New grad ED physicians opposing tPA use for strokes

[Neurologo]

I am seeing more and more young ED physicians fresh out of residencies having almost a militant opposition to tPA use for strokes. They would call mild yet disabling symptoms as "TIA" even though symptoms are persisting and refuse to give tPA. One guy even aborted tPA in the middle of the infusion saying they are the attendings and we the neurologists are just consultants whose recommendation they can reject. Their NIHSS report 2 when it is actually 8 consistently for several days and MRI showing significant strokes.

They are defiant of AHA/ASA guidelines and scoff at the idea that tPA is effective. I know there used to be a party of ED physicians who were very skeptical of tPA. But these young ones are actually militant. Someone mentioned a podcast for ED physicians going around that promotes this movement. Anyone else seeing this trend? I asked my stroke coordinator to report all this to AHA/ASA.

I partly understand where they are coming from but also very concerning for patient care not to mention the headaches of dealing with these mis-educated physicians.

 

[Thama]

It's a real problem. They are everywhere on social media and their own blogosphere about this issue. They stridently reject overwhelming consensus of experts in favor of their own alternative reanalyses and interpretations like they are Scott Atlas presenting alternative facts on something completely outside his/their field. If a study, metaanalysis or set of guidelines supports benefit for tPA,, then they'll just say the authors are in the pocket of Genentech. It's insane stuff coming from an actual medical field.

 

[Telamir]

I haven't run into that. I've had ED docs be skeptical of TPA especially when the NIHSS is low (as we know, it under-estimates posterior circulation strokes) but for the most part once they trigger a stroke alert I have to go to the bedside and barring any major issues with ABCs I take care of the rest. I.E., I assess, they come with me to the scanner, and I decide if TPA will be given or not. Pharmacists mix the medication and the order goes under me. Usually I will track the physician after and say "I'm giving TPA" or maybe not TPA maybe non neurologic, etc etc.

I haven't run into that issue, but I think it's kind of medical-legal suicide from their end if they are stopping your infusions and not letting you treat a patient they consult you on, especially if your documentation reflects this (and it should).

 

[emergentmd]

EM doc here and I don't know of any EM docs that would not push TPA after discussion with neuro.

 

[WiredEntropy]

Are these the same ER docs who intubate every patient who has a seizure?

 

[Telamir]

I've seen a few over-eager intubations (sort of borderline) but thankfully this isn't my experience either.

 

[Thama]

I've seen a few over-eager intubations (sort of borderline) but thankfully this isn't my experience either.

Yeah I've only had to persuade the ED not to intubate a status dramaticus once, and he was a pretty convincing one. Woulda made me think twice if I wasn't looking at PDR on his EEG.

 

[sharkbaitwhohaha]

Yeah I've only had to persuade the ED not to intubate a status dramaticus once, and he was a pretty convincing one. Woulda made me think twice if I wasn't looking at PDR on his EEG.

I'm a PGY5 and its my first time hearing about status dramatics. I love it.

 

[Neurologo]

EM doc here and I don't know of any EM docs that would not push TPA after discussion with neuro.

Perhaps it is dependent on when and where ED docs are trained?

But for these young ones to go directly against the "standard of care" for stroke codes as outlines in American Stroke Association's guidelines that is widely accepted and used by neurologists and stroke centers is pretty daring and foolish. Who do they think the expert witnesses will be and which "standard of care" will be used in court cases involving the use of Alteplase in strokes?

Does anyone know what their scientific justifications for rejecting Alteplase are? They surely act and talk very confident and convinced they are doing the right thing by denying tPA to patients while they don't even understand the concept of TIA or proper way to perform NIHSS or its limitations. They act like crusaders coming to protect the helpless stroke patients from the tyranny of neurologists. Do they act this way with cardiologists in ACS codes with use of IV heparin drip?

 

[Neurologo]

I haven't run into that issue, but I think it's kind of medical-legal suicide from their end if they are stopping your infusions and not letting you treat a patient they consult you on, especially if your documentation reflects this (and it should).

