EMS on AIR

S2:E4 - "FAST-ED - Let’s see some data from the real world." - October 28, 2020

October 28, 2020 EMS on AIR Season 2 Episode 4
EMS on AIR
S2:E4 - "FAST-ED - Let’s see some data from the real world." - October 28, 2020
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EMS on AIR
S2:E4 - "FAST-ED - Let’s see some data from the real world." - October 28, 2020
Oct 28, 2020 Season 2 Episode 4
EMS on AIR

The primary objective of this episode is to provide you with an overview of the initial findings from the first two years of the Oakland County Medical Control Authority Stroke Systems of Care Special Study that is being conducted in southeast Michigan.  The pilot phase of this study went into effect January 1, 2018 and after two years the OCMCA has compiled some interesting and promising findings.  The big guy, Dr. Steve McGraw is here to provide us with an overview of these findings and tell us what they might mean for the future of EMS stroke care.  Dr. Steve McGraw is an ED physician at Ascension Providence Hospitals in both Southfield and Novi, Michigan.  Doc is also the current Oakland County Medical Control Authority EMS Medical Director.  The OCMCA provides EMS oversight to 54 EMS agencies within Oakland County, Michigan.  Even though we are located in Southeast Michigan and we mention our home state a lot, most of the EMS on AIR content applies to EMS on the national and even the global scale. 

Before Dr. McGraw leads the way in the study data discussion, we welcome back Dr. Russel Faust, the medical director for Oakland County Health here in southeast Michigan.  Russ kicks us off with an update of the COVID-19 pandemic for EMS and related healthcare providers.  In addition, we take a little tangent and discuss some recent events that may have caused a little confusion over the last month or so here in Michigan.  Dr. Faust will cover the details, but the bottom line is that in early October State of Michigan Emergency Orders by the Governor were struck down by the State Supreme Court.  It seems that many people did not realize the orders were struck down on a procedural technicality, and a few days later, the technicalities were corrected, and the orders were re-issued by way of the Director of the Michigan Department of Health and Human Services.  So, yes Michigan still has Emergency Orders in place and yes there are components that healthcare providers, like EMS, should be aware of. 

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Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org.  

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Show Notes Transcript

The primary objective of this episode is to provide you with an overview of the initial findings from the first two years of the Oakland County Medical Control Authority Stroke Systems of Care Special Study that is being conducted in southeast Michigan.  The pilot phase of this study went into effect January 1, 2018 and after two years the OCMCA has compiled some interesting and promising findings.  The big guy, Dr. Steve McGraw is here to provide us with an overview of these findings and tell us what they might mean for the future of EMS stroke care.  Dr. Steve McGraw is an ED physician at Ascension Providence Hospitals in both Southfield and Novi, Michigan.  Doc is also the current Oakland County Medical Control Authority EMS Medical Director.  The OCMCA provides EMS oversight to 54 EMS agencies within Oakland County, Michigan.  Even though we are located in Southeast Michigan and we mention our home state a lot, most of the EMS on AIR content applies to EMS on the national and even the global scale. 

Before Dr. McGraw leads the way in the study data discussion, we welcome back Dr. Russel Faust, the medical director for Oakland County Health here in southeast Michigan.  Russ kicks us off with an update of the COVID-19 pandemic for EMS and related healthcare providers.  In addition, we take a little tangent and discuss some recent events that may have caused a little confusion over the last month or so here in Michigan.  Dr. Faust will cover the details, but the bottom line is that in early October State of Michigan Emergency Orders by the Governor were struck down by the State Supreme Court.  It seems that many people did not realize the orders were struck down on a procedural technicality, and a few days later, the technicalities were corrected, and the orders were re-issued by way of the Director of the Michigan Department of Health and Human Services.  So, yes Michigan still has Emergency Orders in place and yes there are components that healthcare providers, like EMS, should be aware of. 

Visit EMSonAIR.com for the latest information, podcast episodes and other details.

Follow us on Instagram @EMSOnAIR.

Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org.  

