T bandaged_brain_400_wht_10344 he use of Alteplase (tPA) in the setting of ischemic stroke has grown to be one of the most controversial issues in emergency medicine and for good reason. It is a trifecta of hardship: time is limited, the evidence for treatment is unclear, and patients are especially vulnerable to the information we provide when making a life changing decision. Unfortunately, most patients have not kept tabs on the literature, and when their health is on the line it is up to you to lay out their options for care.

This month’s case explores the complexities of treating a patient with an ischemic stroke and asks readers to consider how they communicate about tPA with patients and colleagues. For many, this topic may be difficult given the great uncertainty that surrounds tPA and how best to describe the evidence to patients. Recent attempts to summarize tPA information in order to inform patients has only served to highlight the need for improved communications about the existing evidence. For an excellent, and timely, FOAM primer to this issue, check out The Skeptic’s Guide to Emergency Medicine , which provides a great recap of the tPA debate and the most current literature.

The Series

Inspired by the highly successful MEdIC series , What Do You Say? is a case study series that explores difficult patient education scenarios when communication matters most. Every other month, a hypothetical case will be posted with questions for discussion. After a week of community input, relevant experts will provide insight for the community to consider and a curated review of the discussion with expert opinions will be disseminated. Have a difficult patient education scenario that you think would make a great case? Contact me via the contact page or send a tweet to @skobner .

The Case

Dr. Washburn was just rounding the halfway point of her afternoon shift when she was paged to the resuscitation room. She entered to find a new patient, Mrs. Desi accompanied by her husband, Mr. Desi, and her daughter, Jessica.

Dr. Washburn quickly learns that the 62 year-old Mrs. Desi began experiencing right-sided, upper extremity weakness and facial drooping about 30 minutes ago when she was at home eating lunch with her family. Since then, her weakness has gotten worse, and she has become confused.

After completing her history and physical, Dr. Washburn verifies Mrs. Desi’s neurological deficit and learns that she has a history of well-controlled hypertension and Type 2 Diabetes Mellitus. After verifying Mrs. Desi had a normal blood glucose, Dr. Washburn activates her hospital’s stroke protocol.

As the images and report of Mrs. Desi’s non-contrast head CT loads on her computer, Dr. Washburn consults the Neurology team.  The team members agree with Dr. Washburn’s suspicion of ischemic stroke, and they believe Mrs. Desi is a candidate for tPA administration.

While the Neurology team talks to Mrs. Desi and her family about treatment options, Dr. Washburn stands at the bedside. The team strongly advises Mrs. Desi to undergo IV tPA therapy, and, after stating there is a “low, but possible” risk of intracranial hemorrhage, asks for her family’s consent for treatment.

Mrs. Desi’s daughter Jessica turns to Dr. Washburn and asks, “If this was your mom, what would you do?”

You are in Dr. Washburn’s position; what do you say?

Questions for Discussion

  1. How do you represent the risks and benefits of tPA for ischemic stroke when educating patients and negotiating a treatment plan?
  2. What do you say to patients when you disagree with the neurology team’s representation of the risks or benefits of tPA? How do you address this disagreement?
  3. How does your communication strategy differ when talking directly to a patient suffering an ischemic stroke versus a patient’s family who is acting as a surrogate decision maker?

Weekly Summary

The curated community commentary and expert responses for this case were published on September 16, 2014, which includes responses from:


Dr. Anand Swaminathan ( @EMSwami ) is the EM Assistant Residency Director at NYU/Bellevue Hospital Center, founding member of the All NYC EM Conference Committee and EM Lyceum, and faculty at iTeachEM. Dr. Swaminathan also contributes regularly to numerous FOAM resources including EMRAP, ERCast, The Skeptics Guide to Emergency Medicine, EMCrit, EM Literature of Note, Academic Life in Emergency Medicine, and emDocs.net.


Dr. Ryan Radecki ( @emlitofnote ) is an Assistant Professor of Emergency Medicine at The University of Texas Health Science Center at Houston, former AHRQ Patient Safety and Quality Keck Fellow, M.S. in Health Informatics. He is also the creator of the infamous blog, Emergency Medicine Literature of Note, and constant contributor to the FOAM world.

Please feel free to continue the discussion below, however the community commentary for this case has already been generated. Thank you to all participants.