Yes, I write details of why tPA should have been given and who rejected or opposed my recommendation. This is mainly to protect myself.

 

[xenotype]

The expert witnesses will be all be EM physicians as well, not neurologists in most states. Regardless, peer review, hospital administration, and their malpractice providers will make this line of thinking painful for them. Hospital administration won't want anything jeopardizing stroke center accreditation, their malpractice providers will advise them not to do it. The biggest risk would be an adverse peer review finding getting reported to NPDB which could seriously jeopardize future jobs, credentialing/privileges (a much worse outcome than losing a malpractice suit). Talk to any recently trained EM physician and you'll find this belief in varying degrees as its peppered deeply into their CME type blogs and articles from the earliest parts of their training. Thankfully where I did residency a lot of them rotate with us on stroke and there is far less indoctrination with those that rotate with us.

 

[neglect]

I’ve seen this on Twitter I’m afraid, where “foamed” and “rebel” ER docs hopelessly merge any negative thrombolytic therapy as a negative tpa trial, dismiss positive trials, and say that anyone who says otherwise is in Genentech’s pocket. I kinda got in it with them just pointing out the fact they're comparing trials that went out to 9 hours using streptokinase with a positive tPA trial, and it was a swarm of idiocy and accusations of COI. This latter really pissed me off because I do Alzheimer trials with Genentech, which has nothing to do with taking a position about tpa. (The ER people ignored Roche funding, obviously not sophisticated enough to know that Roche bought Genentech years ago and they've largely abandoned throbolytic R&D).

Then about a year ago a lawyer asked me to review a case about a missed stroke diagnosis in which they were trying to say that it was un-treatable anyway. Told them sorry, but this is indefensible (and that'll be money please). Sometimes people need to find out for themselves I'm afraid. I just hope they don't hurt many patients along the way.

And FWIW, I work with a bunch of amazing ER doctors who do things like check visual fields, call for tPA, really think about cases and what they could have done better, communicate issues with their team to improve. I think they're the best doctors in the hospital and I hold them in the absolute highest regard. So it is with something like vertigo to go online and see the idiocy and willful self-delusions of many in their field. I get the issue: that ER doctors have to staff remote places and they oppose strict standard-of-care guidelines. But I don't get their nearly religious fervor where tpa is the devil.

 

[lymphocyte]

This is the thread I've always wanted but was too afraid to create. I'm very grateful, thank you.

I just helped implement a 24 hour telestroke service at our hospital. I basically liased between emergency medicine and the hospitalists.

The only way we got political traction was bringing all strokes under the hospitalists' clinical governance, meaning that a stroke code was activated on triage and then assessed/discussed with telestroke by the medical service. EM only got involved if there were a threat to life with a view to stabilise for further stroke assessment by the medical service. The reason why was purely because of their opposition to tPa. This opposition was uniform, even amongst trainees, and it very much seems in vogue.

I myself am agnostic mainly out of ignorance, because the literature is truely vast (although I'm digging through it). I'm just curious if there are any "counter-skeptical" articles in response to things like this:

SGEM Xtra: No Retreat, No Surrender – Thrombolysis for Acute Ischemic Stroke

Date: February 4th, 2019 Guest Skeptic: Dr. Jerome Hoffman is a Professor Emeritus of Medicine and Emergency Medicine, University of California, Los Angeles. Dr. Hoffman has been a voice of reason …

thesgem.com

I don't have a lot of neurologists at my hospital with whom to discuss the data. I'd very much appreciate any and all resources.

 

[Thama]

This is the thread I've always wanted but was too afraid to create. I'm very grateful, thank you.

I just helped implement a 24 hour telestroke service at our hospital. I basically liased between emergency medicine and the hospitalists.

The only way we got political traction was bringing all strokes under the hospitalists' clinical governance, meaning that a stroke code was activated on triage and then assessed/discussed with telestroke by the medical service. EM only got involved if there were a threat to life with a view to stabilise for further stroke assessment by the medical service. The reason why was purely because of their opposition to tPa. This opposition was uniform, even amongst trainees, and it very much seems in vogue.

