Debate over thrombolytics for acute ischemic stroke

[bougiecric]

In the 2000s-2010s, there was frequent lively debate over the efficacy of thrombolytics for stroke. Mainly emergency medicine vs neurology. Many prominent leaders in EM published articles/essays/podcasts on the topic noting the lack of benefit.

Now, there is no discussion. The directive is to give thrombolytics to everybody, as fast as humanly possible.

Am I just totally out of the loop? Has there been new evidence that says thrombolytics are definitively beneficial for stroke? Why did this debate seemingly vanish overnight?

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[sloh]

CYA medicine

 

[southerndoc]

If you don't give it, you're likely to not have a leg to stand on with litigation. Too many neurologists are willing to throw you under the bus for not giving it. If you give it and they have a bleed, then you're unlikely to be sued. It's standard of care now regardless of how the research played out.

 

[Groove]

Yeah although I don’t believe in it and am doubtful in the utility of thrombolytics, NOT giving it actually carries the highest litigation risk which was contrary to what I assumed (bleeding complications). That was from a malpractice attorney.

 

[xaelia]

Now, there is no discussion. The directive is to give thrombolytics to everybody, as fast as humanly possible.

Fight's over, we lost.

Pharma bought the AHA and astroturfed the literature through their SMEs. If the door-to-needle clipboard gestapo didn't break your resistance, the plaintiff lawyers will.

There's also been a move toward punting this decision to neurology as the decision tree becomes more complex re: windows/workup/neurointervention etc. It has basically migrated outside EM scope other than activating stroke alerts whenever the triage nurse might put something in the chart to that effect.

Ah, takes me back to my first EM publication:

Pharmaceutical Sponsorship Bias Influences Thrombolytic Literature in Acute Ischemic Stroke

Author(s): Radecki, Ryan P | Abstract: Background: The efficacy of thrombolytic therapy for acute ischemic stroke remains controversial in Emergency Medicine and has not been fully endorsed by either the American College of Emergency Physicians or the American Academy of emergency medicine. A...

escholarship.org

 

[RustedFox]

Fight's over, we lost.

Pharma bought the AHA and astroturfed the literature through their SMEs. If the door-to-needle clipboard gestapo didn't break your resistance, the plaintiff lawyers will.

There's also been a move toward punting this decision to neurology as the decision tree becomes more complex re: windows/workup/neurointervention etc. It has basically migrated outside EM scope other than activating stroke alerts whenever the triage nurse might put something in the chart to that effect.

Ah, takes me back to my first EM publication:

Pharmaceutical Sponsorship Bias Influences Thrombolytic Literature in Acute Ischemic Stroke

Author(s): Radecki, Ryan P | Abstract: Background: The efficacy of thrombolytic therapy for acute ischemic stroke remains controversial in Emergency Medicine and has not been fully endorsed by either the American College of Emergency Physicians or the American Academy of emergency medicine. A...

escholarship.org

We just got an email from the brass that this is our new stroke protocol:

1. Call stroke alert.
2. Go to computer.
3. Enter stroke alert orders.
4. Go see other patients.

That's it.
Do not document much of anything.
Do not go to teleneurology with the patient like you used to.
Do not pass GO, do not collect $200.

Honestly? IDGAF anymore.

 

[EctopicFetus]

Here is the thing.. the stuff doesnt work. Neuro needs something to do since the majority of what they diagnose they cant treat well. On top of that throw in huge money for the hospitals and no one seems to give a F about anything else.

Honestly, the more recent stupidity around sepsis is the same. You can be the one to carry the torch and fight the fight but many people just gave in.

I try to find and document every possible excuse to not give TNK. Last shift EMS comes in with a patient with a stroke, they ask me to see the patient. Onset per EMS 1 hour ago.. dig a little.. symptoms for 3-4 days, progressive.. Yeah.. no stroke protocol, no TNK no call to neuro. Head CT positive for CVA.. c’est la vie.

It seemed like she stroked, but outside of any intervention window. I actually think this approach has made me a better doctor for the stroke patients.

But yeah.. the fight is over.. hospitals, pharma and neuro all have $$ on their side.. we have principles and pt centered outcomes.. no shocker we lost and even less of a shock that they broke our will. Now shut up and go see the patient with belly pain for 6 months who is here for another opinion after her colonoscopy, endoscopy, trip to Mayo/Cleveland clinic and do make sure they are “satisfied”.

