EMS on AIR

S2:E14 - "Stroke and the Big City – An interview with Dr. Ethan Brandler about the use of the S-LAMS stroke severity scale by the NYFD Bureau of EMS." Recorded December 28, 2020

January 04, 2021 EMS on AIR Season 2 Episode 14
EMS on AIR
S2:E14 - "Stroke and the Big City – An interview with Dr. Ethan Brandler about the use of the S-LAMS stroke severity scale by the NYFD Bureau of EMS." Recorded December 28, 2020
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EMS on AIR
S2:E14 - "Stroke and the Big City – An interview with Dr. Ethan Brandler about the use of the S-LAMS stroke severity scale by the NYFD Bureau of EMS." Recorded December 28, 2020
Jan 04, 2021 Season 2 Episode 14
EMS on AIR

In this episode, Dr. Ethan Brandler discusses the S-LAMS stroke severity scale that is currently being used by the New York City Fire Department.  Dr. Brandler is an associate professor of emergency medicine at Stony Brook University Hospital and he is also the Associate Medical Director of the university-based EMS system which provides 911 and critical care services. He also provides online medical control for the NYFD EMS service and is the medical director for various EMS agencies around his home in Long Island, New York. He even responds to calls as a paramedic in his hometown of Plainvew, New York.  

 

When he’s not working in the hospital, teaching or going on calls as a paramedic, Dr. Brandler spends time conducting research on behalf of EMS and stroke.  His efforts have produced multiple published papers on the topic of EMS and the use of stroke severity scales, specifically on the S-LAMS scale.  In this episode, Dr. Brandler discusses a lot of very important and interesting things, but primarily he describes why NYFD EMS stroke protocols were updated to include stroke severity scales.  In addition, he walks us through their stroke protocol, the use of S-LAMS, how NYFD prepared to implement the updated stroke protocols into operation and, most importantly, he talks about the real life benefits their stroke patients are experiencing.  If you want to get a hold of Dr. Brandler you can email him at [email protected]

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 [email protected].  

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

Show Notes Transcript

In this episode, Dr. Ethan Brandler discusses the S-LAMS stroke severity scale that is currently being used by the New York City Fire Department.  Dr. Brandler is an associate professor of emergency medicine at Stony Brook University Hospital and he is also the Associate Medical Director of the university-based EMS system which provides 911 and critical care services. He also provides online medical control for the NYFD EMS service and is the medical director for various EMS agencies around his home in Long Island, New York. He even responds to calls as a paramedic in his hometown of Plainvew, New York.  

 

When he’s not working in the hospital, teaching or going on calls as a paramedic, Dr. Brandler spends time conducting research on behalf of EMS and stroke.  His efforts have produced multiple published papers on the topic of EMS and the use of stroke severity scales, specifically on the S-LAMS scale.  In this episode, Dr. Brandler discusses a lot of very important and interesting things, but primarily he describes why NYFD EMS stroke protocols were updated to include stroke severity scales.  In addition, he walks us through their stroke protocol, the use of S-LAMS, how NYFD prepared to implement the updated stroke protocols into operation and, most importantly, he talks about the real life benefits their stroke patients are experiencing.  If you want to get a hold of Dr. Brandler you can email him at [email protected]

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 [email protected].  

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

Geoff Lassers:

Hello, happy new year and welcome to the fifth episode of the EMS on AIR podcast. The mission of the EMS on AIR podcast is to keep healthcare provider safe, informed and prepared Today is January 4 2021. I'm Geoff Lassers, and I'll be your host. This episode was recorded on December 28 2020. This season of the EMS on AIR podcast has been dedicated to putting a spotlight on the world of stroke care and what ems can and will do to help potential stroke victims. Over the last decade tremendous advancements have been made in the amazing world of endovascular therapy for acute ischemic stroke, endo, meaning within and vascular referring to the blood vessels, specifically mechanical thrombectomy, or MT is an endovascular therapy that has made huge advancements and outcomes for patients suffering from large vessel occlusion or LVO strokes. The process of mechanical thrombectomy with a stent retriever involves inserting an intravascular catheter into the femoral artery of the patient and extending the catheter up into the vasculature of the patient's brain, the neural interventionalist the person who actually does this procedure can observe the location of the catheter relative to the clot with the use of direct fluoroscopy, which is basically an X ray video. a stent retriever is then deployed into the clot immediately restoring blood flow to the affected region of the brain by first dilating the vessel and then simply pulling it out. Up until relatively recently, the reality of stroke treatment offered few proven answers for victims of LVO stroke. If LVO stroke patients survived, they were often condemned to lifelong severe disability. Mechanical thrombectomy is proven effectiveness now offers reliable options to patients who had none just a few short years ago. Because of this mechanical thrombectomy with a stent retriever has been established as the standard of care for select patients suffering from LVO stroke. As a result, early recognition of LVO stroke by ems has become a priority for EMS systems around the world. Consequently, a seemingly ever growing variety of stroke severity scales continue to emerge. Remember, stroke screening tools are designed specifically for use by ems to detect signs and symptoms of stroke in the field. They are simple to use and have good sensitivity for detecting the most common types of stroke. These scales were developed to enable ems to identify patients who may be candidates for IV alteplase, more commonly known as TPA, to allow for triage and early notification to the nearest designated Stroke Center. Examples of stroke screening tools are like the Cincinnati pre hospital stroke screen or the Los Angeles pre hospital stroke screen. In contrast, strokes of various scales have been designed to objectively identify the severity of a stroke and recognize reliable indicators of LVO stroke. Essentially, they help ems identify LVO stroke patients who may be candidates for mechanical thrombectomy. Right now, there are many EMS systems across the nation effectively using stroke severity scales to measure stroke and obtain targeted pieces of information about the patient all in an effort to get them to the best possible treatment in the quickest and safest manner. And that's the whole point getting the right patient to the right treatment at the right time. As I've said in previous episodes, EMS systems have a lot of stroke severity scales to choose from, there's RACE, VAN, CPS, SS, PASS, LAMBS, SLAMS, FAST-ED, the list goes on. Since about 2015. I have personally learned about a dozen or so in a fair amount of detail. Most of them are fairly similar and use elements of the National Institute of Health stroke scale or NIHSS the NIHSS is the gold standard of measuring a stroke in the hospital. So it makes sense to start there and identify the key components that can be best leveraged by EMS in the field. During this season, Dr. McGraw and I have spent a lot of time discussing LVO stroke the ocmca stroke study as well as the use of the FAST-ED stroke severity scale, but in this episode, we change things up a bit. today Dr. Ethan brandler is here to discuss the S-LAMS stroke severity scale that is currently being used by the New York City Fire Department bureau of EMS. Dr. brandler is currently an associate professor of Emergency Medicine at Stony Brook University Hospital and is also the associate medical director of the university based EMS system which provides 911 critical care services. He also provides online medical control for the New York City Fire Department EMS service, and he is the medical director for various EMS agencies around his home in Long Island, New York and he even responds to calls as a paramedic in his hometown of Plainview, New York. When he's not working in the hospital teaching or going on calls, Dr. brandler spends his time conducting research on behalf of ems and stroke. His efforts have produced multiple published papers on the topic of ems and the use of stroke severity scales, specifically on the S-LAMS scale. Today, Dr. brandler will discuss a lot of very important and interesting things. But primarily he will describe why New York City Fire Department EMS Stroke protocols were updated to include stroke severity scales. In addition, he'll walk us through their stroke protocol, the use of S-LAMS, how New York City Fire Department prepared to implement the updated stroke protocols into operation and most importantly, talk about the real life benefits their stroke patients are experiencing. If you want to get hold of Dr. bandler. You can find his contact info in the episode description. Please keep emailing your questions, comments, feedback and episode ideas to the ems on air podcast team by email at [email protected] Also, check out our website emsonair.com For the latest information, podcast episodes and other details, follow us on Instagram @ems_on_air. Please whatever podcast platform you use, subscribe to the podcast and leave us a rating and review. It really helps us to grow this project. I really can't tell you guys this enough, please leave us a rating and review and help us get noticed on a much larger scale. Remember, the mission of the ems on air podcast is to keep healthcare provider safe, informed and prepared. So increasing our ratings and reviews gets us noticed by more listeners and more sponsors. And that will lead us to increasing our reach resources, experts and abilities. Bottom line ratings and reviews are vital to the growth of this podcast. And your contribution can give us what we need to serve those that serve our communities. The only cost to us a few minutes giving us a rating and a review on whatever podcast platform you use. We're available on pretty much every platform so it's nice and easy for you. Thank you and enjoy the podcast. Good morning, gentlemen. How are we doing today?

