Debate over thrombolytics for acute ischemic stroke

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I think we "lost" because it does work.
"Work"

No one ever really bothered to re-test NINDS, and – why would they? Genentech stopped sponsoring investigators and supplying drugs to new trials that might diminish the effect size. It probably helps more often than it hurts, but not to the extent where I'd use the pharma-approved AHA propaganda.

Those trials from decades ago aren't generalizable to modern practice, either; we're enrolling different (read: milder) strokes, in general, and we're including comorbidities excluded from those trials and kept on as relative contraindications for years. That said, once you shake out the LVO from those old trials and send them to EVT, yeah, perhaps then you can build back some more of the benefit – small vessels, small territories, reasonable collateral circulation/oxygen diffusion. Too bad we'll never really know.
 
That what I meant by works "a little bit" and why I don't use the AHA diagram to explain benefit. Leaves out the 20% in the original trial who got better on placebo and makes the majority of patients who get no benefit so translucent that most patients look right past them and just look at the pretty green guys who get to dance at their daughter's wedding. Most of those guys would have gotten to dance anyway.

I don't think anyone has tried to extract the LVO crowd from the old trials but I've often wondered the reverse. Maybe the tiny marginal benefits we think we saw were in the LVOs with salvage of some watershed areas that left you still able to at least brush your own teeth. Send all the LVO's to EVT now and maybe what's left gets no benefit. We'll probably never know

Unfortunately there is a lot of things in medicine that fall into the "Too bad we'll never really know category"
 
At least once a month I go to a stroke alert where I tell neuro, "I'm not sure what this is yet but its not a stroke." They usually agree and I'm usually right. Especially true in places where medics initiate the alert in the field.
I’m not pretending medics don’t make bad calls, but the ED I work in has an absurdly low threshold for calling stroke alerts. This phenomena of overtriage is not unique to any one level of certification or practice environment.
 
I’m not pretending medics don’t make bad calls, but the ED I work in has an absurdly low threshold for calling stroke alerts. This phenomena of overtriage is not unique to any one level of certification or practice environment.

The level for activation is trash tier. It's to the point where every tingly panic attack and bells palsy and 117 year old altered mental status is getting activated.
 
"Work"

No one ever really bothered to re-test NINDS, and – why would they? Genentech stopped sponsoring investigators and supplying drugs to new trials that might diminish the effect size. It probably helps more often than it hurts, but not to the extent where I'd use the pharma-approved AHA propaganda.

Those trials from decades ago aren't generalizable to modern practice, either; we're enrolling different (read: milder) strokes, in general, and we're including comorbidities excluded from those trials and kept on as relative contraindications for years. That said, once you shake out the LVO from those old trials and send them to EVT, yeah, perhaps then you can build back some more of the benefit – small vessels, small territories, reasonable collateral circulation/oxygen diffusion. Too bad we'll never really know.
We had NINDS-I which showed no difference, NINDS-II which showed increased ICH, ECASS-I which showed benefit did not outweigh risk, ECASS - II showed no difference, ECASS III showed increased ICH, ATLANTIS A and B were both stopped early due to increased harm and no benefit respectively, MAST EU and ITALY both showed increased harm. Long story short, the findings of the NINDS trial have never been replicated, yet we treat that study as dogma... Why does no one question this???
 
Why does no one question this???
Our generation totally did – but who funds a bunch of skeptics? No one. Who sponsors CME and the guideline writers? Pharma. Game over.

Even just at face value – we've designed massive systems of care, including stroke ambulances, when the 95% CIs are enormous and stray down very close to unity. We don't know the actual effect size of this treatment – random imbalances between groups, unmeasured confounders in comorbidities and stroke syndromes, etc. – we could be barely squeaking by for all these years with little more than specious observational data gathered by those with a vested interest in confirming efficacy.

 
The level for activation is trash tier. It's to the point where every tingly panic attack and bells palsy and 117 year old altered mental status is getting activated.
I typed out a situation where I got called to the carpet for not calling a stroke alert, but it was so absurd that it borderlined on "identifiable medical info" so I deleted it.

The fact of the matter is alerts (stroke, stemi, trauma, sepsis) are so easy to draw datapoints and metrics from that they're an administrators wet dream. Nevermind the fact that the metrics are worthless, but it allows suits to compare themselves to suits at other ED's in some big circle jerk.