Support the show (https://www.patreon.com/emsonair?fan_landing=true)

Hello, and welcome to the EMS on-air podcast. The mission of this podcast is to keep healthcare providers safe, informed and prepared. Today is October 28 2020. I'm Geoff Lassers, and I'll be your host. This episode was recorded on October 23. And I'm sorry it took so long to get out to you. Even though we're a little behind. We still have a great episode for you today. The primary objective of this episode is to provide you with an overview of the initial findings from the first two years of the Oakland County Medical control authority stroke systems of care special study that is being conducted in Southeast Michigan although it's being conducted in Southeast Michigan, they are trying to expand this to outside of the state. The pilot phase of this study went into effect January 1, 2018. And after two years, the OCMCA has compiled some interesting and promising findings. The big guy Dr. Steven McGraw is here to provide us with an overview of these findings and tell us what they might mean for the future of ems. stroke care. Dr. McGraw is an ED physician at Ascension Providence hospitals in both Southfield and Novi Michigan. Doc is also the current Oakland County Medical control authority EMS medical director. The Oakland County med control provides EMS oversight to 54 agencies within Oakland County, Michigan and even though we are located in Southeast Michigan, and we mentioned our home state a lot most of the EMS on air content applies to EMS on the national and even the global scale. Before Dr. McGraw leads the way in the study data discussion. We welcome back Dr. Russel Faust, the medical director of Oakland County Health here in Southeast Michigan. Russ kicks us off with an update of the covid 19 pandemic for EMS and related health care providers. In addition, we take a little tangent and discuss some recent events that may have caused a little confusion over the last month or so here in Michigan. Dr. Faust will cover the details. But here's the bottom line in early October, the state Supreme Court struck down the state of Michigan Governor's emergency orders. It seems that many people did not realize the orders were struck down on a procedural technicality and a few days later, the technicalities were corrected, and the orders were re issued by way of the director of the Michigan Department of Health and Human Services. So yes, Michigan still has emergency orders in place. And yes, there are still components that healthcare providers like EMS must be aware of. Anyway, enough Coronavirus issues and back to stroke, the Oakland County Medical control authority stroke systems of care special study is rapidly expanding. If you'd like to know more information about the OCMCA stroke study, or if your agency or hospital would like to participate visit ocmca.org/stroke. There you'll find all the information you need about the study and how your MS agency or hospital can participate. You'll even find study data as well as a few presentations that you can download. You don't have to be located in Michigan to participate the OCMCA would love participants from all over the US to help us identify the strengths and weaknesses of implementing a stroke severity scale so that we can share our knowledge amongst the entire pre hospital community. Finally, please join us on October 30. That's this Friday for the first ever EMS on-air live streaming event that day starting at 9am We will be hosting three separate one hour lectures presented by stroke experts Chris and Jason from Seitz and Sirens will be joining me on the interview panel as well. This event will be live streaming only on EMSon-air.com go on over to EMSon-air.com. To register for this free event today. Each lecture provides one EMS CE in the medical category towards your state of Michigan EMS license. EMS CE's are sponsored by the Oakland County Medical control authority CE sponsorship. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on air podcast team by email at QI@ocmca.org. Also, please check out our cool new updated website emsonair.com for the latest information, podcast episodes and other details. Follow us on Instagram @emson air and please whatever podcast platform you use, subscribe to the podcast and leave us a rating and a review because it really does help us grow this thing. Enjoy the episode. 

Well, good morning Dr. Faust and Dr. McGraw. How are we today?

Dr. Steve McGraw  4:21  
Good morning. Good to see you guys.

Dr. Russel Faust  4:23  
Good morning. Good to see you.

Geoff Lassers  4:25  
So Dr. Faust, please provide us with an update on the COVID-19 as of October 22.

Dr. Russel Faust  4:31  
How about October 21?

Geoff Lassers  4:33  
Is it October 21?

Dr. Russel Faust  4:34  
No, what's today it's October 23. Today,

Geoff Lassers  4:36  
October 23. How about you give us an update as of October 23 2020.

Dr. Russel Faust  4:41  
We have 19,000 over 19,000 cases here in county. More than 1100 fatalities, unfortunately, but we have greater than 15,000 recovered. Back in mid April. We were seeing a seven day average of well over 300 cases a day we reached nearly single digits In June, down to about 10 a day, and most of August, we were up around 100 cases, new cases of COVID-19 per day. Unfortunately, now, over the last two weeks, we just continued to climb. And we are well into the hundreds here 130 140 150 a day. And the trend is continuing up didn't help us that the Supreme Court knocked down governor Whitmer health orders executive orders. Unfortunately, despite director Gordon reimplementing reinstating virtually all those orders within two business days, when the public heard that the orders have been struck down, everybody said  we don't have to wear a mask, we don't have to maintain distances. And we're paying the price for that right now. Despite the fact that those orders still exist, they're still in place.