 

[Zebra Hunter]

We just got an email from the brass that this is our new stroke protocol:

1. Call stroke alert.
2. Go to computer.
3. Enter stroke alert orders.
4. Go see other patients.

That's it.
Do not document much of anything.
Do not go to teleneurology with the patient like you used to.
Do not pass GO, do not collect $200.

Honestly? IDGAF anymore.

Terrifying.

Neurologists are some of the worst among specialists at getting tunnel vision with regard to incompletely differentiated patients due to the time constraints of stroke care.

I generally call off stroke alerts as soon as they roll through the door if it’s a low probability case to avoid being essentially forced to give thrombolytic therapy for questionable cases like the patient with isolated acute mentation changes, or the young anxious patient with paresthesias from hyperventilation, etc.

 

[RustedFox]

Terrifying.

Neurologists are some of the worst among specialists at getting tunnel vision with regard to incompletely differentiated patients due to the time constraints of stroke care.

I generally call off stroke alerts as soon as they roll through the door if it’s a low probability case to avoid being essentially forced to give thrombolytic therapy for questionable cases like the patient with isolated acute mentation changes, or the young anxious patient with paresthesias from hyperventilation, etc.

Yep.
Watched as neurology TNK'ed several patients last year with their neuro defects being: "it's a drunk woman who can't control her emotions."

 

[EctopicFetus]

We had our head stroke neuro MD say they wanted a stroke alert on all altered patients. I literally laughed and gasped on the call. Called the guy out for having no idea what an ED looks like and then telling him to park the neurologist in the ED cause between psych and drugs/EtOH we have a lot of altered patients. Major tunnel vision.

 

[RustedFox]

We had our head stroke neuro MD say they wanted a stroke alert on all altered patients. I literally laughed and gasped on the call. Called the guy out for having no idea what an ED looks like and then telling him to park the neurologist in the ED cause between psych and drugs/EtOH we have a lot of altered patients. Major tunnel vision.

In similar fashion, I was drug into a meeting about a senior on eliquis who came back into the ER about an hour or so after being discharged from closed head injury. She didn't want to be seen again, just wanted to have a question answered. I obliged her. CT head/c-spine already negative.

She had a delayed bleed several days later after returning with worsening headache.

I was asked: "Why wasn't she made OBS?" by some jackwad admin.

"Because, sir. If I obs'ed every senior with a head injury on a DOAC, we'd need to take over the local high school gymnasium to obs them all."

No effing clue, these people.

 

[TooMuchResearch]

In similar fashion, I was drug into a meeting about a senior on eliquis who came back into the ER about an hour or so after being discharged from closed head injury. She didn't want to be seen again, just wanted to have a question answered. I obliged her. CT head/c-spine already negative.

She had a delayed bleed several days later after returning with worsening headache.

I was asked: "Why wasn't she made OBS?" by some jackwad admin.

"Because, sir. If I obs'ed every senior with a head injury on a DOAC, we'd need to take over the local high school gymnasium to obs them all."

No effing clue, these people.

"Administrator, will you have the patient stay with you for 2 weeks for monitoring?"

 

[TooMuchResearch]

I do talk our stroke neurologists out of thrombolytics for a wasted person approximately once per year.

On the other hand, I've also had one wasted person go for thrombectomy (was out of the window for thrombolytics anyway) in the past couple of years. Chief complaint was effectively "spouse got home from work and speech was more slurred than usual for this time of day but seems better now.*

 

[HoosierdaddyO]

Curious if anyone was willing to share their stump speech with the “numbers” when talking to a patient about the pros vs cons of TNK.

 

[alpinism]

I could rant about thrombolytics for ages but like others have said EBM has ceased to exist in EM.

Those of us in academics who tried fighting this and other harmful practices have either been forced to leave or have retired.

At the end of day EDs nowadays care about reimbursement not outcomes which means protocols that require stroke activation and giving lytics whenever patients complain of numbness or weakness as well as drunks found with alcohol with unsteady gaits who are slurring their speech.
The NYC EDs were so bad when I left it was common to have 10+ activations on shift with sometimes a line outside the radiology department.
If you expressed concerns about these policies you were accused of not being a team player and lectured about following stroke guidelines.

 

[TooMuchResearch]

Curious if anyone was willing to share their stump speech with the “numbers” when talking to a patient about the pros vs cons of TNK.

Neurology does that.