Door to balloon, door to neuro consult, door to TNK, door to whatever.. These were all useful timestamps for internal improvement at one point, but became bastardized by BSN, MSN, DNP, MPH, and PhD capstone projects/dissertations over the years that they're now essentially marketing tools and nothing more..
 
Idk if it's an academics thing or these stories are embellished, but as a neuro resident reading these feels like stepping into a completely different reality.

The vast majority of our stroke codes that get called aren't real strokes. Of the ones that are or could be, most of them don't get TNK anyway. Either the deficits aren't severe enough to outweigh bleeding risk, they're out of the intervention window, on blood thinners, or something else comes up. TNK can be great for specific situations, but it's often not the best next step. I don't see it given that often.
 
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Idk if it's an academics thing or these stories are embellished, but as a neuro resident reading these feels like stepping into a completely different reality.

The vast majority of our stroke codes that get called aren't real strokes. Of the ones that are or could be, most of them don't get TNK anyway. Either the deficits aren't severe enough to outweigh bleeding risk, they're out of the intervention window, or on blood thinners. TNK can be great for specific situations, but it's often not the best next step.
I don't know s*** about f*** when it comes to TNK and stroke management, but I know enough about community and academic medicine to say that it is definitely an academic thing.

In a good academic setting, a lot of thought goes into diagnosis, differentials and risks/benefits of treatments. Out in the community however, it's all about how quickly you can move on to the next case since that's how you get paid. So whatever the fastest route to getting out of the room and on to the next one is the route you're going to take.
 
Idk if it's an academics thing or these stories are embellished, but as a neuro resident reading these feels like stepping into a completely different reality.

The vast majority of our stroke codes that get called aren't real strokes. Of the ones that are or could be, most of them don't get TNK anyway. Either the deficits aren't severe enough to outweigh bleeding risk, they're out of the intervention window, on blood thinners, or something else comes up. TNK can be great for specific situations, but it's often not the best next step. I don't see it given that often.
You nailed it with your first phrase. Youre in academics.

Here's the reality. when you become an attending, ESPECIALLY, if you go into a community hospital, a bunch of factors occur at the same time to rapidly degrade the quality of medicine massively.
1. some people you will interact with were just not great evidence based practitioners even in residency and they went to the community exactly so they dont have to be bound by that so tightly. They're going to do what feels right to them rather than what the data actually suggests. As an extra annoyance, everyone will love them for some reason. That's just how the world works.
2. lots of physicians are 30+ years into practice and 30+ years since they ever seriously refreshed themselves on CME and practice patterns. So they're out there just practicing the way they thought was cutting edge in 1995 or 2000. You know how you are tempted to just phone it in on some of those modules/journal clubs/lectures in residency? That desire to just phone it in and just get the certificate rather than actually learning is 50-100x higher once you're out of residency. If you try to educate these people on being out of date they will let you know that theyve been doing it this way for three decades and they havent killed anyone yet (as a point of fact: yes they have, but its impossible for them to see how many individual bad outcomes were preventable, because no one has that ability to view their practice patterns objectively across time and without ego so all bad outcomes were unavoidable in their mind).
3. In the community lots of things happen just for customer service. Lots of people (especially specialists, but I'm not excluding EM) will happily ignore good medical practice because they feel that keeping the patient alive is the #1 priority, keeping them happy is #2, and actually doing whats *best* for them is #3 or lower. If the dumb thing the patient wants is not likely to kill them but is very likely to make them think you're a great doctor - you do it even if you know better.
4. You no longer have a layer of program leadership to be a heat shield for you against the never ending supply of nurse and MBA administrators who are constantly trying to find a way to quantify, gamify, or both, every element of the medical process. And them being fully and completely wrong about stuff can still make your life a living hell because they get paid to send you emails that you don't get paid to respond to (but you have to), so for them emailing you is a fulfilling experience but its a one-way street for sure. And if they don't like your answer or you ignore them, the annoyances will go from annoying emails, to uncomfortable in person talks, to slaps on the wrist, to formal discipline in a relatively steady manner. And again - often they will be fully incorrect, but since its their job to nitpick everything you do but they don't have the knowledge to understand immediately why you didn't do what they expected you to do, their constant emails will wear down your patience to not just do the thing that leads to the least emails even when it questionable or not indicated at all.
 
