while back. I think the biggest potential comes from the newer techniques of mechanical thrombectomy devices like the Amplatz system. Even after three hours a patient can make close to 100% recovery. It has recieved a lot of exposure PR-wise, even being featured on a recent episode of ER.

So do you think you can get CME credit for watching ER? If so I will start watching again.

[WAS967 97]

So do you think you can get CME credit for watching ER?

No, I do not.