Dr. Ethan Brandler:

Great. Great to be here.

Dr. Steve McGraw:

Good morning, Jeff. Thanks for having us.

Geoff Lassers:

Thanks for joining me. Today we're here with Dr. Ethan brandler. Like we said in the introduction, Dr. Brandler we're gonna let you just go ahead and kick it off. Can you give us an introduction to who you are, what you do, where you do it and why you do it.

Dr. Ethan Brandler:

Thanks for having me, Geoff. I've been involved in ems for more than 25 years, I started as an EMT, and worked my way up to be a paramedic eventually went to medical school. And I've been doing ems throughout in various ways. Currently, I'm an associate professor of Emergency Medicine at Stony Brook University Hospital. And I do EMS There as the Associate medical director of the university based EMS service, which is a critical care and 911 first response agency. I also do online medical control for the fire department of New York, and it's New York City. And then I'm the medical director for a number of communities in and around my home in Long Island, New York for the huntington community first aid squad and for the Hicksville, Fire Department. And I respond quite regularly in my own hometown of Plainview, New York. Basically, as a paramedic, much of what I do outside the emergency department, when I'm not seeing patients is around research at the intersection of neurology, particularly stroke and emergency medicine, and trying to make sure that what EMS is doing is in concert with the things that are going on in hospitals. And with the current trends in an acute stroke care, which is a rapidly evolving field. That's what I do in lots of different realms.

Geoff Lassers:

So as an emergency physician who started out as an EMS provider, it seems a little nuanced that you found stroke and neurology to be the thing that you focused on in tying ems and the hospital together, because most of the time when I talk to people who are doing things to advanced stroke, it seems to be coming from neurology or working with somebody directly from neurology, trying to bring it to ems. And it seems like you're kind of this intermediary. So how did you identify that stroke and not MI or trauma? Or pediatric? What was the reason you chose stroke to say, Hey, I'm going to plant my flag and make a difference here?

Dr. Ethan Brandler:

Well, I guess I've always had a sort of background interest in in neurology, when I was a paramedic. And unfortunately, my grandmother suffered a pretty massive stroke. And it happened when she was in the hospital recovering from coronary bypass. And the the kind of thing that most of the physicians did at that time was just kind of shrug because there really wasn't much that they had to offer her. That kind of disturbed me. And in today's day and age, that probably wouldn't be the case, she would probably get much more aggressive acute care, and she wouldn't have suffered from the disabilities that she did before she died. So I think that making sure that other patients get to that kind of advanced care and in the last Five years that the landscape of stroke care has changed tremendously. And we want to make sure that every patient gets to the best possible care that they can get to.

Dr. Steve McGraw:

Dr. Brandler, I gotta tell you, you and I, I think have been practicing a very similar amount of time. And like you and I was a medical student, a resident ischemic strokes, really, unfortunately, neurology and the house of medicine in general didn't offer a lot because other than aspirin, there wasn't a lot of science to what we were capable of doing. And you probably remember, like I do if they had waxing and waning science, you could offer them heparin. Certainly there were there were some people that would benefit from rhythm control or things like that. But genuinely, it was just a very unsettling and frustrating experience to be able to tell a family Well, your loved ones had this stroke, and we're gonna see how things go. It wasn't that we couldn't offer anything. It's just that what we offered didn't have the impact. And so like you, I'm fascinated by it. But some of that has to do with the time we've been practicing and how things have changed so much.

Geoff Lassers:

Yeah. Dr. McGraw, I can totally agree. And there seems to be a lull that has caused a little bit of this lack of recognition in some situations, or a lack of understanding that stroke all the sudden had this huge bolus of information and treatments and, and what we need to do to expand our capabilities, you know, stroke, education, and ems hasn't changed for decades from the 90s, when they created the Cincinnati pre hospital stroke screen. And everybody got trained on that, because all of a sudden TPA was available. So we needed to create a tool to identify the potential candidates in the field and get them to the closest place. And now there's more evidence. So we had evidence in the 90s, to say, this is why we should be stepping up our game. But now why should we be stepping up our game past what we learned 20-30 years ago, all of a sudden, you're telling me to do so much more, Why?

