A 77-year-old woman with a history of hypertension and left ventricular diastolic dysfunction presented to the emergency department with 1 week of unilateral calf swelling and dyspnea. She denied chest pain, palpitations, hemoptysis, syncope, or known risk factors for venous thromboembolism, except for her age. Examination revealed a slightly anxious elderly woman who was comfortable at rest but dyspneic with minimal movement. She was afebrile, the pulse was 66 beats/min while receiving β-blocker therapy, the respiratory rate was 22 breaths/min, and the BP, 140/86 mm Hg. The oxygen saturation was 88% on room air. There was no elevated jugular venous pressure, loud S2, or precordial lift. The right lower extremity was swollen from the ankle to the knee. Laboratory evaluation findings were notable for an elevated d-dimer level, a negative troponin T level, and a pro-brain natriuretic peptide (BNP) level that was elevated at 1,608 pg/mL (reference range, < 600 pg/mL). Arterial blood gas measurement revealed a pH of 7.45, Pco2 of 30 mm Hg, and Po2 of 59 mm Hg on room air, at rest. The ECG did not show right ventricular (RV) strain. She was placed on oxygen at 2 L/min, and subcutaneous enoxaparin was initiated. A CT angiography (CTA) scan of the chest revealed extensive pulmonary embolism (PE) in the left and right pulmonary arteries with extension into the right upper, right lower, and left lower lobe segmental and subsegmental pulmonary arteries. Ultrasound of the right leg revealed nonocclusive thrombus in the proximal femoral vein. Transthoracic echocardiography demonstrated moderate RV enlargement with hypokinesis. The patient was admitted to the hospital ward where discussions of thrombolytic therapy ensued. As one might anticipate, highly divergent opinions emerged, and there was difficulty reaching a consensus.