JEMS.com Editor’s Note: The medication tPA should be given within three hours of a stroke, not 90 minutes, as stated in thisUSA Today article.
HOUSTON — When fire department paramedics found 50-year-old Gerald Booker unable to drive, his left side weak and his speech slurred because of an apparent stroke, they told the yard laborer he was going for a ride.
Instead of stopping at hospitals closer to his home in the Pleasantville neighborhood of this sprawling city, the paramedics took Booker to Memorial Hermann Hospital, one of more than 660 hospitals across the USA that specialize in treating strokes.
As Booker was driven past the other hospitals on a recent Friday afternoon, he became part of a growing national — and still debated — trend aimed at improving the quality of medical care for strokes. Bypassing closer hospitals to rush people with blood clots or bleeding in their brains to specialty hospitals is an increasingly common way to deliver the most advanced care as soon as possible.
The treatment model is similar to the one developed years ago to help save the lives of those severely injured in accidents or by violence by passing local hospitals to reach one of the 255 U.S. trauma centers.
Likewise, some big-city emergency medical services take people who are having heart attacks to hospitals with fast-moving cardiac teams. Those specialists have shown they can routinely insert a catheter to clear a heart blockage faster than neighboring facilities.
The idea behind the specialty center trend — whether in treating strokes, trauma or heart attacks — is the belief that staffs in such facilities move faster and perform better than those in other hospitals, making up for any extra minutes a patient spends on the road.
A 2007 study in the journal Neurology examined more than 26,000 stroke patients admitted to 606 Canadian hospitals and found there were more adverse outcomes such as death for those treated in “low-volume” facilities — those dealing with fewer than 50 strokes a year — than in high-volume centers that treat 100 or more strokes annually.
“What you get at a stroke center versus a community hospital is a more in-depth and higher level of care,” says James Grotta, chairman of the neurology department at Hermann, which is part of the University of Texas Health Science Center. “We see twice the number of stroke patients as the next hospital in this city. Like anything else, it’s practice, practice, practice. The more you have done it, the better you are going to be at it.”
But some in the medical community are skeptical about emergency crews bypassing community hospitals in favor of farther-away stroke centers. They say many patients who don’t stand to benefit from cutting-edge and often experimental care at specialty centers could get quality care at smaller hospitals.
“It is a very small number of patients who stand to benefit” from being redirected to specialty centers, says Robert Solomon, a board member of the American College of Emergency Physicians. Most patients “will be just as well served, if not better served, by being cared for at their local community hospital, provided that the local community hospital is doing the right stuff.”
Either way, the stakes are high. Stroke is the third-leading cause of death in the USA and the leading cause of disability.
A nation wide effort is underway to boost the quality of medicine by holding hospitals accountable for their performance. Cities and states as well as physician and quality-oversight groups are pushing hospitals that want to become certified stroke centers to follow guidelines for speedy and effective care.
Currently, Delaware, Florida, Massachusetts and New York certify hospitals as stroke centers, and 43 more states have at least some hospitals that are certified by health quality groups as stroke centers. More than a dozen of the largest cities allow their paramedics to take patients who appear to be having a stroke to the specialty hospitals.
In Houston, paramedics are allowed to take up to 15 minutes beyond what it would take them to reach the closest community hospital in order to transport patients to a stroke center. “We train paramedics to treat stroke like a trauma incident,” says Charles Grissom, a Houston Fire Department paramedic captain.
Speed is of the essence
Time is the enemy for stroke patients such as Booker, because the part of the brain that is affected is getting starved for oxygenated blood. Each passing minute results in the death of 1.9 million brain cells, but backers of the stroke-center model of treatment believe getting to the specialty centers where blockages can be cleared quickly still reduces the chance for the kind of irreversible damage that makes strokes so debilitating.
“It’s a race against time trying to get the artery open,” says Grotta, who is standing in a hallway at Memorial Hermann with one of his vascular neurology fellows, Sheryl Martin-Schild, when their pagers beep loudly, displaying the phone number to the emergency room.