Dr. Ethan Brandler:

For the longest time, the only treatment we had for acute stroke, once it already happened, we were not talking about stroke prevention, we're not talking about long term rehab, but the only treatment we had for acute stroke to try and hit it off at the pass and make sure that it didn't go on to cause tremendous disability was TPA. And TPA is helpful, it's helpful to a lot of people. But when you think about all strokes, maybe one in 10, one in 11, will benefit from TPA of the people who get it. So of the people who get TPA, and the vast majority of stroke patients in the United States, probably only 7 or 8% of them actually get TPA. So for the last 30 years or so from the 90s, when TPA came into use for stroke to the present time, only about 7% of all stroke patients get TPA, those 7%, only one in 10, or one in 11 actually benefit from TPA. So we're rushing to get people to a treatment that only a few of them are going to be eligible for and an even smaller fraction are going to benefit from nowadays, since 2015. We have these fancy new intra-arterial therapies where we can actually go into somebody's head through the blood vessels, just like for a coronary catheterization, go into the cerebral vessels, and we can pull out a clot, perform a mechanical thrombectomy and stop the stroke in its tracks. And of the people who qualify and get thrombectomies, we've gone from helping 1 in 11, to helping one in two to three. So we're going to have a massive impact on those people. And the ones who qualify for thrombectomy are the ones having the biggest strokes. So we're going to prevent a tremendous amount of disability, if we can get people to a hospital and a surgeon or interventionalist, who can go into that person's head, pull that clot out and really have a really fantastic chance of making them better. And it's our job to try and figure out to some extent in the field, who is likely to have such a significant stroke that would be amenable to thrombectomy. And that's really what we're going for.

Dr. Steve McGraw:

you made a great point. And to the extent that we can identify those people and get them to treatment earlier. Certainly That's better. You also i'm sure recognize that the severe disability of some of these large vessel occlusions is impactful and life altering. But can you comment a little bit also on the overall mortality of people that have these large vessel occlusions and yet don't receive that kind of advanced care? They often fail from TPA, and then we don't just talk about unfortunately, their disability which is significant, but these people die.

Dr. Ethan Brandler:

Yes. So severe stroke is a highly morbid event, it probably more than 10% of people who have large vessel occlusions will die if they're not treated. We don't really have enough information now to know how much impact on mortality we're really going to see in the greater population as we're starting to apply these treatments more and more. But we know that we are definitely reducing some degree of mortality, but many of those people who are going on to die may continue to die. But those people who would live with significant disabilities, those are the people that are helping the most.

Dr. Steve McGraw:

Yes, yeah. And you're right, the ones that have the most severe impact are the ones we help the most. And while it is true, we don't yet know the impact on total mortality, cost of care, hospitalization, length of stay, returned to work a lot of those factors when you evaluate those that sustain large vessel occlusive strokes, again, the providing them with the best care and the most timely fashion, I think are where some of the winds really are for this technology. And

Dr. Ethan Brandler:

just an illustrative story, when this type of procedure was in its infancy, actually, right before it became widely accepted. Before the 2015 publication came out. One of my colleagues had a very large stroke at home, he had an ischemic stroke, he lost his verbal ability. And this is a physician, he has all the risk factors, hypertensive diabetic, he's obese, he was a perfect setup for it, he had a stroke at home, the paramedics who attended to him recognized him as a physician from our institution, which was capable of performing thrombectomy. And they recognize that he had a terrible stroke, they actually called medical control and ask for permission to drive him pass two hospitals to our hospital, because they knew that we were offering this additional treatment, and then he had the best shot of getting some degree of relief. Today, he's still a practicing emergency physician works next to me all the time. And he went from being completely nonverbal, and not being able to move his entire right side to the next morning cracking jokes with some degree of verbal disability. And now his job ability is totally intact as his ability to practice medicine at a high level. So I can tell you firsthand, these kinds of treatments have tremendous, tremendous impact.

Dr. Steve McGraw:

It's a very compelling story. And certainly one that a lot of folks that have seen this type of technology implemented can relate to, I will also say that, I'm really grateful to you for advocating for both our EMS providers and their patients to systems. And that story, you told the medics received medical control permission to bypass two hospitals not capable of the same therapy that he received at your institution. And ultimately, as we get better and better at determining field levels of injury to the brain, I think that's where this has to go, we have to get the right patient to the right kind of care and the right time parameter whenever we can, whenever we can make that decision, which really, I think is a great source for me of why I'm so thankful for your work, evaluating the ability for field personnel to determine levels and severity of stroke. And the likelihood of a large vessel occlusion amenable to intervention is really kind of something that is been occupying us in Oakland County, Michigan, for several years as well. And and I'd love to understand a little bit more about both your studies and the things you've been able to show.

Dr. Ethan Brandler:

I was at the International Stroke Conference, when the results of these five major trials were announced,

Geoff Lassers:

can you give us an overview, I just want to give a kind of a cascade of the data that supports us expanding our abilities in the pre hospital setting for stroke. And it really drops from the capability of mechanical thrombectomy, removing large clots from large arteries in the brain. So can you kind of give our listeners a little background of what it really meant, when those five studies dropped? You know, five years ago,

Dr. Ethan Brandler:

right, I was at the big stroke meeting that's run by the American Heart Association, the American Stroke Association, it was immediately recognized by everybody at this trial that these results were going to have tremendous impact on outcomes for stroke patients. However, everybody also realized that this fantastic treatment was only going to be available to a select few patients who made it to the right place. So first, let me tell you about what what are these trials found almost, with almost identical results, which is remarkable considering they were done all over the place. One was done in Australia, one was done in the Netherlands, a couple were done across the United States in Europe. And within the same meeting the same three day period, I think it was four, the five were reported and one was reported like two weeks before. So we had all come with this preparation of the thing was the Mr. Clean trial, which was I think, from the Netherlands, they showed that if people got to thrombectomy, within a few hours of having their stroke event within the few hours of their last known well, and they got to the place where they could do it. There was a one in three chance of a person going from not being able to walk and take care of themselves to being able to operate independently go about their business, maybe they used a cane, and we came with that first trial in the forefront of our imagination. And then the next four trials came out and they all basically said the exact same thing which is remarkable which almost never happens anywhere in medicine that they all said that this has a tremendous impact and if we can get people to care early and we identify that little permanent damage has been done. done to the brain. And we go and we pull those clouds out, these people do great. And the trials differed mostly in terms of how they decided that a person was a good candidate. So some of them relied on very advanced imaging techniques. And some of them relied on history and the simple, plain noncontrast CT scan, those that relied on the noncontrast CT scan showed the exact same thing, same benefits as those that relied on the advanced imaging. What we've learned subsequently, subsequent to those trials, there have been several other trials published, which look at the benefits of using advanced imaging techniques beyond the simple noncontrast CT scan. And we can find other patients, in addition to those patients that we were treating in the five original trials, who would also benefit and they may not benefit as much because a greater amount of time has elapsed and a greater amount of brain may have died in that period of time. But there's still brain at risk that can be saved. And that's what those later trials show. Those later trials also showed that TPA could be administered a little bit later if those advanced imaging techniques were favorable, and would have some positive benefits. So we've expanded in the last few years, the numbers of patients who can get TPA, and the numbers of patients who can get thrombectomy. And much of that is driven by the advanced imaging, every primary Stroke Center has the ability to do a noncontrast ct, more and more hospitals are developing the ability to do CT angiography that is looking at the blood vessels and finding those clots finding those blood vessels that are obstructed, and a few of them have the advanced ability to do what's called a CT perfusion scan, where they're able to see how much brain has died and how much brain is getting less than optimal blood flow that could potentially be saved by doing an intervention, whether that intervention be TPA, or that intervention be a mechanical thrombectomy. So now, our goal is to get people to the places where they can either do that advanced imaging, and then ship that patient on to a comprehensive center which can do the intervention or just take the patient directly to the intervention center, keeping in mind that at every step along the way time elapses. And as time elapses, some brain cells are going to die. And Jeff saver who's the author of the fast mag trial, which is probably one of the most important trials in emfs. To date, particularly related to stroke care, it didn't show great results, using magnesium as a treatment to prevent brain damage and stroke. But what he did was it showed that we could do significant research studies and it also develop the Los Angeles motor scale through the course of that study, and the development of the Los Angeles motor scale has probably been one of the most important things to come out of that trial. And it's become an assessment that paramedics are known to be able to perform, to perform well, to perform consistently. So that we can take the information that comes from those scales, and use it towards directing the care of our patients. And in this case, ems is responsible not only for starting IVs, and checking blood glucose and doing ACLS type interventions, but Ms is responsible for determining the destination, it's the hospital destination, that is often going to determine what happens with these patients. And that's where our focus has become that decision is extremely, extremely important.