4. You no longer have a layer of program leadership to be a heat shield for you against the never ending supply of nurse and MBA administrators who are constantly trying to find a way to quantify, gamify, or both, every element of the medical process. And them being fully and completely wrong about stuff can still make your life a living hell because they get paid to send you emails that you don't get paid to respond to (but you have to), so for them emailing you is a fulfilling experience but its a one-way street for sure. And if they don't like your answer or you ignore them, the annoyances will go from annoying emails, to uncomfortable in person talks, to slaps on the wrist, to formal discipline in a relatively steady manner. And again - often they will be fully incorrect, but since its their job to nitpick everything you do but they don't have the knowledge to understand immediately why you didn't do what they expected you to do, their constant emails will wear down your patience to not just do the thing that leads to the least emails even when it questionable or not indicated at all.
THIS
 
I get a kick out of how some of you guys discuss risks vs benefits of thrombolytics. In no world am I allowed to do that. We were given a script by corporate to tell the patient. Obviously the script is: a) incredibly brief (can't delay administration) and b) essentially demands the patient accept the thrombolytic.
 
I get a kick out of how some of you guys discuss risks vs benefits of thrombolytics. In no world am I allowed to do that. We were given a script by corporate to tell the patient. Obviously the script is: a) incredibly brief (can't delay administration) and b) essentially demands the patient accept the thrombolytic.
I discuss risk benefit of anything I'm doing if it's relevant and there is time.
 
I get a kick out of how some of you guys discuss risks vs benefits of thrombolytics. In no world am I allowed to do that. We were given a script by corporate to tell the patient. Obviously the script is: a) incredibly brief (can't delay administration) and b) essentially demands the patient accept the thrombolytic.

Wut lol.

Why would anyone ever work this job?
 
I get a kick out of how some of you guys discuss risks vs benefits of thrombolytics. In no world am I allowed to do that. We were given a script by corporate to tell the patient. Obviously the script is: a) incredibly brief (can't delay administration) and b) essentially demands the patient accept the thrombolytic.

This sounds a bit like practicing medicine without a license.

It would be a shame if someone besides you were to accidentally post it to the internet somewhere.
 
This sounds a bit like practicing medicine without a license.

It would be a shame if someone besides you were to accidentally post it to the internet somewhere.
They have their corporate lackeys with medical degrees sign off on all this junk.
 
They have their corporate lackeys with medical degrees sign off on all this junk.

True statement. I'm small on the admin ladder but if anything is clear to me, it's that the patient-facing roles are left holding the bag. If a lawsuit happens from any of this, the people involved in setting up this system will never be named. The low hanging fruit is the ed doc that "negligently" harmed the patient.
 
Hot off the press

In 6 months, when the stroke coordinator is pushing you to give tpa for every case of acute vertigo, remember that this was not a study of acute vestibular syndrome, it was a study of patients with an appreciable deficit and diagnosed with a stroke by either an experienced clinician and most often mri (well over half, which they bury in the appendix). Population was also fairly young (50% < 65) and only 10% on aspirin at baseline. (But I’m sure we can find a Genentech sponsored medfluencer, err sorry I mean ‘content expert’ to argue that it’s definitely applicable to the 80 year old on dapt who presents with isolated vertigo)
 
Hot off the press

In 6 months, when the stroke coordinator is pushing you to give tpa for every case of acute vertigo, remember that this was not a study of acute vestibular syndrome, it was a study of patients with an appreciable deficit and diagnosed with a stroke by either an experienced clinician and most often mri (well over half, which they bury in the appendix). Population was also fairly young (50% < 65) and only 10% on aspirin at baseline. (But I’m sure we can find a Genentech sponsored medfluencer, err sorry I mean ‘content expert’ to argue that it’s definitely applicable to the 80 year old on dapt who presents with isolated vertigo)
Up to 24 hours? Wtf...
 
Hot off the press

In 6 months, when the stroke coordinator is pushing you to give tpa for every case of acute vertigo, remember that this was not a study of acute vestibular syndrome, it was a study of patients with an appreciable deficit and diagnosed with a stroke by either an experienced clinician and most often mri (well over half, which they bury in the appendix). Population was also fairly young (50% < 65) and only 10% on aspirin at baseline. (But I’m sure we can find a Genentech sponsored medfluencer, err sorry I mean ‘content expert’ to argue that it’s definitely applicable to the 80 year old on dapt who presents with isolated vertigo)
It should probably be built into a triage administered protocol to make sure we hit our door to med times. There could be a cheesy VHS video they roll in strapped to a cart to discuss risks before they give it. Easy dispo. Door to ICU admit in under 15 minutes.
 