 

[Porfirio]

I give up on strokes. Neuro/hospital/pharm wants the $$$. Patients want “something.” It’s like ordering a CT scan for the 80th billion time a patient has abdominal pain. We know it causes harm but $$$ and want “something” done.

Side question: what’s your record for number of different MRI brain scans in one patient for stroke within 24hrs?

3.

 

[Groove]

Curious if anyone was willing to share their stump speech with the “numbers” when talking to a patient about the pros vs cons of TNK.

I stick with the NINDS data and tell them the risk of head bleed is around 6% with roughly 50% mortality if they happen to be the unlucky 6%. This seems fairly in line with ECASS III, IST-3 and 2014 Lancet meta ~ 2-7% sICH.

I have found over the years that in presenting those numbers, I can pretty much talk anyone out of tPA if I really think it's a bad idea. I reserve it for those patients in their 90s where you've got a new neuro grad fresh out of residency on the teleneuro consult and you just know in the pit of your stomach that this is not going to end well and you'd never want your own grandmother to pick the TPA arm. I will often just close the door, have the discussion with pt and family, get them on board with saying no and then relay that to the stroke neurologist. That way we aren't arguing about it over the monitor and confusing the pt/POA.

Just to put it in perspective, you have a mortality rate with TPA 35-80 times higher compared to cardiac catheterization. Yet, this is mainstream treatment for stroke? I just can't fathom we'll still be injecting drano into people 20 years from now for stroke. Hopefully, the future is 100% endovascular rescue.

Strokes are much more difficult and higher litigation risk for those of us that work in the community because we often times do NOT have a neurologist at the bedside other than a teleneuro cart and the TPA order is being entered by us. Contrary to a tertiary care center where you've got an entire stroke team evaluating the pt and entering the TPA orders. Strokes in those types of environments are very easy.

 

[EctopicFetus]

In similar fashion, I was drug into a meeting about a senior on eliquis who came back into the ER about an hour or so after being discharged from closed head injury. She didn't want to be seen again, just wanted to have a question answered. I obliged her. CT head/c-spine already negative.

She had a delayed bleed several days later after returning with worsening headache.

I was asked: "Why wasn't she made OBS?" by some jackwad admin.

"Because, sir. If I obs'ed every senior with a head injury on a DOAC, we'd need to take over the local high school gymnasium to obs them all."

No effing clue, these people.

One other approach which i love is to use their own stupidity against them. “hey admin jackwad, if you guys can get the hospitalists to agree that would be awesome. Just do that and publish this is our protocol.”

Just wait til CMS gets wind of this scam.. lol..

 

[Brigade4Radiant]

We are no longer allowed to call code strokes off unless neuro sees the patient. We also got rid of out in house neurologists for teleneurology

 

[xaelia]

We are no longer allowed to call code strokes off unless neuro sees the patient. We also got rid of out in house neurologists for teleneurology

I wouldn't be surprised if there's a line of legal attack for failure to administer tPA that involves arguing a hospital is negligent if they don't have a protocol in place to delegate this decision to neurology.

"The whole country employs cardiologists because an EM physician shouldn't make the call on how to manage an MI, why would stroke be any different?"

 

[RustedFox]

We are no longer allowed to call code strokes off unless neuro sees the patient. We also got rid of out in house neurologists for teleneurology

Same here.
It says very clearly in the email that we got last week: "Never cancel a stroke alert."

 

[TooMuchResearch]

We are no longer allowed to call code strokes off unless neuro sees the patient. We also got rid of out in house neurologists for teleneurology

Not...allowed? So a jackwad administrator has clearly decided they are the doc in the pit practicing medicine?

 

[TooMuchResearch]

Same here.
It says very clearly in the email that we got last week: "Never cancel a stroke alert."

Just accumulate your evidence for a whistle blower claim and retire.

 

[RustedFox]

Not...allowed? So a jackwad administrator has clearly decided they are the doc in the pit practicing medicine?

I love that "jackwad" is catching on.

"Jackwad" is the new "Jenny McJennyson".

 

[EctopicFetus]

The difference between neuro and cards is that cards intervenes. Neuro doesnt get their hands dirty..

 

[Rendar5]

Curious if anyone was willing to share their stump speech with the “numbers” when talking to a patient about the pros vs cons of TNK.

33% increased chance of improvement compared with aspirin only. 2% chance you will die. Do you feel your symptoms are severe enough to risk a 2% chance of dying?

