There are about 750,000 new strokes every year in the United States [66]. Of these, about 85 % or about 635,000 are ischemic. It is widely reported that only 3–5 % of all ischemic strokes receive rt-PA [67] but in reality the proportion is closer to 25 % in well-organized stroke centers [68, 69]. About half of the US population lives within a reasonable distance of such centers, i.e., a travel time short enough to allow thrombolytic therapy [70]. Let’s assume therefore that about 317,500 stroke patients were near enough to a stroke center that they could have been treated, and that 20 % of them, or about 63,500 would have been treated had the ED physicians been organized and ready to treat. The first full year of drug approval was in 1997 since rt-PA received approval for use in stroke patients in June of 1996. The national body speaking for most ED physicians, the American College of Emergency Physicians (ACEP) issued a joint statement in 2012 with the American Academy of Neurology (AAN) endorsing the use of rt-PA for acute stroke [71]. The truly remarkable thing about this joint statement was that ACEP was essentially retracting an earlier statement that—while not opposing the treatment—seemed to suggest the treatment was in some way optional. Specifically, the ACEP statement contained the phrase that ED MDs were under no obligation to offer rt-PA to acute stroke victims if they did not have the training to do so. By comparison, the AAN, American Heart Association, and other organizations were urging physicians to become trained, and courses such as the one described in this textbook were available. As mentioned in the introduction to this chapter, newsletter writers were spreading untruths about the study among the ED physician community. Some of these distortions found their way into reputable journals [72]. So between 1997 and 2012 the ED physicians in the US were unsure whether the drug should be used or not. During these 15 years, a minimum of 63,500 patients per year, or 952,500 patients, could have been treated, assuming early adoption at stroke centers. About half of all patients treated with rt-PA for acute stroke enjoy a full, complete resolution of their deficits, so about 476,250 Americans remain disabled today due to the publications and opinions of a few demagogues who promoted untruths and myths about rt-PA; the remainder would have been improved significantly but not free of any disability. In 1996 the lifetime cost of an ischemic stroke was estimated to be $90,981, so very conservatively, these newsletter commentators cost the United States over $43 billion dollars, unadjusted for inflation since 1996.

Would all stroke centers have adopted rt-PA early? We will never know, but the estimates here are very conservative and likely the use of rt-PA would have been farther and faster than even these estimates. There can be now doubt however, that even if the demagogues cost only one stroke patient the opportunity for a full and able-bodied recovery, they have cost us all too much. It is one thing to rationally and intelligently question a new therapy in medicine, as Dr. Caplan did for us in the first two editions of this textbook. It is quite another thing, however, to eloquently persuade well intentioned ED physicians that the entire approval process for rt-PA—from the NIH, to the investigators, to the FDA—was somehow tainted by corporate influence and other mistakes [6, 7]. The data from the NINDS trial have withstood multiple tests by independent statisticians and commentators [73]. The main findings have been replicated many times. Dr. Caplan and other critics were proved wrong, and as good scientists, have stated so. The newsletter publishers and self-appointed “experts” have never recanted or acknowledged their errors, and they continue to publish their for-profit newsletters.