I myself am agnostic mainly out of ignorance, because the literature is truely vast (although I'm digging through it). I'm just curious if there are any "counter-skeptical" articles in response to things like this:

SGEM Xtra: No Retreat, No Surrender – Thrombolysis for Acute Ischemic Stroke

Date: February 4th, 2019 Guest Skeptic: Dr. Jerome Hoffman is a Professor Emeritus of Medicine and Emergency Medicine, University of California, Los Angeles. Dr. Hoffman has been a voice of reason …

thesgem.com

I don't have a lot of neurologists at my hospital with whom to discuss the data. I'd very much appreciate any and all resources.

The best counter-skeptical articles are the authoritative guidelines from the AHA and the Cochrane meta-analysis. There's really no point in making blog posts attempting to counter bad-faith arguments like SGEM has consistently made on this topic - anyone citing negative studies of thrombolytics that pre-date alteplase or that use completely different administration criteria (based on cardiac criteria before we understood what we were doing in stroke) is doing exactly that.

 

[xenotype]

This is the thread I've always wanted but was too afraid to create. I'm very grateful, thank you.

I just helped implement a 24 hour telestroke service at our hospital. I basically liased between emergency medicine and the hospitalists.

The only way we got political traction was bringing all strokes under the hospitalists' clinical governance, meaning that a stroke code was activated on triage and then assessed/discussed with telestroke by the medical service. EM only got involved if there were a threat to life with a view to stabilise for further stroke assessment by the medical service. The reason why was purely because of their opposition to tPa. This opposition was uniform, even amongst trainees, and it very much seems in vogue.

I myself am agnostic mainly out of ignorance, because the literature is truely vast (although I'm digging through it). I'm just curious if there are any "counter-skeptical" articles in response to things like this:

SGEM Xtra: No Retreat, No Surrender – Thrombolysis for Acute Ischemic Stroke

Date: February 4th, 2019 Guest Skeptic: Dr. Jerome Hoffman is a Professor Emeritus of Medicine and Emergency Medicine, University of California, Los Angeles. Dr. Hoffman has been a voice of reason …

thesgem.com

I don't have a lot of neurologists at my hospital with whom to discuss the data. I'd very much appreciate any and all resources.

Absolutely insane. The hospital should just have primary stroke center accreditation pulled, which would happen anyways if they don't have a director which I'm guessing is you. I would have bowed out of any acute stroke involvement with the hospital and let them figure it out. The administration really should be on your side as they usually are just contracting out the entire ED staff to EmCare or TeamHealth anyways. A single complaint from administration to these management companies would cause a big 'political shift' at these EM management companies, as the hospital can always hire their own and get rid of the contract.

 

[lymphocyte]

Absolutely insane. The hospital should just have primary stroke center accreditation pulled, which would happen anyways if they don't have a director which I'm guessing is you. I would have bowed out of any acute stroke involvement with the hospital and let them figure it out. The administration really should be on your side as they usually are just contracting out the entire ED staff to EmCare or TeamHealth anyways. A single complaint from administration to these management companies would cause a big 'political shift' at these EM management companies, as the hospital can always hire their own and get rid of the contract.

I'm no director. I'm an intensive care trainee in Australia. This was a very small part of a project to establish 24 hour acute stroke services in rural and regional Australia. Our hospital was a pilot site. The fight was fought by whatever means, and I'm proud of the work.

Our EM doctors are well regarded and a great bunch of human beings. Everyone is trying to do right by their patients. It would be nice to meet their arguments head-on, if you have any helpful articles to share, that's what I'm mostly after - a contrarian view of the contrarian view. Quoting the AHA/ASA guidelines is NOT helpful when they're own college expresses scepticism about all the data underlying these guidelines.

 

[xenotype]

I'm no director. I'm an intensive care trainee in Australia. This was a very small part of a project to establish 24 hour acute stroke services in rural and regional Australia. Our hospital was a pilot site. The fight was fought by whatever means, and I'm proud of the end result.