Geoff Lassers  5:49  
He could explain that a little bit further. For those people listening right now, the Michigan Supreme Court deemed that the emergency orders could not be could not stay in place. But what you're saying right now in the audience is that they are still in place.

Dr. Russel Faust  5:52  
 They are in place. What they deemed is that the procedure used by the governor was not proper, okay. And they struck down the orders on that basis. But the fact remains, Director Gordon at MDHHS has the authority to put in place public health orders emergency health orders in the context of a global pandemic and a national pandemic. So they were reimplemented immediately. And instead of having 10 separate orders, he just basically all listed them in a single health order. The following Monday was struck down on Thursday or Friday, and the following Monday, they were all back in place. You know, that includes social distancing, that includes masks when out in public that includes collections of people 10, or fewer indoors, 100 or fewer outdoors. And of course, half the population right now is ignoring all of those. And again, we're paying the price for that right now we're seeing that.

the perception issue that currently exists is certainly in favor of Oh, the Supreme Court knocked it down, not the follow up punch line of well, they made the modifications necessary to keep them constitutional. Essentially,

you got it.

Geoff Lassers  7:07  
So I think it's really important for everybody listening to not allow any type of misinformation to cloud their judgment. Because, again, the emergency orders were struck down based on procedure, not based on the actual intent of the order or the actions described in the order.

Dr. Russel Faust  7:24  
They struck it down on a procedural basis. Just a technicality, essentially, right. But of course, the republicans are suing, again, to try to strike down director Gordon's orders. But you know that that'll be months in process just as the original ones were.

Geoff Lassers  7:40  
So as we see the spike going on right now, are we seeing any change in the death rates?

Unknown Speaker  7:43  
in the fatalities? No, we're not. We're not seeing an uptick yet in the fatalities. What's interesting is, and I'm sure Dr. McGraw can comment on this as this, this kind of third wave kind of kicked in. We were really seeing a lot of the younger generation, the college kids that were going back on campus, and were not maintaining distance not wearing masks, and we're becoming infected. But a lot of them were sent home from campuses against recommendations by CDC, they returned home they infected their parents, grandparents. So you know, right now, when we look at the age distribution, all those new positives right now, the uptick we're seeing in this third wave really span the gamut of younger age groups. That is, it's the the 20 somethings that 30 somethings 40 somethings 50s and 60s. Before I stopped my little rant here, I really want to give a strong shout out to everybody getting vaccinated for influenza, because here's the issue, a co-infection with influenza and COVID doubles your mortality risk, at least doubles. This is a study published out of the British Medical Journal and a couple other follow up studies original suggested that in the age range 60 above a co-infection doubled your mortality follow up studies are suggesting that virtually any age range it at least doubles your risk of death. If you get influenza, and COVID infected. Man, you know, you cannot take this risk. You cannot risk giving someone else the flu. Just get your flu shot this year, wear your mask, maintain some physical distance. And you know, we'll see a decreased flu season We'll see. We'll be able to knock down COVID. But again, this is not rocket science. It just takes a couple things.

Dr. Steve McGraw  9:40  
Dr. Faust, I'm really glad you said that because none of this is actually hard. No, none of this is complicated. I think some true shame belongs to that attorney that told people to go out and quote "burn all their masks" end quote. What a reckless and shameless and frankly dangerous outlook to spread. I mean, she may be euphoric about her notion that she successfully argued a case in front of the Supreme Court. But if people follow her medical advice, as an attorney, it will lead to the death and disability of unnecessary people. And unfortunately, she can't take those words back. This was really dangerous, shameful behavior, I don't begin to tell people how to adhere to the law or utilize the legal profession. I'm profoundly angry that someone in her position would use her status to give medical direction and suggest unwise reckless medical behavior to our public. I won't say her name, but it was in the it was in the light press. And I'm saddened by that. I'm saddened by someone that would be so wanton and considered an expert in her field to have such utter disregard for the health and safety of the public. 