 

[DocEspana]

In the 2000s-2010s, there was frequent lively debate over the efficacy of thrombolytics for stroke. Mainly emergency medicine vs neurology. Many prominent leaders in EM published articles/essays/podcasts on the topic noting the lack of benefit.

Now, there is no discussion. The directive is to give thrombolytics to everybody, as fast as humanly possible.

Am I just totally out of the loop? Has there been new evidence that says thrombolytics are definitively beneficial for stroke? Why did this debate seemingly vanish overnight?

Threefold issue

1. the government stepped in and said they formally side with the AHA/neurologists. That is basically the only one you need to know because thats the only issue that actually matters in the end

2. this is such a massively profitable thing that pharmaceutical companies, a few years after the debate began, flooded the literature scene with absolutely ****ty studies that on their own merits were totally pointless and carried no weight. They were unconvincing and poorly designed. Essentially we had complete agreement that the benefit was clearly measured in hours, days, or weeks (really in 30 day neurologically intact survival), but now they were putting out studies claiming people were recovering in seconds (aka they started counting TIAs as thrombolytic success stories) and published those as positive findings. But they essentially juiced the numbers on a meta analysis by flooding it with crappy but incredibly positive (too positive) studies, where suddenly the math turned on the meta analysis because 'junk data in junk data out.' The neurologists (as a generalization) didn't even read their own literature. They were told the meta analysis has become more favorable and that was all they needed to hear.

3. Our main academic warrior in the field was a guy named David Newman out of Mt Sinai in NYC. He... um.... had a kink that was incompatible with good medical practice. And despite the fact that he was right (about thrombolytics, not about sexually abusing patients), the baby gets thrown out with the bath water when youre a sexual abuser. SO MANY of his amazing improvements to evidence based medicine and to dispelling old mythologies we all clung to are just reverting back to their old superstitious ways because no one wants to consume his material any more. Its essentially been scrubbed from the internet.

 

[DocEspana]

We just got an email from the brass that this is our new stroke protocol:

1. Call stroke alert.
2. Go to computer.
3. Enter stroke alert orders.
4. Go see other patients.

That's it.
Do not document much of anything.
Do not go to teleneurology with the patient like you used to.
Do not pass GO, do not collect $200.

Honestly? IDGAF anymore.

I'm sitting right next to a laminated page that says we now have two different classes of stroke alert. Class A is the obvious stroke cases. Both classic and convincing posterior cases. Class B is "anyone with dizziness for less than 24 hours. First or worst headache of life within last 24 hours regardless of intensity or location. Any confusion or AMS less than 24 hours. Any unliteral paresthesia, even if exclusively digits". Not surprisingly its signed off by the clinical practice committee and the head of neurology but no one in the ED.

Class B is essentially a priority CT and a neuro consult, though thankfully neuro signs off on almost all of these. My partners probably call like 8 stroke alerts a day and 7.5 of them are Class B because of this. I just flat out refuse to take part in this insanity and there hasn't been any administrative complaints yet.

 

[DocEspana]

Yep.
Watched as neurology TNK'ed several patients last year with their neuro defects being: "it's a drunk woman who can't control her emotions."

In residency my director wanted me to get administrative experience (we had an administration "psuedo-fellowship" for senior residents who wanted $5,000 extra a year for a lot more responsibility) and sent me to the M&M committee among others. So I noticed a trend of TPA patients getting life threatening GI bleeds with high frequency. Talking like 16-18%. And they continually pointed out that the stupid resident was seeing a pattern that didnt exist. That life threatening GI bleeds 3-4 days after TPA is not a TPA complication. Except IT IS. THATS WHAT THE ORIGINAL DATA SHOWED ON TPA. nah. silly resident. They swore their TPA had a 0.000000001% complication rate and any bleeding outcomes afterwards were unavoidable acts of god no one could see coming.

Wrote my residency required research project on it. My boss told me I'm not going to M&Ms any more X-D. Its okay, i had plenty of other administrative stuff I had to do for him for the $5k anyway, was happy to be off of that meeting.

 

[DeadCactus]

The same thing that ruining medicine as a whole:
1. The healthcare consumer cannot reasonably assess the quality of healthcare they are given and are likely actually generally more happy with worse and more expensive care.
2. The entire system is financially incentivized to do more, not do better. Physician's receive more medicolegal protection and better patient satisfaction by doing more (and potentially paid more depending on the model). The hospital bills more by doing more. The insurance company pays more, can increase premiums, has more opportunities to refuse payment, and increases total profits by more being done. The government looks good to its constituents and donors by mandating these interventions that make patients and the healthcare system happy.

