A few months ago, possibly while you weren’t looking, the debate regarding the utility of tissue plasminogen activator (tPA) in acute ischemic stroke was finally settled. Even if Genentech and the American Stroke Association haven’t won over many hearts and minds in the emergency medicine community, the war is effectively over. The forces aligned in favor of tPA fought the battles that mattered by funding the people authoring the guidelines and hospital quality measures, not via sniping in the academic literature. Given the prevailing medicolegal climate in many states, coupled with the institutional interest in stroke center certification and the growing reach of telestroke services, holding out as a conscientious objector to the use of tPA grows ever more perilous.

However, all these factors pale in the context of the public-shaming hit job from The New York Times titled, “For Many Strokes, There’s an Effective Treatment. Why Aren’t Some Doctors Offering It?”¹ If you didn’t read the article, its general tone should be apparent from the title. The author wades into the debate over tPA by pitting the two sides against each other with a biased portrayal of their positions: the neurologists, beleaguered and confused by the opposition to their sterling evidence, and the emergency physicians, which the author described as being led by shyster figurehead Jerome Hoffman, MD, professor of emergency medicine at the University of California, Los Angeles, and his cadre of disinformation trolls on social media. The author effectively implies only the lunatic fringe would contest the efficacy of tPA, and even the lead subject of the article, Christopher Lewandowski, MD, an emergency physician at Henry Ford Hospital in Detroit, is considered a victim. The pervasive reach of anti-tPA dissent, according to this reporting, prevented his father from receiving the blessed miracle of “clot-busting” therapy.

Hyperbole and exaggeration aside, this obviously is not an appropriate characterization of our specialty nor of some of our most respected leaders in the critical appraisal of medical evidence. Also, it isn’t productive to refresh, ad nauseum, the back-and-forth regarding the efficacy of tPA, tweeting out the enrollment imbalances, the effect sizes, or the relative relevance of the trials that did not result in statistically significant positive findings. The most important lessons from this odd article in the Times relate to why, 23 years after the National Institute of Neurological Disorders and Stroke tPA clinical trial was published, such uncertainty persists regarding the appropriate treatment of patients suffering acute ischemic stroke and why it remains such a fiery topic.²

Persistent Uncertainty

First, the practice of the emergency physician has been dictated by outside specialty societies without proper collaboration and appropriate understanding of our specialty. The management controversy associated with acute ischemic stroke is hardly an outlier in emergency medicine. Over the past decades, we have been subject to implementation mandates for early goal-directed therapy (EGDT) for sepsis, recommendations for early provocative testing for patients with chest pain, and high-dose steroids in spinal cord trauma, among countless others. Many of these treatment pathways and recommendations demand profound reorganization of systems of care in the emergency department.