Dr. Russel Faust  10:50  
 Well I mean, obviously, it comes down from the president and on, because, you know, he clearly has disdain for science and medicine and his expert opinion being provided by the likes of Anthony Fauci from CDC. So, I mean, it's fairly pervasive right now, let me say this, I do get this kind of quarantine fatigue, this burnout that everybody has their own staff are profoundly burned out. But the real difference that we see in public health, and I'm sure you're experiencing this at the hospital, is that early on, we had this sense of camaraderie. We're on the same page, we're all in the same boat. We're working toward the same goal to prevent this pandemic from sweeping the nation. When there was a positive case at a facility, everybody worked together, everybody was cooperative, there was a sense, we are on the same team. Now, when we go to do case investigations and contact tracing. People don't cooperate, they refuse to give us names of close contacts and exposures. It's become a very adversarial relationship. And that is incredibly frustrating. And it adds to the burnout. Our staff at public health can tolerate an enormous amount of frankly, abuse and overwork. But it helps if there's some gratitude and cooperation in the public. And now there just isn't, and they're really feeling it. You know, we've had death threats of our personnel. We've had parents of athletes that are being quarantined, show up and demand to speak to the epidemiologists who quarantine their child, so they can bully them into releasing the quarantine. And we have, frankly, just horrible misinformation coming out of urgent cares that are, quote, "clearing" people end quote from quarantine based on rapid antigen tests and other inappropriate misinformation. So it would just help if everybody wore the damn mask and maintain at least six feet from other people.

Dr. Steve McGraw  12:47  
Yeah, I'm not asking people and I'm praying that we never have a situation where it's felt that due to the overwhelming volume of hospitals, we have to tell people to have a stay at home order. The only way to make sure we don't get to that point is for people to do exactly as you describe, wear a mask, keep six feet or more frankly, between each other. And that's especially true when you're around groups of you know more than is your immediate family. Even something as simple as just going to the grocery store or being in a gathering for a function with your coworkers. This isn't a lot of work to put on a mask, we've all gotten used to wearing them when we need to. And if we don't, The unfortunate thing is we're going to look like April, again, that is my nightmare. I just don't want to go back to a situation where any of us have to endure something like we all went through in Southeast Michigan back in April and early May. It was devastating. I still have staff that and myself included grieve for the folks that we saw in such critical illness dying so frequently. And so tragically, I wouldn't wish that on anybody. And we can all we can all do our part to prevent us from getting back there. But burning masks or disagreeing with and mocking or worse threatening public health officials and medical providers is exactly the wrong direction. A national policy of doing everything we can to minimize risk and maximize safety will keep all of us from a lockdown. And it will keep our economy headed in a better direction that will allow us to avoid unnecessary death and disability. It's totally within our control. But we've received such poor leadership. And frankly, we've received such poor information from the people that have it at their hands to talk to the most expert people in the world. It's shocking. It is a historic failure of leadership. And I just want us to get to the point where we're pulling the wagon in the same direction again.

Dr. Russel Faust  14:44  
It's pretty bizarre because you and I have lived through the time when they implemented the seatbelt laws. And I remember you know everybody bitching and moaning about that and refusing to wear seatbelts. You know, this isn't a lot different but I don't remember any death threats during the seatbelt implementation and wasn't quite as out of control and crazy as this is.

Geoff Lassers  15:06  
 This quick commercial break is brought to you by American CME. If you or your EMS agency need to catch up on your stroke knowledge go on over to AmericanCME.com. There you'll find multiple courses approved for EMS CE's that focus on stroke, I highly recommend the course identifying large vessel occlusion strokes with FAST-ED. This course walks you through the FAST-ED stroke severity scale step by step shows you how to score the criteria of the scale and provides additional details to successfully guide EMS through the process. Or if you want to focus on the fundamentals, check out the course anatomy and pathophysiology of stroke, which breaks down each region of the brain. Or check out the large vessel occlusion stroke course, which introduces EMS to large vessel occlusion strokes and provides great detail and information. All three of these courses are approved for 0.5, EMS continuing education credits in the medical category. Did I mentioned that you can access all of American CME content for free? Yeah, free. And now back to the show.

 So you guys are speaking to his evidence based decision making models. And evidence is produced from data, the scientific method and a number of other processes....

Dr. Russel Faust  16:20  
Leave it to Geoff to take it back in an erudite scholarly direction.

