Stroke Job

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Once again EMS, or in this case an EMS like service, is being asked to make up for hospital deficiencies.

Nation’s first mobile stroke unit unveiled in Houston

The University of Texas Health Science Center at Houston (UTHealth) Medical School, in partnership with Memorial Hermann-Texas Medical Center, are unveiling the country’s first Mobile Stroke Unit Monday.

According to a news release the ambulance is equipped with a computed tomography (CT) scanner that allows a mobile stroke unit team member to quickly assess whether a patient is having a stroke caused by a blood clot and if so, the clot-buster tPA (tissue plasminogen activator) can be administered. The stroke unit will be run in conjunction with the Emergency Medical Services of the Houston Fire Department, Bellaire Fire Department and West University Fire Department.

Keep in mind that the “window” for initiating this treatment is three hours from the time of onset of symptoms. The problem with Strokes is that they can start at any time of the day or night. In fact, it’s entirely possible that a patient could be sound asleep when a the Stroke starts. Because of that patients might not know the exact time of onset. That of course is limitation of this unit, but it’s not the only one. It’s another ambulance on the road, which means more potential for collisions and injuries.

“It typically takes roughly an hour once a stroke patient arrives in the emergency room to receive treatment. So if we can actually put the emergency room in the ambulance and take the CT scanner to the patient, we could treat the patient at the scene with the medication and save that hour,” said James C. Grotta, M.D.,

Here is where the using EMS to solve an in hospital problem part. The gold standard for door to CT time is 45 minutes. That means that once the patient is in the Emergency Department they should be in the CT scanner withing 45 minutes. If it’s taking an hour to get that done, then the hospitals need to improve their practice. About a month ago I was with a relative when he had the sudden onset of Stroke like symptoms. An ambulance was summoned, he was transported to a nearby community hospital and he immediately went into CT. The ambulance crew did their part, which was to identify the signs and symptoms, do a blood glucose check, start an IV, and do a 12 Lead EKG, and most importantly called the hospital on the radio to tell them what was going on. . Truth be known, the IV and EKG could just as easily have  been done in the hospital, but that’s not the point here. The point being that a small community hospital in a smallish city in New Hampshire had a patient in and out of the CT in much less than an hour. If they can do it surely a university affiliated teaching hospital should be able to do it.

Is the problem in Houston with the EMS system? Does the fire department not train it’s paramedics to recognize a stroke, do a Cincinnati Stroke Scale, check a blood glucose, prioritize transport, and notify the hospital of the incoming patient?  If that’s the case, then maybe the money invested in the specialty ambulance should be put in to training. Does the city not have stroke specialty centers? Then that should be addressed.

“The stroke unit will be located at The University of Texas Professional Building in the Texas Medical Center. It will respond to calls within a three-mile radius and patients will be transported to comprehensive stroke centers including Memorial Hermann-TMC, Houston Methodist Hospital and St. Luke’s Medical Center. It will carry a paramedic, neurologist, nurse and CT technician and run alternate weeks as part of the clinical trial at UTHealth.”

I understand that this is part of a trial, but I still don’t see the value of this unit. A three mile response radius is pretty small and to make matters worse it seems as if there are several hospitals in the general vicinity. I could see more benefit for this type of unit if it were out further away from the large medical centers, but then you would run in to response time issues.

Grotta, co-principal investigator of the study, said: “We know we can speed up treatment but we don’t know how much that speed will affect recovery.” .“We really don’t have data on how receiving tPA within the first hour after symptoms start affects patient outcomes, including the amount of disability. This study will help us determine how much more helpful it is to receive tPA within that first hour.”

Intuitively it would seem that earlier is better, but in medicine that’s not always the case. Even at that, if earlier is better, how is that going to translate in to practice in the field? It’s certainly not going to be practical to staff every ambulance with a paramedic, neurologist, nurse and CT technician.

Cynically speaking, this sounds like a gimmick meant to add to physicians curriculum vitae than a serious attempt to improve medical care. Next time I hear a doctor talking about how best to use scarce medical resources, maybe I’ll show him this article and ask how this study fits in.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

2 COMMENTS

  1. Mr TOTW (Mr. Artifact?) –

    I don’t think that this is a case of EMS trying to solve the ED’s problem. However, it IS a case of a stroke researcher who truly believes that the extra few minutes will prove decisive. Dr Grotta is a very smart neurologist, so we’ll see.

    The rest of Dr Grotta’s CV is interesting – he’s involved in some real Yeager-like pushing of the envelope. An example is “Phase IIB/III Trial of Tenecteplase in Acute Ischemic Stroke: Results of a Prematurely Terminated Randomized Clinical Trial.” In this study, they looked at tPA versus TNK, another thrombolytic.

    In the context of a controlled trial, the intracranial hemorrhage rate for tPA was 16%! The original NINDS trial only had a 6% bleed rate – progress!

    So, his CVA is going to be an extremely rich mine to dig up for Twitter pearls and scary statistics.

    Thanks a million TOTW/Artifact!

  2. A scanner in an ambulance? Must be a VERY large unit as even the most basic head scanner weighs hundreds of pounds and requires a significant source of power….as in typical tube voltage exceeds 120K.
    Most mobile scanners are in Winnebago sized vehicles. Second is thatnyou simply CANNOT scan anyone while the unit is moving so the vehicle must sit still and scan before transporting to the hospital. Next, IF you can get a diagnostic scan….a procedure which takes a minimum of 10 – 15 minutes which does not take into
    account the need to screen patients for allergys and renal insufficiency before giving them the needed IV contrast that stroke protocols require you need a radiologist to read the exam. Either theMD is on board or you have to transmit the image data to him……MORE time. And all thisntime is being burned while the patient is NOT at a hospital…..where he could be worked upmfor all the other possible sources of stroke like symptoms.

    The reason why many possible CVA patients wait a very long time to be scanned after arriving in an ER is that ER MS’s don’t generally practice medicine, they practice test ordering….and one of their MOST favorite test is the CT scan. So the scanner in any hospital of size is usually backlogged 24/7. THAT is why patients wait.
    Because to most ER MD’s EVERY patient with SOB/hypoxia/CP/elevated D-Dimermust have a PE and MUST have a CT Chest RIGHT EFFING NOW! All belly pain must be an aneurysm….SCAN EM NOW! EVERY headache is a bleed in the brain…..SCAN EM NOW! You get my drift……some hospitals have 2, 3 even 4 CT scanners….and all are kept booked by STAT scsns. Tell an ER MD the CT scanner is broken and you will get the same look as you get when you tell a kid Santa is dead and Christmas is cancelled.

    Defensive medicine, reimbursement driven by “do more exams get more money” and the generalized decrease in the quality of MD coming out of med schools due to the dumbing down of America as a whole and the problem becomes untenable.

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