Don’t become a tragic statistic: Act FAST for stroke care
You or someone close to you starts experiencing symptoms that could be a stroke. Because minutes matter, don’t hesitate or try to drive to the nearest hospital – call 911 for an ambulance. The journey through assessment and treatment begins immediately.
EMS does the detective work
“They (paramedics in ambulance) need to determine the ‘last known well,’ and that might be from family, maybe the patient can’t speak for themselves,’ said Lisa Lyons, RN, stroke program manager at Cape Cod Hospital in Hyannis. “They need to do a blood glucose, make sure that’s not the problem and they’re going to do that FAST exam, and other assessments, and they’re going to call it into the hospital as a stroke alert. It gets all the players in motion before they even arrive at the hospital.”
Paramedics will also try to gather key information about the patient’s medications and recent health history.
Most strokes are ischemic, and they occur when a clot blocks blood flow in part of the brain, causing brain cells to die. About 15 percent of strokes are hemorrhagic, and happen when an artery leaks blood into the brain.
The Importance of “last known well”
“Last known well” refers to when the patient was last known to not be experiencing any stroke symptoms, such as weakness, droopiness or numbness on one side of the body or face, confusion, severe headache or difficulty speaking, seeing or walking. FAST is an acronym for some of these symptoms, plus “time to call 911,” according to the American Stroke Association.
Establishing “last known well” is critical because an untreated stroke kills 2 million brain cells a minute, said Neurologist Michael E. Markowski, DO, medical director of Cape Cod Hospital’s stroke program. Patients determined to be having an ischemic stroke can be helped with a “clot-busting” drug, but only if it can be administered within 4.5 hours of “last known well” for patients younger than 80, and within three hours for patients over 80, he said.
If patients are unable to speak or are confused, paramedics may try to determine “last known well” from a patient’s phone activity, family members or neighbors, said Jean Estes, RN, manager of Falmouth Hospital’s stroke program. If the patient woke up with stroke symptoms, “last known well” would be set as when they went to sleep. Over 20 percent of strokes are discovered upon waking, Dr. Markowski said.
At the Hospital
After the paramedics have called in a stroke alert to either hospital’s emergency department, staff prepare for the patient’s arrival in the following ways:
- A doctor and nurse get ready to meet and quickly examine the patient and perform a blood sugar test, Estes said. Lower blood sugar can mimic an ischemic stroke, and, according to the American Stroke Association, diabetics, people who have problems with producing insulin and processing glucose, are twice as likely to suffer a stroke as non-diabetics.
- Radiology clears time to do a quick CT (also called CAT or computed tomography) scan of the patient’s brain. A CT scan without contrast can determine if symptoms were caused by a hemorrhagic stroke or a tumor, Lyons said. A CT-A, or CT scan with an angiogram, which can detect blood vessel blockages, may be ordered.
- A telehealth consult with a neurologist specializing in stroke assessment is called in. Both hospitals contract with groups that provide this service. The stroke expert can review the radiology report, talk with the emergency department doctor or nurse and speak with the patient after CT. The expert can help decide whether an intravenous clot-busting drug should be administered, Dr. Markowski said.
“Telehealth (for stroke consults at Falmouth Hospital) goes back to at least 2006,” said Neurologist Michael T. Leahy, MD, medical director of Falmouth Hospital’s stroke program. “It’s very well established.”
Telehealth gets an expert involved much faster than waiting for a local neurologist to drive in to either hospital from their office or home, Dr. Markowski said. Both he and Dr. Leahy review stroke cases after they’ve been admitted.
Stroke program protocols follow guidelines set by the American Heart Association and American Stroke Association. Speed is essential. Both hospitals aim to have the patient into a CT within 25 minutes upon arrival and have a telehealth neurology consult ready at about the same time. Estes estimated that it takes about six minutes to do a non-contrast head CT, and another six minutes for a CT-A. Guidelines work to get delivery of clot-busting medication into qualified patients within an hour of arrival at the hospital.
“It’s really super, super fast because the brain loses 32,000 brain cells every second you’re having a stroke,” Estes said. “Thankfully, we have billions of brain cells.”
Which Treatment Path?
After the CT scans and consult, a decision is made to:
- Use clot-busting drugs, called thrombolytics. “If they are going to get thrombolytics, we have two nurses ready to mix up this medicine and give the medicine as quickly as we can. And then the patient will be assessed for changes in their mentation or any other bleeding issues. Assessments will be done every 15 minutes, so pretty much that nurse is in that room the whole time,” Estes said.
- Remove the clot surgically, called a thrombectomy or mechanical retrieval. Patient has a clot, but doesn’t qualify for thrombolytics because too much time has passed, or they are on certain medications, such as blood thinners, or they recently had a heart attack, a bleeding episode, trauma or other medical contraindication. Only eight off-Cape hospitals in the state perform this procedure, Estes said, and it must be done within 24 hours from “last known well,” Lyons added. “We’re going to package them up and send them to Boston as quickly as we can, and that’s usually done by med flight, and that’s because med flight is the fastest way we can get there. If it’s raining and med flight isn’t flying, then we’re going by ground,” Estes said.