Geoff Lassers  16:24  
I don't know what any of that means. But I think I'm going to help. So as we look at our decisions from an evidence based perspective, you know, the other primary driver of us talking today is going to be the data produced from the Oakland County Medical control authority stroke systems of care special study, where we are measuring the ability of EMS personnel to use a stroke severity scale to identify the presence of stroke, as well as quantify how severe it might be.  

Dr. Russel Faust  16:47  
I was just gonna mention this.

Geoff Lassers  16:48  
Yeah,

Dr. Russel Faust  16:48  
 yeah. 

Geoff Lassers  16:49  
Okay. Cool.

Dr. Russel Faust  16:50  
We're just talking about that.

Geoff Lassers  16:51  
Oh, that's great idea.

So, in 2017, Oakland County started their study development in 2018, they started the study with one agency. We've covered this in the last couple of podcasts. And today, we want to talk about the data that we've produced from there. To do that. I want to kick it off with Dr. McGraw, can you please guide us into the data collection process for Oakland County, and give us a little context of this is a special study so that when people hear the word study, they often think peer reviewed and a lot of other things. Now, we do have an IRB for this. But right now we're in the data collection phase so can you please give context as to before we give the data? What is this data really encompassing?

Dr. Steve McGraw  17:32  
Well, thank you, Geoff. We're really sort of pioneers in trying to assess the capability of our EMS providers to identify stroke prior to hospital arrival, communicate that information to the emergency department, and then ultimately compare it to the assessment of the emergency physicians national self stroke scale, and comparing that to the FAST-ED down in the pre hospital setting. Ultimately determining the outcome of the patient and sort of reverse engineering to determine how best we can improve the training and improve the ability for the EMS providers to recognize what they're seeing. That really requires diligence training and then retraining as time goes by. In 2018 and 2019, the special stroke study in Oakland County assessed in our pre hospital fraud using one agency 82 patients, it was a very effective study and examining how well they were able to apply FAST-ED correlating that with the NIH stroke scale to hospital and outcomes. Really, the sum total is with a greater than 70% sensitivity, they were able to provide an assessment pre hospital that agreed with the findings in the hospital on arrival. And then ultimately by outcome, I think the most important thing about that is that 71% or 75%, depending on the year may not sound that great, but I will tell you that exceeds their ability and our ability as pre hospital providers to accurately identify ST elevation MI, and we've been doing that for almost 20 years in our system now, at least since 2002. So in a short amount of time, we've introduced a whole new paradigm of assessment in the field, correlating it to emergency physician assessment as they arrive to the department and then looking back from the outcome study what they originally found it how it applied to the findings on CT scan, and by the endovascular neurosurgeon. I think it's also important to recognize that they've improved in their ability identify the mimics or the false positive FAST-ED studies in the sense that initially we were in the 25 to 35% range. And now false positives are 30% or low, consistent, lower consistently. And that goes again towards increasing their specificity, not just their sensitivity, finding focal neurologic deficits. It's not easy, especially in the brief time that a pre-hospital provider can do their assessment, as well as there's confounding things. The initial part of a stroke may not look exactly how it will 10 and 30 minutes later, as some of the surrounding area from the brain insult begins to be impacted it almost That sounds intuitive, but if you think about it from a physiologic standpoint, the stroke becomes more declarative after the first five or 10 or 20 minutes such that when we get to the emergency department very often, the findings are now considered hard findings, instead of a subjective drift, say for prone interpretation with the upper extremity. Now the patient has a flacid pearlitic arm, if you wonder one of the reasons why I think we have a little bit easier time determining a positive and a stroke scale versus the FAST-ED. It's simply the delay that it takes to transport the patient and have them assessed by the physician, we benefit with the clarity of time. And so to some of the lack of sensitivity or increased error rate or mimic rate, I would argue that really isn't the fault of the EMS provider, that's simply a matter of we have the benefit of being given a selected patient who already likely has a neurologic deficit and has had enough time for it to be more pronounced. Any questions about that, Geoff? Because I think that's an important point when I sort of subdivides some of the data.

Geoff Lassers  21:00  
Absolutely, it's very clear, but I one thing I want to do is help people because when I started this process, you and our partner, David Mills, on this project, we're talking about sensitivity and specificity. And I thought you were talking about your emotions, and just pointing at things that are very specific. So can you give us a little bit of background for everybody listening? who's new to specificity and sensitivity as I was? 

