In stroke, emergency rooms tend to flush money away

“So what do you think about the new hospital?”

“Well, if you had cut any more corners it would be a circle. A very small circle.”

“Hmmph. We are quite pleased with it. You can’t make money in these tough economic times without making certain adjustments.”

“Speaking of adjustments, I noticed there still aren’t any toilets in the bathrooms and the grand opening is tomorrow. And when are we going to have an MR tech in-house at night?”

“In light of the economic crisis, we decided to go with a more traditional bathroom fixture…”

“Like a hole in the ground?”

“I’ll have you know that more than half the planet's population uses squat toilets, and research shows that they are more sanitary, conserve water, and are cheaper.”

“You’re not kidding!”

“No. And we won't be able to afford an MR tech at night, either.”

“Why? Is it more economical to squat in a CT scanner?”

I was traveling in Asia this year and was astounded to visit many brand new buildings that had only Eastern-style toilets. What is with that? I don’t want to sound like some smug, superior, intolerant Western-centric American tourist, but who exactly is behind this dastardly plot? Terrorists? The communists? The dry-cleaning industry? I am still plagued by nightmares because I have neither the skill nor the dexterity to use them. Does the rest of the world have no doddering elderly or frighteningly clumsy people, like me, who fall in? I realize Eastern toilets have been around for thousands of years, but there have been some amazing advancements in the past 200 years-like the porcelain commode.

Which, curiously, brings me to a very similar question: Why does everyone order CTs to rule out stroke instead of MRI? I can’t blame this one on the dry-cleaning industry, but for the vast majority of patients, you cannot rule out a stroke with a CT inside of three to six hours, while an MR diffusion sequence will be positive within 30 minutes.

In some hospitals, a patient will get a second CT scan and an MRI after the MR tech comes in, just to be certain. With CT angiography and perfusion scanning, patients now get these additional radiation-intense studies with the associated contrast load as well. This happens even though only a minority of stroke patients have thrombosis of the larger vessels that can be diagnosed on these studies. And they are often ordered when the patient is outside the window for tPA treatment. Why? So no one can possibly get sued for missing a stroke.

Dr. George Lantos, an associate professor of radiology and neurology at Albert Einstein College of Medicine in New York, recently wrote in a letter to The New York Times: “My stroke neurologists and I have decided that if treatment does not yet depend on the results, these tests should not be done outside the context of a clinical trial, no matter how beautiful and informative the images are. At our center, we have therefore not jumped on the bandwagon of routine CT perfusion tests in the setting of acute stroke, possibly sparing our patients the complications mentioned.”

Which raises another interesting point: the majority of patients who come to the hospital to rule out a stroke in fact haven’t had have a stroke, so many may be getting unnecessary exams, radiation, contrast, drugs, and expensive hospital stays. If you can do an MR diffusion sequence that takes less than two minutes and send the images to be read via teleradiology, you can have an actual answer before the patient even gets off the table. And studies have shown that gradient and FLAIR sequences are sufficient to identify most hemorrhage as well as CT does.

We are also faced with a changing legal landscape, or, as some might say, minefield. Here in California, SB 1237 will more than likely become law next year with the intent to try to regulate radiation exposure. The original bill was quite broadly worded, such that any radiation exposure to a pregnant woman had to be reported to the California Department of Public Health, even a simple brain scan. More recent iterations will require all radiation doses to become part of the patient’s permanent medical record. Overdoses will have to be reported to patients, physicians, and the Department of Public Health. How an overdose is to be defined is rather vague and could even be construed as an unnecessary CT scan. Porsche intends to roll out a flashy ad campaign for lawyers based on their prospects from this law.

Luckily, the much anticipated new American Academy of Neurology evidence-based guidelines for stroke diagnosis recommend diffusion imaging as superior to CT in the first 12 hours. The guidelines were published in the July issue of Neurology and authored by P.D. Schellinger of the National Institutes of Neurological Disorders and Stroke. Among the ramifications discussed was that even though MR may initially be more expensive, it would eventually save money through improved diagnosis and treatment with less imaging. The only problem the article mentioned was the willingness of hospitals to adopt the guidelines and staff their facilities accordingly.

When I recently asked an ER physician why he didn’t order an MRI instead of a CT on a patient (one who was well outside the allowed tPA window), he told me there was no MR technologist in-house. When I then asked the CT tech if the hospital had ever considered cross-training him for MR, he told me he wanted to be cross-trained but administration objected because it would increase his pay grade to that of an MR tech, about an additional $14,000 in California. For hospitals that are advertising themselves as “Certified Stroke Centers of Excellence” this seems a false economy. They should get on board the bus.

Just as horse-drawn carts gave way to the internal combustion engine, clinicians should upgrade patient care by using MR in stroke diagnosis instead of CT. And the rest of the world should upgrade to commodes so everyone has the opportunity to drive the porcelain bus after a night of drinking without freaking out.