More specific to this, I think EM as a specialty is burnt-out. The energy is just not there to care and do unpaid, unappreciated work like this kind of advocacy.

 

[TooMuchResearch]

I'm sitting right next to a laminated page that says we now have two different classes of stroke alert. Class A is the obvious stroke cases. Both classic and convincing posterior cases. Class B is "anyone with dizziness for less than 24 hours. First or worst headache of life within last 24 hours regardless of intensity or location. Any confusion or AMS less than 24 hours. Any unliteral paresthesia, even if exclusively digits". Not surprisingly its signed off by the clinical practice committee and the head of neurology but no one in the ED.

Class B is essentially a priority CT and a neuro consult, though thankfully neuro signs off on almost all of these. My partners probably call like 8 stroke alerts a day and 7.5 of them are Class B because of this. I just flat out refuse to take part in this insanity and there hasn't been any administrative complaints yet.

So all the intoxicated people or febrile elderly people in your ED get a CT head just because neurology says so?

 

[DocEspana]

So all the intoxicated people or febrile elderly people in your ED get a CT head just because neurology says so?

Per policy, yes. I ignore it. Most of my coworkers are either brand new graduates or older physicians who are one foot out the door to retirement - they just do whatever the laminated sheet tells them. SO MANY stroke alerts called on sepsis or intoxication. Thankfully, this "stroke alert" is really just a neuro consult and stat CT and not the whole rigamarole of a real stroke alert. Still have to hear it called overhead in the ED each time.

 

[RustedFox]

The same thing that ruining medicine as a whole:
1. The healthcare consumer cannot reasonably assess the quality of healthcare they are given and are likely actually generally more happy with worse and more expensive care.
2. The entire system is financially incentivized to do more, not do better. Physician's receive more medicolegal protection and better patient satisfaction by doing more (and potentially paid more depending on the model). The hospital bills more by doing more. The insurance company pays more, can increase premiums, has more opportunities to refuse payment, and increases total profits by more being done. The government looks good to its constituents and donors by mandating these interventions that make patients and the healthcare system happy.

More specific to this, I think EM as a specialty is burnt-out. The energy is just not there to care and do unpaid, unappreciated work like this kind of advocacy.

Hey, look!
Something we agree on!

 

[WhatJobDoIPick]

EM is done. Stick a fork in it. Honestly it's such a joke of a field. I'm a babysitter that gets paid $250/hr. Make your money now cause it ain't gonna last.

 

[RustedFox]

EM is done. Stick a fork in it. Honestly it's such a joke of a field. I'm a babysitter that gets paid $250/hr. Make your money now cause it ain't gonna last.

See, the kids that are coming OUT of residencies now.... they're just garbage.
They can't rock acuity, they can't rock volume, they can't think.

 

[BoardingDoc]

See, the kids that are coming OUT of residencies now.... they're just garbage.
They can't rock acuity, they can't rock volume, they can't think.

But they won't have to. They'll have the laminated stroke/sepsis/PE/whatever cards. Problem solved.

 

[Tiger26]

Threefold issue

1. the government stepped in and said they formally side with the AHA/neurologists. That is basically the only one you need to know because thats the only issue that actually matters in the end

2. this is such a massively profitable thing that pharmaceutical companies, a few years after the debate began, flooded the literature scene with absolutely ****ty studies that on their own merits were totally pointless and carried no weight. They were unconvincing and poorly designed. Essentially we had complete agreement that the benefit was clearly measured in hours, days, or weeks (really in 30 day neurologically intact survival), but now they were putting out studies claiming people were recovering in seconds (aka they started counting TIAs as thrombolytic success stories) and published those as positive findings. But they essentially juiced the numbers on a meta analysis by flooding it with crappy but incredibly positive (too positive) studies, where suddenly the math turned on the meta analysis because 'junk data in junk data out.' The neurologists (as a generalization) didn't even read their own literature. They were told the meta analysis has become more favorable and that was all they needed to hear.