- Hospital admission under stroke program protocols: If the patient’s symptoms improve or they are not qualified to receive thrombolytics, they may be admitted to Cape Cod Hospital or Falmouth Hospital. Patients who receive thrombolytics at Falmouth Hospital may be transferred to Cape Cod Hospital or to an off-Cape facility.
- Whether or not to operate on a hemorrhagic stroke. “If it’s a hemorrhagic stroke, then both hospitals will evaluate. Does it need neurosurgery? That could be here. Or the patient would go to Boston,” Lyons said. Small hemorrhagic strokes can be treated with medicine, and the body will absorb the leaked blood, according to Dr. Leahy.
Admission and Afterwards
- Evaluation: A patient will be evaluated in the emergency department by a nurse using the National Institutes of Health stroke scale, an assessment that describes a patient’s stoke symptoms in eleven categories. The patient would also be screened for problems with swallowing. If the patient fails a test to swallow 90 ml of water, oral medication, as well as food or drink, would be prohibited and speech and language therapists would be contacted, Estes said.
MRIs can also distinguish strokes from TIAs (transient ischemic attacks), which result from temporary blockages of blood to the brain. Sometimes called mini-strokes, TIAs may indicate a full stroke is pending, according to the American Stroke Association.
“Sometimes they don’t have strokes at all,” Estes said. “Sometimes the MRI comes back negative, and they have stroke-like symptoms that came and went, TIA, and they’ll be discharged. The benefit of having them stay, we’ve addressed some of their risk factors, we’ve looked if they have hypertension, their lipid panels, we’ve educated them, maybe tweaked some of their medicines.”
- Admission: A hospitalist will admit the patient and begin treatment with medications designed to limit the risk of another stroke. These often include a statin to lower cholesterol and aspirin or other drugs to thin the blood and decrease clotting. Whether the patient takes medicines to control diabetes or hypertension (high blood pressure) will be checked.
The hospitalist may order various tests, including MRIs (magnetic resonance imaging) to evaluate the stroke area, echocardiograms to look for clots or faulty valves in the heart, and heart monitoring for signs of atrial fibrillation. Atrial fibrillation raises the risk of stroke 4-6 times and causes one-fourth of strokes in people over 80, according to the National Institute of Neurological Disorders and Stroke. “Hypertension is the biggest risk factor really, for a stroke, so this might be their discovery of a diagnosis of hypertension as well,” Lyons said.
- Education: For patients who are limited to bed, the nursing staff will ensure a patient’s legs are fitted with pneumatic sleeves that intermittently apply pressure to prevent clots from forming, Estes said. Nurses will also educate patients about their condition, treatment and ways to prevent a recurrence, and ensure safety measures to prevent falls are in place.
- Physical and Occupational Therapy: Patients will begin seeing occupational and physical therapists, something they can continue after they’re discharged. Stroke patients typically stay in the hospital three to four days, Dr. Markowski said.
Many more people could benefit from emergency stroke treatment, but they opt to try and wait out stroke symptoms at home. While they are upward of 20 reasons why someone may not qualify for clot-busting therapy, getting to the hospital too late excludes the majority of ischemic stroke patients, Dr. Markowski said.
“Time is brain,” he said. “The sooner you get to the hospital, the sooner some life-altering care can be delivered. Call 911 and you’ll be transported to the hospital and treated immediately.”
Public awareness of the need to quickly address a possible stroke hasn’t reached the level of awareness of heart attack symptoms, Lyons and Estes said.
“We’re lagging behind cardiology,” Estes said.
“And physiologically it’s very similar; treatments are very similar,” Lyons said.
Even if symptoms turn out to be a TIA and not a stroke, getting checked promptly could be life-saving.
Award-Winning Care On Cape Cod
Stroke programs at both Cape Cod hospitals were developed following the U.S. Food and Drug Administration’s approval of Intravenous Alteplase (t-PA) for ischemic stroke treatment in 1995, Dr. Markowski said. Before that, “I think it was ‘diagnose and adios,’” he said. There wasn’t much doctors could do.
Estes estimated Falmouth Hospital sees between 380 and 415 patients with strokes or TIAs a year and Lyons said Cape Cod Hospital sees about 50-70 stroke admissions monthly. Dr. Markowski said Cape Cod Hospital is one of a few “extra high-volume” stroke centers in the state and can have more than 80 people with stroke symptoms in a month. Both local hospitals have won American Heart Association and American Stroke Association “Get with the Guidelines” awards several times for their commitment to stoke care.
“Cape Codders should know that we have an award-winning stroke program and a wonderful staff of physicians at CCHC to ensure they can receive world-class stroke care here on Cape Cod,” Dr. Markowski said.