Our EM doctors are well regarded and a great bunch of human beings. Everyone is trying to do right by their patients. It would be nice to meet their arguments head-on, if you have any helpful articles to share, that's what I'm mostly after - a contrarian view of the contrarian view. Quoting the AHA/ASA guidelines is NOT helpful when they're own college expresses scepticism about all the data underlying them.

Ah this makes more sense- the regulatory environment in the US regarding stroke is quite different and rural locations change everything. Defensive medicine is also a much more powerful force over here in the US and malpractice carriers well know they are more likely to get sued when tPA is not given (and potentially end up in a big settlement).

This review (one of many) seems to have convinced the extremely biased EM evidence review site 'TheNNT' to change their recommendation. In 2013 their recommendation was the usual resistance you are running into. There is a discussion on their site that may help you have these conversations and change some minds. Personally, I think there is a worldview difference from how a neurologist thinks and an EM physician thinks, and bridging this gap is extremely difficult (as is changing anyone's mind on any strong belief really).

 

[neglect]

Ah this makes more sense- the regulatory environment in the US regarding stroke is quite different and rural locations change everything. Defensive medicine is also a much more powerful force over here in the US and malpractice carriers well know they are more likely to get sued when tPA is not given (and potentially end up in a big settlement).

This review (one of many) seems to have convinced the extremely biased EM evidence review site 'TheNNT' to change their recommendation. In 2013 their recommendation was the usual resistance you are running into. There is a discussion on their site that may help you have these conversations and change some minds. Personally, I think there is a worldview difference from how a neurologist thinks and an EM physician thinks, and bridging this gap is extremely difficult (as is changing anyone's mind on any strong belief really).

Wow, thanks for that. One thing I noticed in dealing with Foamed was the very biased approach towards anyone not in the ER 'tribe.' Again, this was vertiginous for me given my uniformly awesome relationship with the ER docs I know and work with. Instant animosity and distrust.

So it was somewhat refreshing to see Dr. Eddy Lang on the pro side of the debate, who's a very respected ER doctor in Calgary. I'm afraid neurologists have to just keep doing what we're doing and let the ER doctors sort themselves out. There's a large degree of tribalism here that we can't see or fight.

 

[chocomorsel]

This is the thread I've always wanted but was too afraid to create. I'm very grateful, thank you.

I just helped implement a 24 hour telestroke service at our hospital. I basically liased between emergency medicine and the hospitalists.

The only way we got political traction was bringing all strokes under the hospitalists' clinical governance, meaning that a stroke code was activated on triage and then assessed/discussed with telestroke by the medical service. EM only got involved if there were a threat to life with a view to stabilise for further stroke assessment by the medical service. The reason why was purely because of their opposition to tPa. This opposition was uniform, even amongst trainees, and it very much seems in vogue.

I myself am agnostic mainly out of ignorance, because the literature is truely vast (although I'm digging through it). I'm just curious if there are any "counter-skeptical" articles in response to things like this:

SGEM Xtra: No Retreat, No Surrender – Thrombolysis for Acute Ischemic Stroke

Date: February 4th, 2019 Guest Skeptic: Dr. Jerome Hoffman is a Professor Emeritus of Medicine and Emergency Medicine, University of California, Los Angeles. Dr. Hoffman has been a voice of reason …

thesgem.com

I don't have a lot of neurologists at my hospital with whom to discuss the data. I'd very much appreciate any and all resources.

Why are you afraid to create a thread on an online forum?
It’s anonymous and creates great and sometimes controversial discussions.
Whatever the case, these people can’t reach through the wire cables and beat you.
Come visit the anesthesia forum and you will quickly lose your fear of creating a debate online.

 

[neglect]

Why are you afraid to create a thread on an online forum?
It’s anonymous and creates great and sometimes controversial discussions.
Whatever the case, these people can’t reach through the wire cables and beat you.
Come visit the anesthesia forum and you will quickly lose your fear of creating a debate online.