3. Our main academic warrior in the field was a guy named David Newman out of Mt Sinai in NYC. He... um.... had a kink that was incompatible with good medical practice. And despite the fact that he was right (about thrombolytics, not about sexually abusing patients), the baby gets thrown out with the bath water when youre a sexual abuser. SO MANY of his amazing improvements to evidence based medicine and to dispelling old mythologies we all clung to are just reverting back to their old superstitious ways because no one wants to consume his material any more. Its essentially been scrubbed from the internet.

I wonder what Newman's up to these days--he was my hero in EM, so that was a bit of a gut punch

 

[DocEspana]

See, the kids that are coming OUT of residencies now.... they're just garbage.
They can't rock acuity, they can't rock volume, they can't think.

I mentioned above my current job is (perhaps a little premature for only pgy-12) a bit of a slow retirement ramp that pays meh but is low stress, yet we still have brand new graduates. And they really shouldn't be there, it's relatively low acuity, mostly solo coverage, and moderate volume on the back of how much low acuity there is just coming by for a flu test/therapeutic radiation of their chronic cough. Not a place to start a career. As the only non-boss in that "has more than 2 years and less than a retirement worth amount" of experience window, I took three of them under my wing to make sure they actually learn good practice in case they want to go somewhere more normal acuity. Leads to A LOT of phone calls both when I am at work and when I'm not, as we cover multiple sites and they're often solo coverage.

God Almighty. Two out of the three of them went to seemingly elite residencies. All three of them are just crippled with pretty straightforward management questions on anyone more complicated than an obvious discharge or obvious admit. Very much they are overpaid triage nurses and they're amazing at doing whatever wikem or open evidence says to do - and no hate to those two websites I love them - but can't think outside the box in the least when a patient is a blend of sick but not sick enough or has some unique undifferentiated thing and you just sort of have to improvise. If there isn't a laminated answer, they get paralyzed with the decision.

I think it's getting better. But maybe I'm kidding myself. I just know back in my day I was always told to just "figure it out myself" and the only metric that was important was "are they healthy enough to make it back ambulatory if you're wrong when you discharge them." Which is a metric I like and I use all the time.

 

[sloh]

Were they…..powerhouse residences though? 🙂

 

[DocEspana]

Were they…..powerhouse residences though? 🙂

as a person who went to a clown college residency next to many 'powerhouse' residencies, I hate that term.

I learned how to clown intubate and manage crashing clowns. Can even tie my gum bougie into a little dog - clown skills.

 

[The Knife & Gun Club]

We just got an email from the brass that this is our new stroke protocol:

1. Call stroke alert.
2. Go to computer.
3. Enter stroke alert orders.
4. Go see other patients.

That's it.
Do not document much of anything.
Do not go to teleneurology with the patient like you used to.
Do not pass GO, do not collect $200.

Honestly? IDGAF anymore.

One of the smartest EM attendings I know likes to say “Don’t try to outsmart the easiest chief complaint in medicine”

Call the stroke alert and be done with it. Tele-neuro gets paid a lot of money to absorb this medical-legal risk of this decision from the comfort of their home.

We as a speciality may not agree with teleneuro’s decision but at this point the broader medical community doesn’t care what I think. I’m there to manage their airway if they lose it and make sure something else isn’t going on.

 

[WhatJobDoIPick]

One of the smartest EM attendings I know likes to say “Don’t try to outsmart the easiest chief complaint in medicine”

Call the stroke alert and be done with it. Tele-neuro gets paid a lot of money to absorb this medical-legal risk of this decision from the comfort of their home.

We as a speciality may not agree with teleneuro’s decision but at this point the broader medical community doesn’t care what I think. I’m there to manage their airway if they lose it and make sure something else isn’t going on.

Yeah I need to do a lot more of this and just stop caring. We lost the war. TNK fits the "don't just stand there, do something" model that the muggles just love.

 

[Emapp20177]

Call the stroke alert and be done with it. Tele-neuro gets paid a lot of money to absorb this medical-legal risk of this decision from the comfort of their home.

Is this common? At all of the shops in my region, the ED manages strokes. Neurology doesn't even want to be called on stroke activations.

 

[carbonizedeyesockets]

I've asked neuro residents and attending about the "controversy" with TPA and they almost universally respond with "what controversy".

As other have said, it's settled. The war was lost.

I'm in agreement that "stroke" is pretty easy. Where I've worked, the decision for TPA or thrombectomy is left to the on-call neurologist. They may do a video eval of the patient, but typically we just talk and they review the images themselves. I document the conversation and move on. Aside from my initial eval of the patient, my brain turns off and I coast.