Geoff Lassers:

Agreed. And so now that gives us some data to help us understand how that evolution happened. And before the in hospital treatments of advanced imaging, mechanical thrombectomy. And knowing more about what TPA can and can't do, well, we really were limited in what we could do in hospital, which means that we were limited in what we could do in the field. So before these patients had almost no treatment capabilities, they had whatever happened happened, whatever died, died, whatever lived lived in the brain. And you went on from there. Now we're talking about getting back to work pretty quickly in the relative sense. But all of that information, all of the value, all of the benefits is predicated on time. Now people can go to the hospital themselves when they have a stroke, a loved one might identify and take them to the hospital. But we all know, patients that arrived by EMS have a greater chance of better outcomes from what I understand. Right? So that means how do we use EMS to leverage and capture more of these patients and then identify more information so that we can get them to the right place as quickly as possible or not really the right place to the right intervention as quickly as possible, so that we can minimize the problems that occurred. So really what got developed are the stroke severity scales, and those of you who've been listening to previous episodes know that in Oakland County, we're using a stroke severity scale, FAST-ED, now stroke severity scales versus stroke screening tools like Cincinnati pre-hospital stroke screen, the Los Angeles pre-hospital stroke screen, those identify the presence of potential neuro-deficits. And that's how we would identify stroke. Now, we're using stroke severity scales to more acutely and gather more detailed evidence and information to make quicker decisions about where and when and how a patient gets to a certain hospital. So in New York City, they're not using fast Ed. So Dr. Brandler, what is your opinion on stroke severity scales, which one are you using in New York City and why?

Dr. Ethan Brandler:

So stroke is a complicated disease, and it can manifest itself in lots and lots and lots of different ways. And the ways that we've been screening for stroke for the past 30 years, really largely unchanged. Let me tell you a little bit about how strokes screening tools, and now the stroke severity scales were developed, when we were trying to develop these scales, what they did was they took the existing scale that the doctors and nurses were using in the hospital, there's a like a 14 or 15 point scale called the NIH stroke scale, which I'm sure many of you are familiar with. And it's very complicated to perform. It's got lots and lots of different severity levels for the different pieces of the exam. But it's highly reproducible. That is to say that when different people do the same exam on the same patient, they get the same result. So what was done in developing those scales was they boiled those scales down to the two or three elements that were most highly predictive of stroke. And in the population of patients they had in Cincinnati, the patients who were having the most, many strokes had arm weakness, they had facial droop, and they had language abnormalities. And that's how the Cincinnati pre hospital stroke scale was developed. And the statistical methods is what's called a stepwise logistic regression. And basically, that just selects out those elements that are the most predictive of stroke. Many of the other scales that you will hear about, like the race scale, the Cincinnati pre hospital stroke severity scale, the van scale, theFAST-ED scale, which you are using are all essentially the same thing. They've done the same elements. And they figured out not only which elements are most predictive, but how much severity for some of them is necessary to give us a good idea that there's a large vessel stroke going on.

Geoff Lassers:

Yeah, I've noticed that the core of all of these scales is pretty much the same. It's just picking out the pieces of the NIH SS that work best for your system, you know, everybody's got a slightly different set of conditions.

Dr. Ethan Brandler:

it's not just their system, but their population of patients.

Geoff Lassers:

That's probably a better way to say it. Yeah, I have to do yes,

Dr. Ethan Brandler:

none of those scales were developed using paramedics. And that's why these things are a little bit different. And that's why I felt that it was important when in selecting a scale to have something that paramedics were already familiar with. And so the Los Angeles motor scale is a little bit different from all of those because it actually has one element that's not in the NIH stroke scale, the hand grip portion of the NIH stroke scale, there is no hand grip in the NIH stroke scale. It's only found in lamps, but paramedics were already doing it in their trauma assessment.

Geoff Lassers:

I do want to cover that real quick. Because I've talked to a number of neurologists who've said the only thing a grip strength is going to tell you is which hands are dominant. And I've talked to other people like yourself who say no grip strength is great. And now it's in lams. So can maybe you Dr. Brandler. And also you Dr. McGraw kind of comment on the fact that grip strength, should it be used during neurological assessments, because in FAST-ED, it certainly is not. And I was taught by our neurologist team, just we're not going to teach that. So I don't want to confuse anybody.

Dr. Steve McGraw:

You know, Geoff that you bring up point of interest to me, because it's funny, like Dr. Brandler, I do think there's a role paramedics have been doing it for years. The reason neurologists generally don't support its use is especially in the elderly, the ability to squeeze similar power on both hands may not be and is often not correlated to a severity of stroke. But like him, I think when the grip strength is absent, that's one of the things a paramedics are very capable and historically familiar with. So I can see both sides of the argument. And I'm really curious, Dr. Brandler, if you find that the folks that have done this for a long time can determine an absolute grip strength, not so much comparing the subtle differences in power right arm to left arm, but rather, the presence or absence of grip strength is confirmatory in the ability to use the S-LAMS. The answer is I'm not sure.