I feel this..I do some admin stuff. I was on a call with the head stroke neurologist.. He loves TPA/TNK more than he loves his wife im sure. He said “I want a stroke eval on all patients with AMS, confusion etc”. I said, hey bud.. Love it.. Just park the neurologist in the ED every friday and Saturday night. They can see all the patients EMS rolls in.

I said, listen you have literally 0 clue what we do. We wont be doing this unless you commit the resources to sit the stroke neurologist in the ED. Then on my next shift I sent him an email of all the patients that would have “qualified” for a consult. That quickly and not surprisingly ended right there.

In hindsight it’s all so easy, the MMQBing is real. Stroke alert, trauma alert, sepsis alert, STEMI alert. Etc etc etc. We also have special protocols for OB patients. I said, if every patient is special then thats perfect and puts them all on a level playing field.

Most recently we got our very own “sepsis coordinator”, my mind is blown. This Nurse tells us what and how to document. I think the response should be why dont you put whatever you want in the chart and I’ll sign off (like I would for a scribe) if I agree. I have too much stuff to deal with. Let’s be super honest.. in 5-10 years we will look at the resources we are currently pouring into sepsis and realize it is a tremendous waste with no change in outcomes. Would we not be better served in this time of a lack of RN resources using these people at the bedside?

The world is upside down.
 
I feel this..I do some admin stuff. I was on a call with the head stroke neurologist.. He loves TPA/TNK more than he loves his wife im sure. He said “I want a stroke eval on all patients with AMS, confusion etc”. I said, hey bud.. Love it.. Just park the neurologist in the ED every friday and Saturday night. They can see all the patients EMS rolls in.

I said, listen you have literally 0 clue what we do. We wont be doing this unless you commit the resources to sit the stroke neurologist in the ED. Then on my next shift I sent him an email of all the patients that would have “qualified” for a consult. That quickly and not surprisingly ended right there.

In hindsight it’s all so easy, the MMQBing is real. Stroke alert, trauma alert, sepsis alert, STEMI alert. Etc etc etc. We also have special protocols for OB patients. I said, if every patient is special then thats perfect and puts them all on a level playing field.

Most recently we got our very own “sepsis coordinator”, my mind is blown. This Nurse tells us what and how to document. I think the response should be why dont you put whatever you want in the chart and I’ll sign off (like I would for a scribe) if I agree. I have too much stuff to deal with. Let’s be super honest.. in 5-10 years we will look at the resources we are currently pouring into sepsis and realize it is a tremendous waste with no change in outcomes. Would we not be better served in this time of a lack of RN resources using these people at the bedside?

The world is upside down.
The study would be nearly impossible to do, but I would be very interested to see what impact Stroke Center certification has on outcomes when you zoom out just a bit to the community. When you account for not just the impact of inappropriate lytics administered due to itchy trigger fingers and excessive use of radiation for symptoms that an extra 5 minutes would tell you are not due to stroke, but also include the impact of having EMS crews drive farther to stroke centers, taking nursing care away from other patients, etc...I would bet dimes to dollars that Stroke Centers make their communities less healthy.
 
I feel this..I do some admin stuff. I was on a call with the head stroke neurologist.. He loves TPA/TNK more than he loves his wife im sure. He said “I want a stroke eval on all patients with AMS, confusion etc”. I said, hey bud.. Love it.. Just park the neurologist in the ED every friday and Saturday night. They can see all the patients EMS rolls in.

I said, listen you have literally 0 clue what we do. We wont be doing this unless you commit the resources to sit the stroke neurologist in the ED. Then on my next shift I sent him an email of all the patients that would have “qualified” for a consult. That quickly and not surprisingly ended right there.

In hindsight it’s all so easy, the MMQBing is real. Stroke alert, trauma alert, sepsis alert, STEMI alert. Etc etc etc. We also have special protocols for OB patients. I said, if every patient is special then thats perfect and puts them all on a level playing field.

Most recently we got our very own “sepsis coordinator”, my mind is blown. This Nurse tells us what and how to document. I think the response should be why dont you put whatever you want in the chart and I’ll sign off (like I would for a scribe) if I agree. I have too much stuff to deal with. Let’s be super honest.. in 5-10 years we will look at the resources we are currently pouring into sepsis and realize it is a tremendous waste with no change in outcomes. Would we not be better served in this time of a lack of RN resources using these people at the bedside?

The world is upside down.

HCA doc here. The sepsis "coordinator" has been a thing for us for years. It's about as useless as you describe it.
 