Like me in my Twitter conversation, thinking, “Oh, these aren’t stroke experts, they’ve never done a stroke trial. I have. I’ll educate them.” Then I realize they are delusional, creating their own meta-analyses across all thrombolytics and all times. Then a non-MD hack pulled my COI where I do research with Genentech and told me I’d violated disclosure ethics.

This did not create a great discussion. If anything, they immediately dismissed me for a neurology pharma ***** and stiffened their resolve.

So for me it isn’t fear, it is just a sense that this is a firm and fixed delusion where words won’t work. I wish them and their patients the best and believe their ideas will be sorted out in malpractice verdicts and settlements and in quiet discussions with their ER and even neuro buddies whom they actually like and respect.

 

[turkeyjerky]

I'd be interested in seeing a point-by-point rebuttal of the anti-TPA points. It seems the standard neurologist rebuttal is simply "of course TPA works. It's FDA approved (but only <3 hrs) and AHA recommended!"

 

[Thama]

I'd be interested in seeing a point-by-point rebuttal of the anti-TPA points. It seems the standard neurologist rebuttal is simply "of course TPA works. It's FDA approved (but only <3 hrs) and AHA recommended!"

First, the recommendation of the relevant professional society and the approval of the FDA should carry a heavy weight, as those recommendations are made by those with the most expertise in this field, rather than acute care generalists who only interface with stroke at one brief stage in the process.

But to answer the question, here are the common ones:

1) "Yes there is a benefit to disability at 3 months, but look at the increased bleed risk! It looks almost as large as the mRS reduction!"

The nice thing about using a 90 day disability metric is that adverse outcomes due to bleeding are baked in. The significant disability reduction occurs even with the bleed risk included. The increased bleed risk is scary for neurology and EM alike as it's our most immediate feedback, but the important thing is how people are living afterward, not how often our anuses pucker when a post-tPA CT pops up.

2) "The fragility index of NINDS was low!" "IST3 was poorly run!" "The authors changed the primary outcome mid-study!"

I'm lumping these together because the answer to these and similar criticisms is the same. None of the major tPA trials was perfectly run and only NINDS really stands on its own, though it probably wasn't ideally powered for such a noisy signal. Some of the more wild criticisms of how studies were run have to be interpreted in context of the history of the trials, where multiple trials with similar criteria but different endpoints were being run simultaneously, so when one trial looked positive the field had to shift mid- course. The fact that the data comes from multiple moderately-powered studies with similar criteria means that well-performed pooled analyses and meta-analyses are a better tool than looking at the individual study data, which is why the current AHA recommendations cite those papers rather than the original trials. Conducting a larger repeat placebo-controlled trial as often demanded by the EM blogosphere simply isn't ethically plausible as we clearly lack clinical equipoise to give placebo in a trial context at this point.

3) "There have been 11/14/xx tPA trials and you guys are just cherry picking the ones that worked!"

Some of those trials didn't even use alteplase. Others had wildly different criteria, with early ones being based on cardiac thrombolysis criteria before we understood the huge differences. It took analyzing the failed trials to find the real efficacy window. Lumping these together as if we just tried the same drug in the same way over and over until random chance gave us a spurious result is such a fundamentally dishonest argument that it frankly discredits the integrity of anyone who uses or even alludes to it for support.

4) "You're a Genentech shill!"

Caught me red handed. I expect my check in the mail any day now.

 

[neglect]

First, the recommendation of the relevant professional society and the approval of the FDA should carry a heavy weight, as those recommendations are made by those with the most expertise in this field, rather than acute care generalists who only interface with stroke at one brief stage in the process.

But to answer the question, here are the common ones:

1) "Yes there is a benefit to disability at 3 months, but look at the increased bleed risk! It looks almost as large as the mRS reduction!"

The nice thing about using a 90 day disability metric is that adverse outcomes due to bleeding are baked in. The significant disability reduction occurs even with the bleed risk included. The increased bleed risk is scary for neurology and EM alike as it's our most immediate feedback, but the important thing is how people are living afterward, not how often our anuses pucker when a post-tPA CT pops up.