Dr. Ethan Brandler:

we don't absolutely know that. So I think it's time for me to talk a little bit about what we're doing or what we've done in developing the scale that we use in New York City. The S-LAMS or modified S-LAMS score, we're not using just the limb score research that we did at Stony Brook where we had the paramedics from our university based EMS service, do it exams on patients in the emergency department we had EMTs. And paramedics I should say do those exams. And we compare them with the exams that were being done by the neurologists roughly contemporaneously, and we look to see which of the elements were most helpful. And in some of our interim analyses, I'm getting to this because we found that grip strength was really the biggest predictor of large vessel occlusion different from the other elements in the scale. Just to give you an idea, or reminder, the lams score uses arm strength, the ability to keep the arms roughly at a 90 degree angle to the body, the facial grimace, and the grip strength. And those are graded on the Cincinnati pre hospital stroke scale, which was in protocol in New York State and still is in protocol in New York State. As the single stroke identification tool includes the facial grimace includes the arm strength, and includes language abnormalities, and those language abnormalities can include dysarthria, which is the inability to form the words so that they sound correctly, and aphasia which is the ability to actually understand and speak language. And to have those words make sense, the Cincinnati kind of clums those things together, it's not so, so clean as the neurologists have it in the NIH stroke scale, but that's fine. You have to keep in mind that whatever we do any other piece of exam or any piece of exam, when you can muddy the waters, because we can find things that don't make sense, we can find things that are in the lower extremities that relate to prior injuries to the spinal disc issues to all kinds of different problems, and that just muddies the waters. And it's very difficult to interpret some of those things in the field without spending a huge amount of time taking a detailed history and doing a very detailed physical exam. There was one study that was done, I think it was in North Carolina, where they edited all these other additional elements, particularly the leg, and they found that produced more garbage in terms of results than it did significantly. results that separated strokes from non strokes.

Geoff Lassers:

It sounds like you are measuring the population that you actually have in human beings and the population you have in EMS providers, all the calls, they go on what bandwidth do they have to actually download this and naturalize the skills, and then identify the highest specificity and sensitivity to capture the most patients that are going to benefit.

Dr. Ethan Brandler:

It's precisely it.

Geoff Lassers:

and you identify that S-LAMS is the best for your current geographical area, as we've identified as FAST-ED's for hours. And I think that's the big point here. Again, most of these are all the same, you got to identify the parts and the ones that are best for your system to get the most benefit. And I know previously, sir, you and I talked about your measurement and evaluation of the sensitivity and specificity of the different stroke severity scales, and part of that was in your decision making process from your group to identify that S-LAMS was going to be best for you or at least LAMS was with the adding of speech. So can you talk about remind everybody the significance of specificity and sensitivity.

Dr. Ethan Brandler:

When you're talking about doing a diagnostic test, you have to think about how the test is going to function when it's applied in the real world. those tests have characteristics and the characteristic of the test. As you maximize the sensitivity, you maximize the ability to find a stroke where it exists. What happens when you maximize sensitivity, if you have a very fine net, so that you don't allow anything that's that's a stroke to get through that net, you will also capture a lot of things that aren't strokes. So it's the specificity that helps you to make sure if you have a very high specificity, it really makes you think that this is a stroke when I find it, if the test is positive, then I think that it really is a stroke. And really, there are two other test characteristics that we think about. There's something called a likelihood ratio. And the likelihood ratio is just to re-jumbling of the same numbers, but it allows you to understand how well that particular test performs, regardless of the population that it's in. And that's really important is thinking about the likelihood ratio. So the positive likelihood ratio is probably the most important thing how often we are to find a stroke. And when we do find it, how likely is it to actually be a stroke? And that kind of summarizes that for all corners. regardless of who's applying the test, how good is the test, there's a similar ratio called the negative likelihood ratio, which says how good is the test and making certain that when you are looking for stroke, if you don't see one using the test that it truly isn't, it's a true negative. That's really important, but you have to understand that no matter what test you use, No matter what tests you use, all of these different scales based on physical exam are going to have a limited ability to really, truly separate things out. And you have to be willing when you construct a system around the scale to get some chaff with your wheat. And the system has to be willing to understand that some people are going to be transported who don't have strokes, some people are going to be transported who don't have large vessel occlusion strokes that are amenable to thrombectomy. Some people are going to be transported who have hemorrhagic strokes, who might benefit from that center, but still don't have a large vessel occlusion, they have a severe stroke, it's a bleeding stroke as opposed to an ischemic stroke. And you have to look at that as a win for the patient. And thus, a win for the system. Also,

Geoff Lassers:

it's really capturing as many strokes as you can and then as accurately as you can measure them, but in all reality, it's never a perfect thing in the hospital. So we can't expect the EMS providers to have 100% accuracy because we both know that seasoned physicians still miss these things or overcall these things,

Dr. Ethan Brandler:

well, for sure, overcall way over call, and different hospitals and different hospital networks will have different tolerances for overcall. Some places want there to be lots and lots of calls, so you don't miss any. And some don't want you to call too often because they don't want to be bothered with nonsense. And then the one thing that we didn't mention in all of these discussions are the strokes that won't show up on any of the popularly available stroke tools that are out there. And those are the strokes in the posterior circulation, we very rarely will we pick up a posterior circulation stroke in the field, unless the story is spot on perfect for it is very, very, very hard for EMS providers, because none of the elements of the NIH stroke scale, which are used in most of the various pre-hospital scales are really that good at picking up posterior circulation strokes. And those will continue to be things that we miss. And those are things that are hard for paramedics to get. But they're also things that are hard for doctors in the hospital to get and they are the most frequently Miss type of stroke all around. So I don't want paramedics knocking themselves for missing a posterior circulation stroke, when three days later somebody comes back to them and says, Hey, remember that guy you saw the other day? Because the emergency department physicians are also having difficulties with this. And many of the things that we've developed to deal with that issue.Don't work that well.

Geoff Lassers:

Right? It seems we haven't solved that riddle in the hospital yet. So you can't expect anybody in the field to get it. The only time I've even thought posterior stroke is because I spent months and months reading about it. How many EMS providers are reading about posterior stroke, while not the ones who aren't doing education like myself. So I'm like, Yeah, I might even consider it, let alone look for it. Right.

Dr. Ethan Brandler:

It's a very, very difficult area of medicine for everybody involved.

Geoff Lassers:

Right. Okay, so we talked about the tool to test those are the stroke severity scales want to know about FAST-ED, there's plenty of episodes this season. But Dr. brandler, you were working on a truck that day, we walk into a house, we see a patient, we have our initial assessment, and we need to start doing neurological exams, walk me into how you use S-LAMS, and then all the potential different things that can happen and walk me to transporting this patient.