The study would be nearly impossible to do, but I would be very interested to see what impact Stroke Center certification has on outcomes when you zoom out just a bit to the community. When you account for not just the impact of inappropriate lytics administered due to itchy trigger fingers and excessive use of radiation for symptoms that an extra 5 minutes would tell you are not due to stroke, but also include the impact of having EMS crews drive farther to stroke centers, taking nursing care away from other patients, etc...I would bet dimes to dollars that Stroke Centers make their communities less healthy.

You don't even have to do a study with regards to stoke centers since nearly every paper comparing US ED patients to non US ED patients located in other countries without specialized hospitals shows that we have worse outcomes.

The crazy thing is that we even have studies that have shown that even for the richest US patients that are treated at the best US hospitals outcomes are worse than for the average patient in other similar first world countries.
 
HCA doc here. The sepsis "coordinator" has been a thing for us for years. It's about as useless as you describe it.
This is exactly why I left my last HCA hospital ED job. 1 sirs criteria and sepsis order set all day long or useless sepsis coordinator won’t stop with the useless emails.
 
Man, just wait until it's FEDERAL LAW to get bent about sepsis:
In a powerful show of support, the bill has also been endorsed by the American Hospital Association and the Federation of American Hospitals,

That says all I needed to know about this bill
 
Man, just wait until it's FEDERAL LAW to get bent about sepsis:
Listen, I find myself using actual critical thinking medicine skills less and less as time goes on.

I tried to practice reasonable medicine for years and all I got was emails about stuff I didn't do right and peer review.

I turned off my thinking and suddenly no more emails, no more peer review.

Message received!
 

About the Legislation:​

The bill would guarantee an investment of $20 million annually that would:

  • Expand outreach and education to hospitals to encourage adoption of the CDC’s comprehensive new sepsis guidelines, Hospital Sepsis Program Core Elements.
  • Finalize and implement a sepsis outcome measure. A sepsis outcome measure would have significant, system-wide impacts on U.S. healthcare through:
    • Standardizing sepsis care across hospitals
    • Incentivize hospitals to improve, process that would lead to reductions in mortality and morbidity
    • Lowering healthcare costs by implementing effective early interventions
    • Drive Data Transparency and Quality Improvement by requiring hospitals to report sepsis outcomes publicly
    • Strengthen sepsis programs nationwide by encouraging greater hospital investment in sepsis care
  • Improve data collection on pediatric sepsis
  • Create an incentive program for hospitals to improve sepsis outcomes

Key Facts on Sepsis:

  • Sepsis kills more than 350,000 Americans each year — more than opioid overdoses, breast cancer, and prostate cancer combined.
  • It leaves countless others with life-changing disabilities, including amputations, cognitive damage, and PTSD.
  • 1 in 3 hospital deaths is linked to sepsis.
  • The total annual cost of sepsis care is estimated to be between $62 billion to over $80 billion per year.
 
1/5 deaths each year in the US are due to sepsis? Where, exactly, are they? At "St Elsewhere", or "St Mary Lost-in-the-Woods", or where?
As someone who fills out a lot of death certs in people that die at home…it’s a pretty common thing to write in the absence of data to support anything else.

The death certificate makes you choose a cause. Can’t say unknown, which is the realistic truth in around 30% of cases, even if there is a likely culprit (chf, cancer, etc) that you write on the bottom line reflecting the main cause of decline. The way they are made in most states makes you choose a narrative kind of approach

E.g.
Hypbolemic shock
2/2 upper gi bleed
2/2 gastric ulcer
Helicobacter pylori

Or acute hypoxic resp failure
Aspiration pna
Dysphagia
Stroke


A lot of people have minimal intake at the end of life, and so for many it’s probably acute renal failure, but many also have aspiration pneumonia and have either acute hypoxic respiratory failure or “suspected sepsis.” Acute renal failure due to lack of intake causes perception issues (they died because they were not eating not they were not eating because they were dying) so guess which one gets chosen

The way the death certificate is crafted is flawed. I strongly suspect this is also why “heart disease is the leading cause of death.” Every community doc wrote “mi” when they didn’t know for like thirty years, and as a result funding gets moved to that.

It’s all a little crazy.

Also just because someone dies of something, doesn’t mean they “should” have died from something else or that it was preventable. Sepsis is the final pathway of a lot of deaths, that doesn’t mean it should have been treated (terminal als, repeated strokes with minimal quality of life, end stage cancer etc)
 
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