2) "The fragility index of NINDS was low!" "IST3 was poorly run!" "The authors changed the primary outcome mid-study!"

I'm lumping these together because the answer to these and similar criticisms is the same. None of the major tPA trials was perfectly run and only NINDS really stands on its own, though it probably wasn't ideally powered for such a noisy signal. Some of the more wild criticisms of how studies were run have to be interpreted in context of the history of the trials, where multiple trials with similar criteria but different endpoints were being run simultaneously, so when one trial looked positive the field had to shift mid- course. The fact that the data comes from multiple moderately-powered studies with similar criteria means that well-performed pooled analyses and meta-analyses are a better tool than looking at the individual study data, which is why the current AHA recommendations cite those papers rather than the original trials. Conducting a larger repeat placebo-controlled trial as often demanded by the EM blogosphere simply isn't ethically plausible as we clearly lack clinical equipoise to give placebo in a trial context at this point.

3) "There have been 11/14/xx tPA trials and you guys are just cherry picking the ones that worked!"

Some of those trials didn't even use alteplase. Others had wildly different criteria, with early ones being based on cardiac thrombolysis criteria before we understood the huge differences. It took analyzing the failed trials to find the real efficacy window. Lumping these together as if we just tried the same drug in the same way over and over until random chance gave us a spurious result is such a fundamentally dishonest argument that it frankly discredits the integrity of anyone who uses or even alludes to it for support.

4) "You're a Genentech shill!"

Caught me red handed. I expect my check in the mail any day now.

Wow. This is one of the best things I’ve read on this subject, or any subject, here or anywhere! Thanks!

 

[sharkbaitwhohaha]

First, the recommendation of the relevant professional society and the approval of the FDA should carry a heavy weight, as those recommendations are made by those with the most expertise in this field, rather than acute care generalists who only interface with stroke at one brief stage in the process.

But to answer the question, here are the common ones:

1) "Yes there is a benefit to disability at 3 months, but look at the increased bleed risk! It looks almost as large as the mRS reduction!"

The nice thing about using a 90 day disability metric is that adverse outcomes due to bleeding are baked in. The significant disability reduction occurs even with the bleed risk included. The increased bleed risk is scary for neurology and EM alike as it's our most immediate feedback, but the important thing is how people are living afterward, not how often our anuses pucker when a post-tPA CT pops up.

2) "The fragility index of NINDS was low!" "IST3 was poorly run!" "The authors changed the primary outcome mid-study!"

I'm lumping these together because the answer to these and similar criticisms is the same. None of the major tPA trials was perfectly run and only NINDS really stands on its own, though it probably wasn't ideally powered for such a noisy signal. Some of the more wild criticisms of how studies were run have to be interpreted in context of the history of the trials, where multiple trials with similar criteria but different endpoints were being run simultaneously, so when one trial looked positive the field had to shift mid- course. The fact that the data comes from multiple moderately-powered studies with similar criteria means that well-performed pooled analyses and meta-analyses are a better tool than looking at the individual study data, which is why the current AHA recommendations cite those papers rather than the original trials. Conducting a larger repeat placebo-controlled trial as often demanded by the EM blogosphere simply isn't ethically plausible as we clearly lack clinical equipoise to give placebo in a trial context at this point.

3) "There have been 11/14/xx tPA trials and you guys are just cherry picking the ones that worked!"

Some of those trials didn't even use alteplase. Others had wildly different criteria, with early ones being based on cardiac thrombolysis criteria before we understood the huge differences. It took analyzing the failed trials to find the real efficacy window. Lumping these together as if we just tried the same drug in the same way over and over until random chance gave us a spurious result is such a fundamentally dishonest argument that it frankly discredits the integrity of anyone who uses or even alludes to it for support.

4) "You're a Genentech shill!"

Caught me red handed. I expect my check in the mail any day now.

Thank you for writing this up!
I've always been curious about their thinking, but I've been too lazy/didn't care enough to read their blogs.