Dr. Ethan Brandler:

So the first thing we're going to do is once we've established that we don't have to do any major ABC interventions, we're going to do a finger stick and the finger stick blood glucose is absolutely essential. And I can tell you, when we looked at the system, we still find from time to time hypoglycemia as a cause for stroke like symptoms. And I can tell you that I myself have fixed it in the field, fixed strokes, because I gave them sugar. And clearly that's not a stroke. But for all the world It looks like an obvious stroke. So please, even if clearly a person's got gross hemiplegia, and you know their gazes off to one side and they're they're really, really obviously a stroke, do the blood glucose. And I can't say that enough times. I can't say that enough times do the blood glucose. Whenever I give a lecture on this, whenever I speak to paramedics and EMTs about stroke, the most important thing that you can do is not miss something that's easy and fixable in the field, in spite of the fact that we talk about this all the time. This is something that is still missed. And it's something that is so ridiculously simple to not have happened,

Geoff Lassers:

you know, I'm going to talk to anybody you poke them in the finger, it says a number and you go Okay, and the other one is you know you're talking about considering stroke mimics ask if they have a history of seizures. Did they have a seizure? You know, there's a lot of little easy things you can cross off the list immediately so that we don't over-call these things. This quick commercial break is brought to you by American CME. American CME is an online continuing education learning platform designed for EMS Providers by EMS providers. Their mission is simple create and host high quality video based EMS CE content with the aim of improving the quality of EMS care while drastically reducing or eliminating the cost associated with EMS training. American CME courses focus on the most current topics and science related to the EMS industry and are available in a format that makes them convenient to access and complete. 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 just want to focus on the fundamentals, check out the course "Anatomy and pathophysiology of stroke" which breaks down each region of the brain. Or you can even check out the large vessel occlusion stroke course which introduces EMS to LVO stroke and provides great details and information. All three of these courses are approved for 0.5 EMS continuing education credits in the medical category, and they're approved for EMS CE's and pretty much every state if you need CAPCE accreditation. Well, American CMEs got you covered on those courses to the EMS on AIR podcast will continue to release more episodes on AmericanCME.com. This means that EMS providers can earn EMS continuing education credits by completing an entire podcast episode, a brief post course quiz and a survey. To do this visit AmericanCME.com, click on the courses link then click on free courses. Scroll through the course list and look for the courses with the EMSonAIR podcast logo. Right now there's a total of 16 episodes of the EMSonAIR podcast available on AmericanCME.com. For EMS credits, this includes the first five episodes of season two, which focus on EMS and stroke. If your EMS license is coming up, get on over to AmericanCME.com and get you some credits, think about it cruise into work kicking back and engaged in an EMS on your podcast episode and earning CE's Come on. Does it get better than that for EMS CE's? Did I mention you can access all of American CMEs content for free? Yeah, free. And now back to the show.

Dr. Ethan Brandler:

Right. So after you do the blood glucose, the way we have it structured in New York City is you do the S-LAMS assessment. And the S-LAMS assessment is doing the Los Angeles motor score, coming up with a number and then looking for speech abnormalities. Basically, we've combined the stroke screening tool, the Cincinnati which has everything completely encompassed in the lambs with the exception of speech. And we've added the speech back. So we have Cincinnati and LAMS together. And we just call it S-LAMS. First thing you're doing when you walk into a room, you know, you're saying hello to the patient and making sure that the patient is responding to you appropriately. And one, their speech sounds normal. And two that their speech, the words make sense. And they're able to repeat back to you a sentence. Anybody who's alert and oriented that you would score is being alert and oriented probably has normal speech, from the point of view of aphasia, although not 100%. But if they can answer those questions that you would be normally asking for level of consciousness and they can answer them appropriately. And you understand the words and they make sense. That person has normal speech, if the words come out, but you can still understand them. They might be mumbling, you know, you ask them what month it is, and they tell him you know, (................)it's December, okay, so you need to, then you know that their thought process around that word is intact, but they're having trouble getting it out, and why they're having trouble getting it out, well, maybe they're drunk. Maybe they're hypoglycemic, or maybe they're having a stroke.

Geoff Lassers:

Or maybe they're always like that.

Dr. Ethan Brandler:

certainly.

Geoff Lassers:

And that's the one I always tell people is like, you got to always when you're doing an assessment you're assessing compared to their normal. Yeah, so if somebody has Speeched deficits, I'm asking them or their people around them, is that normal for them? Because I work in a community with a lot of people in their golden years. Guess what, a lot of them already have speech problems.

Dr. Ethan Brandler:

That's certainly true. always comparing against baseline isn't essential, no matter what the complaint is, no matter what the problem is, how different is this from an hour ago from a day ago from a week ago, whenever it is that you last saw that person and sometimes it's helpful if you know the patient beforehand, which we don't often have in EMS. The next step after understanding language is going to be looking at the face that he asked the patient to smile to show you their teeth. Sometimes if people who have language abnormalities, it's not always possible To get them to understand the word, so you have to mimic it for them, you have to pantomime, so that they can try and mimic you. So you ask them to smile, Show them how you're smiling and push on them and encourage verbally in a very positive way, come out and show me your teeth, let me see your teeth, you have to be relatively aggressive with it. And then you do your arm strength assessment. Now, there's a subtle difference in the way that LAMS in Cincinnati does the arm strength assessment in Cincinnati, they look for what's called pronator drift, where you have the patient extend their arms straight out in front of them with the palms facing up as if they're holding a pizza. And again, that's something that you may have to mimic for them or demonstrate for them, the LAMS square has you hold your arm straight out as it is in the NIH stroke scale. Either way, it doesn't really matter that much. If you're good at assessing for pronator drift with the hands in the pizza box position, the first thing you'll see is the fingers of one hand typically spread apart and the thumb turn towards the inside. That's pronation. And if you see that you have to consider that might be a positive case, even if the arm doesn't completely come down. So you would grade that a little bit. If you're doing the arm straight out in front of you, it's a little bit less sensitive, and you'll see one arm drift down as compared to the other. And it's always a left to right comparison. And when we're looking for strokes, no matter what it is that we're doing, whether it be the looking at the face, where by asking the patient to smile, you expect them to mobilize the muscles of both sides of their face. When you're doing the facial assessment, you're asking the patient to mobilize both sides of their face simultaneously, when you're doing the arm assessment, you're trying to get them to independently move both arms, but you're always doing any sort of neurologic assessment, whether it's because of trauma, or because of stroke or any other situation, you're always always always comparing left to right.

Geoff Lassers:

My perspective, I'm looking at you doing an assessment, am I looking at your left, left or right or my left, left to right,

Dr. Ethan Brandler:

it really doesn't matter. What matters is if one side is different from the other,

Geoff Lassers:

you're not saying that there's an order of operations, you're just saying the comparison is looking for symmetry.

Dr. Ethan Brandler:

That's correct. That is 100%. Right? The order does not matter. Ideally, you assess both arms in the pre hospital world at the same time, the NIH stroke scale would have you do them independent. So there's a subtle difference. But the important thing is that you can see and your partner can see from across the room, that there's a difference. And those are assessments that that piece of the assessment should be entirely interpretable from across the room. And then the last piece is the grip strength, which is the last piece of the Los Angeles motor scores that grip strength. And you ask the patient at the same time, not one after the other, but at the same time to squeeze both your hands by always give give the patient's just two fingers to squeeze. So I can get my hand out if they forget to let go. And that's the same thing you should be doing in trauma, right? That's the same thing that you're doing in trauma and all the while you have to encourage the patient properly to perform. Even if the patient is incapable of understanding language, the tone of your voice has to be positive and encouraging and trying to get them to mimic what it is that you're doing. Even if they can't understand language. If you're doing the FAST-ED score, and you see that the patient has it deviation off to one side, sometimes you have to move your body to the place where they can see you. So you can try and get them to work with you because they may be neglectful. Particularly if you're off to the patient's left that they'll there'll be a problem.