Dr. Steve McGraw  21:20  
Sure. So the first one is, I think the best one to recognize and that's the one that's more intuitive. That's the sensitivity. How often if the disease is present, do we identify it as being present? That's how sensitive an effort is specific is how often we identify that it's not present and is truly not present. That's specificity. So in the case of the stroke, sensitivity is how often our EMS  impression is that a stroke is occurring, and how often it really is occurring. Whereas in specificity, it's how often did we not think it was occurring and it wasn't occurring? That's the ability to determine specificity. The way that you can determine sensitivity is to know the true positives separated and exclusive of the false negatives. The true positives, then identify those that have the disease. And when you minimize the false negatives, you've also minimized the number that your sensitivity is errant. Similarly, in specificity, you're able to identify your your ability to identify the lack of the presence of disease, separated from the false negatives, meaning those that have the disease more identified. So you want every endeavor you go into, you want to have the highest amount of sensitivity, but you also want to have the highest amounts of specificity. In the sensitivity case, you're identifying those that really have it in the specificity, you're identifying those that have it and also noting that the ones that don't have it are not positive, the mimics would fall into impacting your specificity, because you would have an elevated suspicion when it wasn't present. Your false negatives would impact your sensitivity, because the disease is present, but you are tested and determined that so in both cases, you want to maximize them, you want to maximize how sensitive your test is. And you also want to maximize how specific it is. But you can imagine to how some of those imperatives almost work at counter currents to each other. If we do a study or procedure that captures as many of the true positives as we can we sort of cast a wider net, the number of false positives can creep up. And that would affect your specificity. However, we try to maximize our specificity. by drilling down and only the hardest, most positive true positives, then we might have have some abnormally high false negative rates, which would impact your specificity. And regrettably, when you're trying to maximize sensitivity, you might inadvertently impact your specificity. And if you're in trying to dramatically impact your specificity, you might inadvertently impact negatively your sensitivity. So the truth is, our whole goal is to increase both. I think what we saw over the course of the two years is both an increase in sensitivity that came from more awareness, better diligence, doing the FAST-ED and being more experienced with the FAST-ED made people better at it. And we also improved our specificity by learning what mimics were present, those sort of false positives that could fool anybody. But especially when you're first learning to do a procedure like the FAST-ED, you might get fooled more often than otherwise, what we saw over both 2018 and 2019 was an improvement in sensitivity and an improvement in specificity. I'm very proud of that. I'm very proud of this agency that did so much work in this regard. We've learned a lot about how to train people to have that occur, and I know going into 2020 as we expand into more agencies and spread this out across a greater number of providers. Not only were our sample size go up, in fact, I think it's a reasonable expectation that we'll go from 80 some cases to 400 cases. But that alone will increase our ability to do statistical analysis. What I really I think we took away from the first part of the study was how best to help our providers do even a better and faster learning curve, and make their ability to provide this study and provide this data and fewer false positives and more true positives in the study earlier on going forward. So that'll be exciting. I mean, anticipating not only the growth and the increased in ability to slice and dice the data, but also having more people involved getting a better understanding of how best to train the trainer, and train the individual providers. There'll be an exciting time in the next year,

Geoff Lassers  25:51  
very much so and one of the last episodes I talked to the Seitz's brothers, and one of them is Jason sights is a Madison heights firefighter paramedic, who's the second agency in the study. And I asked him, you know, what's the biggest challenge of teaching FAST-ED, and he made it very clear that FAST-ED is actually easy to teach, it's easy to understand, it's essentially a checklist, you learn to adopt it into your practice very easily. He said, The biggest challenge is tempering the passions of EMS, because once they realize that this tool can then segregate the severity of a stroke, they get in their minds that the best thing to do for this patient is take them to a place that can do intervention. However, the data is clear that we take them to the closest Stroke Center in our area. Now, the conditions we have in Oakland County with the plethora of stroke centers is much different than an area with like, let's say one hospital in three County area, that's a much or two hospital and a three County area. That's a much different situation. So your gave us the data and the sensitivity and specificity of us dipping our toe in the water and see where it's going. But can you please kind of pay homage to us looking at the transportation protocol being mindful of the potential change. But right now, I don't think it's in the purview of the Oakland County Medical control to just change that transportation protocol now, but it's steeped in evidence.