Martin-Schild, who heads the stroke team at the moment on this day, phones the emergency unit to hear about Booker’s symptoms.
Within a few minutes she, Grotta and others, including nurses, technicians and medical students, descend upon Booker. Before the team can decide what tool to use, they must pinpoint the problem in Booker’s brain.
The drug Activase, also known as tPA, could melt a clot causing a stroke. And a corkscrew-shaped catheter that can be snaked into the brain might yank out a clot.
The corkscrew catheter is useless, however, if the problem is a “bleeder” — a blood vessel that has ruptured in the skull. Giving tPA to melt the clot can cause more bleeding if the problem is a ruptured blood vessel. So the doctors must get a CT scan. But the clock is ticking, and tPA must be given within 90 minutes of the first signs of a stroke to help.
The ability to perform a CT scan quickly is a key element of a hospital becoming a stroke center. Hermann, like many other hospitals, has a CT scanner in the emergency department so it can do scans fast. Instead of taking a patient to the radiology department on another floor for his “head CT,” which might take a half-hour in a community hospital, a patient can be scanned immediately.
Assessing the options
Fifty-five minutes after her pager alerted her to Booker’s stroke symptoms, Martin-Schild is looking at a CT image of his brain. She sees what Grotta calls “a very large clot” — about 1 centimeter long — that has lodged in a critical T-shaped juncture “taking out the blood flow to the whole right side of his brain.”
Martin-Schild quizzes a medical student about what dosage of tPA they should give him.
An hour after the stroke team was called to the emergency room to see Booker, he is getting tPA, which Grotta notes has about a 1 in 5 chance of melting the clot and returning normal blood flow to Booker’s brain.
Even so, Grotta says, it’s “his best shot.”
However, because Booker is in a stroke center, he has more options. Grotta has a member of the stroke team check with another doctor in radiology to see whether he would be available soon to snake a catheter into Booker’s brain to retrieve the clot. He will.
Still, nothing is simple in medicine. The new corkscrew catheter is being tested at Hermann as part of a nationwide clinical trial. Martin-Schild explains the trial to Booker’s family and asks whether they’ll consent to allow the use of the corkscrew. Booker may be assigned randomly to get the catheter treatment, but he also may be selected to just get drugs.
Either way, the medical world will benefit from what’s learned.
A study to yield results
Booker says he understands and asks to be enrolled in the study. He and his family sign consent forms.
“Either way, there is risk,” says his niece Glenda Hawkins.
The trial is designed to see if the risks of using the catheter, which includes bleeding, rupturing blood vessels and sending clot fragments farther into the brain, are justified by a benefit.
“Half of us think it works, and the other half think it doesn’t,” Grotta says. “All I know is that half of us are wrong, and I don’t know which one it is.”
To answer the question with some certainty, the trial uses randomization — admitting patients to the trial with similar conditions and randomly assigning some to the drug treatment, the others to the catheter.
So less than 15 minutes later, a computer in another state decides Booker’s fate. He is put in the drug-only arm of the study.
“The computer has decided,” Martin-Schild tells Booker, explaining he will not get the corkscrew catheter and instead will “get the full dose” of medication.
“When did I have a stroke?” Booker asks. “Today?”
“Yes,” Martin-Schild says.
In the hallway, his sister-in-law, Stephanie Booker, who is visibly shaken, says, “He was well one minute and then not. I guess he’s in the best place he could be.”
As the trend of bypassing community hospitals in favor of specialty centers continues, doctors and health care regulators will continue to weigh the evidence to see whether the practice is good for patients. So far, results have been promising.
A 2006 study in the journal Neurology found that when New York paramedics took patients to stroke centers, the staff delivered care faster than at hospitals not designated as stroke centers.
Today, nearly four months later, Booker says he’s doing “pretty good.” He has limited movement with his left arm and numbness in his left foot, and needs a walker to get around. His speech is fine, but he is unable to work.
“They say it’s going to take time,” Booker says.