Geoff Lassers:

So we've noticed that in eye deviation, you really have to set the stage for them to allow you to assess that because you know, you got a partner doing a blood pressure on one side, you got another one sticking EKGs on the other side, and you're in the middle of asking questions, you're assuming they can see their periphery, you're assuming they're reacting to their site to their periphery, but they might not be they might be reacting to the touch of that. So you almost have to segregate those people away and really get a good look at what they're looking at or what they can look at.

Dr. Ethan Brandler:

Right. So you have to make sure you're at the center of their attention wherever that attention may lie, assuming they're alert. If someone's truly unconscious, they're either having a basilar stroke, or they're not having a stroke at all. They're having that one of those posterior circulation strokes, and likely you're going to have bigger fish to fry.

Geoff Lassers:

In our study. Right now in Oakland County, the biggest number of stroke misses are the obtunded. I can't communicate semi conscious to unconscious patient where, again, my priorities are not identifying neuro-deficits, they're maintaining your airway. They're doing things your body might be getting to shutting down into that sense right there.

Dr. Ethan Brandler:

And if you don't do those things, those people will die for sure. Those things have to be the priority and they have to there's a reason that D comes after A. So we definitely don't expect anybody to deviate from that. There's an understanding that those cases will be missed.

Geoff Lassers:

And now each step of S-LAMS I'm assuming is scored. Right? And what's your scale there and FAST-ED it's a zero to nine and a four or greater is a high likelihood of an LVO or severe stroke. What is for S-LAMS?

Dr. Ethan Brandler:

for S-LAMS, I think the maximum total score is a six as compared to a five on the LAMS score, the threshold is the same as is used by most of the systems that use the LAMS score, which is a LAMS score of four or so we have an S-LAMS of greater than or equal to four constitutes a positive test. And that's what we use as the break point for making that destination decision, which is the reason that we're doing these scores.

Geoff Lassers:

Okay, so walk me through that I've assessed my patient, I've gathered all my information, I got a last known well, I got a date and time of symptom discovery, I've done a blood sugar. I've talked to the family I know about anticoagulants, I've grabbed the next of kin. Now, in New York City, what I need to do is I need to call medical control and identify if this patient four or higher which hospital they'd like me to take them to? Or is, is that decision up to the EMS provider? Or do they relay that to medical control and tell them where to go, because not every hospital can take care of a severe stroke in these circumstances.

Dr. Ethan Brandler:

right. So before we get to making that important destination decision, there's a couple of things that we also want to assess for. Unfortunately, we don't include the presence or absence of anticoagulants in our assessment, but one of the things that we do is exclude a number of patients, and the one that we exclude patients where there is a an immediate history of seizure, because that's part of the chaff that we're trying to get rid of. And in a prior internal study, we found that anybody who had the word seizure mentioned anywhere on their ems note didn't have a stroke. Now, that is not true, in reality, but it is, for our purposes, it works. So we want to make sure that that seizure is not in the picture.

Geoff Lassers:

again, to you talking about selecting for your population, right?

Dr. Ethan Brandler:

we have a very high predominance of seizures. And we do see definitely see Todd's paralysis, which is what looks like a stroke after a seizure. But that was our data internally. So we wanted to use that. And that's only a subtle modification. If you go back to the original Los Angeles pre hospital stroke scale, they included the exclusion elements that we include also in the New York City S-LAMS score. So we exclude people who are bed bound or wheelchair bound, we exclude people who are younger than 45 years old, because clearly those people never have strokes, right? No, that's not true. But for the vast majority of the time, we have to most of those patients who may have neurologic deficits are not having a stroke, and we can't transport absolutely everybody with a little bit of dysarthria and think that they're having a stroke, most of those are going to be due to some other cause in the younger population, the older population, and old is 45, it's much more likely that it's caused by a stroke.

Dr. Steve McGraw:

Do you guys stratify also with last known? Well, yeah, one of the things that I'm really kind of inspired by in your system is how you take into account there are some people that can still be salvaged, but just they don't have a window where TPA would even be a viable option.

Dr. Ethan Brandler:

Right. So we do try to exclude those people, we're looking for a window of six hours. So the way the protocols written is within five hours, so that we can get patients to care within six, which is the New York State standard for when to call a stroke code in the emergency department. So our feeling is, is that those are the people that we should be using this bypass protocol for, interestingly enough, as we discover that the window for acute stroke care expands itself, or is expanded based on imaging, we might have to change that. But we've elected to understand that we potentially can help people, we can transfer those people. The other things that we've discovered is that those people who've lasted six hours and have been are salvageable may be able to last seven hours. So they might be amenable to secondary transport anyway, so we can potentially not transport them directly to the Comprehensive Center and screen them in the primary centers. Those people who potentially will benefit after six hours can probably wait a little bit longer anyway, but the ones within six hours we want to get because we don't want them to miss out on TPA regardless. So getting back to Geoff's question about how does the decision get made. So the way our protocol is structured right now is based on the fact that paramedics can only transport to specialty centers that are recognized by New York State. It's an interpretation of the local law that regulates EMS. So the way the scale was set up, that medical control piece will disappear once the vast majority of the thrombectomy capable centers are designated as such by New York State. And that's a process that's in evolution, and we're trying to get that happening in as many of those facilities as possible. But until that designation is official, we are relying on the assurances of the leadership at those various hospitals that they're willing and able and are providing thrombectomy services. On a 24/7 basis, and that they'll inform medical control when those services are not available so that we don't send people there. So right now the process is you do a LAMS score, you find that the patient doesn't have any of the exclusion characteristics, you pick up the phone, you call medical control, the medical control operator does a brief screening exam, gathering some basic information about the call, so that we can include that in our quality assurance process more than anything else. And then the paramedic in the field and the paramedic who's screening the call at medical control. That's the way we're structured. Together, we'll make sure that they both believe that the closest primary Stroke Center and the closest thrombectomy capable center or as determined by the computer, the computer has that list built in and has all the characteristics of each hospital built in. Once they agree that everybody's on the same page strictly from a time perspective, than the present that information to the physician who says Yes, go to the Comprehensive Center, if you meet the threshold, you go to the Comprehensive Center, or thrombectomy capable center is the way the language is in our protocol. The role of the physician in this particular case is not to come up with any sort of grand notion that only a physician can come up with. But it's to allow to facilitate from a regional legal regulatory way that bypass of one hospital in favor of another because we officially know something different about those hospitals, then the state does. And we're making a decision that's in the best interest of the patient, or so we think we're starting to discover, as I review papers from other places and other situations where I see lots of other places are setting up similar systems where there's a bypass protocol, and we're starting to see improved outcomes really improve patient outcomes from patients who are going to be thrombectomy capable places. And we're seeing an increase in the number in the fraction of patients who are able to walk out of the hospital after having what is initially perceived of as being a major disabling stroke.