Dr. Steve McGraw  27:06  
I'm really glad you offered me the opportunity to talk about this because I do know that we're a little bit unique in Oakland County, we have 17 hospitals and serving about 1.3 million people. So we are blessed. We have, as you describe, I think accurately a plethora of primary stroke centers, we also have comprehensive stroke centers or thrombectomy capable centers dotted around our county as well. And to the extent that we will one day augment our transportation protocol, I think it will be with the knowledge that our providers have demonstrated the ability to identify a large vessel occlusion with more likely than not threshold. What's interesting is the state can't really just focus on the way we can have of one county, they have to think about these long transport conditions out  of state. And that's where I think you're going to ultimately see more patients with harder findings where the pre-hospital providers have special training such as FAST-ED, and are capable of identifying someone having firm findings of stroke, even at that point, being able to use their own protocols in their medical control to preferentially go to a hospital capable of providing either thrombectomy or comprehensive stroke management. I don't think we're there yet. I think we have a lot more training to do. And frankly, I think we have a little more probability because it won't matter if you're going to a primary stroke center that can give TPA and they have to transfer to someone capable of dealing with an LVO. If it's relatively close, I'll just give an example. If you went to Providence Southfield, say, and the thrombectomy wasn't capable of being performed until you were then subsequently taken to Providence Novi that's 16 miles. That's one sort of window on how close it could be. And I would argue that 16 miles, as long as you have EMS capable of that inter-facility transfer, probably not a big deal. However, what if it was 25 miles or 35 miles to the nearest comprehensive Stroke Center. That's not true in Oakland County, but it's true in a lot of parts of our state. And where the imperative I think becomes significant is recognizing that in a severe stroke is identified by a pre hospital provider, a severe stroke, say a FAST-ED score greater than four. So we have real hard findings, real neglect, real flaccid paralysis, real aphasia, one of the things that's going to correlate with that is both an elevated stroke scale and a high likelihood if they're caught within the window of an ability to salvage brain, but that's unlikely to occur simply with TPA alone when the score is that high. And I think in certain cases with certain transport times and distances, you could make an argument that we'd be better off traveling a little bit extra primarily to the Comprehensive Center or the thrombectomy capable center, then stopping for TPA, which isn't likely to be successful in the case of a large vessel occlusion and then having to arrange for additional transport to that same distance or further, I just think that we'll have to grow up a little bit, we're going to have to have more capability around the states to do thrombectomy's and have more comprehensive stroke centers. But once we've done the front end, which is to get more of our EMS providers trained and how to do FAST-ED, or similar pre hospital nuance study, and that's not to suggest any shade on the Cincinnati stroke scale. I am a big fan of that. But that's like learning to take a blood pressure doing a FAST-ED, or one of the other races or one of the other, more nuanced correlative tests, takes more training, but gives more information to the likelihood of a large vessel occlusion. And in doing so, when more of us are trained that way, I think then we'll have to have the conversation about how far is too far to go to get TPA and not get ultimately in a high scored patient, the ability for thrombectomy that'll be a more coaching conversation we can have, but we had to answer the first question primarily, which I think I can say with confidence. Our studies in 18 and 19, demonstrate that EMS providers can identify large vessel occlusion by virtue of an elevated FAST-ED score, and that 70% of the time, an actual stroke will be identified and correlated to a high NIH stroke scale in the emergency department. All we have to do now is get a bigger sample size to correlate the outcome data and the vascular data that we're going to learn that our future phase in 2020 and 2021. It's a fascinating time to be evaluating stroke, especially in stroke for the pre hospital providers, but the role they're going to play in identifying those patients that need subspecialty care and care that isn't necessarily available in every hospital, or every primary Stroke Center is going to be fundamental to our ability to enhance the health and safety of our patients.

Geoff Lassers  31:44  
Absolutely. And I think one of the biggest opportunities that we saw when we were implementing this wasn't necessarily introducing the scale to them. But it was to fortify the fundamentals of stroke management and data collection on scene and really take advantage of that the number of patients that had a primary impression of stroke, or TIA in 2016 versus 2018 was nearly half, that mean that the citizens of Bloomfield township got twice as healthy when it comes to stroke, it means that our providers became essentially twice as accurate as discerning stroke. And it's not like they were bad at it before. This is something in EMS where the stroke education has not changed since the mid to late 90s. So it was an opportunity to say, Hey, here's what we think is going to work. Let's put it in play. And it turns out, it's working. The other things it's doing is increased the number of mimics identified and stopped false activations of stroke. In addition, to give you a little context, as to the patients that were missed strokes, an overwhelming number of the strokes that were missed, were patients that were so obtunded or alert oriented time zero, that a stroke assessment really wasn't done. And the EMS providers, essentially we're focusing on the fact that this was an unresponsive or a non reacting patient and focusing on other things and not putting a primary impression of stroke. So it's not like they missed an emergency. It's very specific. And if you compare this to national numbers, and I think in future episodes, we should do that. I think you're going to see that not a whole lot of training went into this, a whole lot of prep work did, but not a whole lot of training at the agency level in a whole lot of benefit at the patient, hospital and systematic level. And what we're learning here I think can be easily adopted anywhere, even if you don't adopt either FAST-ED or any stroke severity scale, because at the end of the day, you may believe a gold standard treatment is that a comprehensive or thrombectomy, but are you delivering gold standard treatment on scene collecting: last known well, blood sugar, time of  symptom discovery, next of kin information, all of this stuff that makes Dr. McGraw's decisions faster to keep the ball rolling, because like we said in the last episode, it's not like I'm gonna take on a doctor McGraw and he's gonna suck a clot out or stitch up a bleed inside their head. He's gonna call the next guy, and then that guy is going to call the next person and then that and it's going to keep going down to this person is either living a better lifestyle or continuing their care. 

Dr. Steve McGraw  34:14  
You know Geoff, I'm so glad you said that because there is no doubt we have observed change in the quality and effectiveness of the assessments being performed. I just worked clinically yesterday and I will tell you a good example is the medic's not only brought me an early morning patient with a wake up stroke they had inquired before the patient even arrived not only their last known well, but did they wake up during the night and find that they were having any no you woke up at one o'clock in the morning and you were able to walk and do everything? Well, then your last known well wasn't when when you went to bed. It was one o'clock in the morning. They were really really focusing in on trying to help me and the patient determine when the window of that sort of the time zero has to be counted from and to your point. We're really finding that as we go forward, our providers are a wealth of the ability to help us not only the blood sugar but is the patient on blood thinners. If the goal is really for me to administer with the nursing staff TPA in 45 minutes, I not only have to score them and assess when they arrive, they have to get a CT. And then they have to have the CT interpreted by a radiologist so that I don't give it to someone blood in their head while they get the TPA. We're doing a CT angiogram and a CT perfusion study, I can't tell you how important is to get all that done in is close to 45 minutes as we can at least get the TPA infused. Well, everything that the EMS providers do for us on the pre-hospital end to contributes to that information being shared with us and getting us ready before the patient even arrives, makes that 45 minutes achievable. And I know that because when patients come in with a stroke by private car, and they arrive to the emergency department, we don't typically get it as fast as we do when we're notified by the pre hospital notification that hey, we're bringing you a code stroke. This is the last known Well, most of our hospitals now have our EMS providers take the patient right to the CT scanner on their EMS cart or get in quickly off the cart and under one of our ER carts to the CT scanner fully dressed, I just need that initial plain CT of their brain to get an idea of whether or not they have a bleed, and what else I can do to start getting that assessment done for the TP infusion to begin in 45 minutes, but we're better when the patient calls 911 than we are if the patient just arrives by private car and we have to do an assessment at triage and bring it back. You guys make us better and you make the patient's ability to get TPA faster than it otherwise might be. Don't ever minimize that because the sooner we get the medications on board and see if it works or not, the sooner we start to determine if they need extraction of their clot. Everything has a role to play. And the first and primary critical role that EMS is providing to us is only enhanced by their ability to do a FAST-ED or similar pre hospital stroke assessment.

Geoff Lassers  37:00  
And you couldn't have said that better doc

thank you to everybody listening. That is all for the show today everyone and as always, thank you to Dr. Faust and Dr. McGraw you dudes are fun to podcast with. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on-air podcast team by email at QI@ocmca.org. Also, check out our updated website EMSonair.com. For the latest information, podcast episodes and other details. Follow us on Instagram @emsonair and please whatever podcast platform you use, subscribe to the podcast and leave us a rating and a review because it really does help us grow this podcast. Thank you for listening to the EMS on-air Podcast. Stay safe and have a great day.