Dr. Steve McGraw:

Dr. Brandler, You and I can recall back in our careers when we had TPA for ST elevation MI's. And in 2003, there was a landmark study in England Journal of Medicine that indicated patients with field determined ST elevation MI on their EKG, had a better outcome by going to the hospital that provide cardiac intervention 24/7 as opposed to a hospital that no matter what the gussto trial said receive TPA and we're sort of quote cool down, unquote. And in fact, it really changed the way field management of chest pain indicated both the patient's vital signs and rhythm and ultimately their field 12 lead EKG as either transported transferred electronically to the hospital or determined by a paramedic, both of which have some potential for error, but are actually quite sensitive for the most likely to be intervened on ST elevation MI's. And truly I think we're sort of at that point now where in stroke management, we're starting to see, well, not an EKG for the brain, pre hospital stroke skills becoming nuanced and specific enough that they can tease out as you correctly say, you know the the wheat from the chaff and then able to apply determinative logic to who would best benefit from going past one hospital, it is unable to do thrombectomy and interventions to one that can it reminds me a lot of how we first managed ST elevation MI's before everyone had widespread access to 24/7 cardiac intervention, we're starting to see enough people develop the skill and talent necessary to do cerebral interventions. And now we're being asked to once again to differentiate those patients that would and maybe wouldn't benefit from those abilities.

Dr. Ethan Brandler:

That's a very appropriate assessment of the problem. But I think that that stroke is very different. In many respects. As you pointed out, for the vast majority of ischemic chest pain patients, the 12 lead really, really is an objective determining factor in in making that decision. And the stroke scale is nowhere near as sensitive or specific as that 12 lead EKG, and never will be. But the outcome difference between those people who get TPA for MI as compared to intravascular intervention. And comparing those people who get TPA only for stroke versus intravascular intervention, that difference is tremendous. And stroke patients are far more likely to benefit from intravascular intervention when they have their large vessel occlusion as compared to just getting TPA, as compared to the MI patients for whom the benefits of a cardiac cath as compared to TPA are far more subtle. So there's far more at stake and the tests are not nearly as good. So I think it's an even bigger problem than we had with MI. because much of the time the MI diagnosis is unequivocal, but the stroke diagnosis can still be equivocal. If physical exam change changes over time. So the exam that the paramedic sees in the field when they examine the patient initially may be different from the exam in the back of the ambulance, and may be different from the exam on arrival at the hospital. And the 12-Lead EKG, once it's printed on paper is unequivocal even though it can change.

Geoff Lassers:

Yeah, I think one thing that I do like about the analogy to a 12-lead is a objective lead based on my assessment found the set of circumstances, I've eliminated these other ones. And when I see this, I do that. And that is a very comforting thing in ems, when I'm expected to know a lot about a lot, or at least the surface about a lot. What I do like about it, thinking about it as a 12-lead is I think about it as a treatment that gives me information and I make a decision on that immediately. Although the information it does glean is not written down as mathematically as an EKG is compared to but I do appreciate the analogy there, Dr. McGraw, and it is a really hard thing to do. And I think it's amazing to say there's more at stake with less tools to assess for it to a point. You know, that's that's huge. And the other side of that is even though let's say an EKG monitor cost you 20-40 grand, I have no idea what these things cost, that's pretty cheap, compared to putting something definitive, like a CT scanner in the back of an ambulance. And you might say, well, let's do that. Well, the cost prohibitive is the juice worth the squeeze. And what we're really getting down to and instituting stroke in ems. is understanding the balance between what do you need in your area for your patients and your resources? And then what do you have available to you and your EMS providers, right? So you made a number of decisions, you guys instituted S-LAMS, and you seem to have a system that's actually benefiting people, you've said people are walking out of situations out of the hospital, they would have never walked out under their own power. That's awesome. Now, here's my question. Where's the magic? The Magic isn't making the decision selecting a tool and putting it into protocol words. How did you Institute this with 1000s of EMS providers? Dozens of hospitals? How do you go from Okay, this is the plan towards we're actually doing it because that's going to be the big one for a lot of places.

Dr. Ethan Brandler:

Well, you know, that discussion is going to be very different in different EMS systems. When we talk about EMS systems, everybody always likes to try this out. But it's really true. You've seen one EMS system, you've seen one EMS system and everybody does different parts of it a little bit differently. In New York City, we have a regional council that controls the protocols for all the providers in the region. everybody is on the same protocol. Everybody's doing the same thing in the back of the ambulance. everybody is on the same page in that regard.

Geoff Lassers:

Well, my question is more specific to you have your EMS providers in the field doing one thing? And all of a sudden, hey, next Tuesday, you're doing S-LAMS on the road? How did that get installed?

Dr. Ethan Brandler:

Right. So it was a major league partnership, the first thing that we we developed the scale, and we were developing the scale at the same time, we were starting to have discussions around bypass. And the most important thing that we did in this process was we got all the stakeholders together with the help of the American Heart Association, the American Stroke Association, the New York chapter, what we did is we got everybody in the same room. And we showed them the data. And we showed them how doing this was going to benefit patients. And we told them that we were going to do bypass when we got enough hospitals to be capable and distributed in an equitable way. That is to say that all patients within the city of New York would have a similar access to that advanced care if we put such a program in place. So the transport times couldn't be too great for one segment of the population as compared to the other. And that was an exceedingly important process, making sure that we had an equitable distribution of care. And we said we were going to do it essentially come hell or high water because there was a decision made on the by the medical leadership of the fire department, there was a decision made at the regional council level that everybody was pretty much on board with the idea because they saw that there was tremendous benefit to the treatment that we were trying to get people to. And we wanted to make sure that our patients got to those treatments.

Geoff Lassers:

So how did you get the training and implementation to them, though, like you convinced everybody with data, but how did you actually get Bob the paramedic physically.

Dr. Ethan Brandler:

So once we decided that we were going to do this, and we built the protocol, we had to do training. So there was a series of videos created by the fire department and distributed by the Regional Council. The Training and Education Committee, which is run by a paramedic at the regional council put together that training package and made sure that it was distributed and that people could get credentialed by doing the online course, which included a video demonstration of the system originally, remember that we were using things that paramedics and EMTs were familiar with in the process. So mostly they had to learn how the lamb score was different from the Cincinnati score. And they had to learn the elements of the flow sheet which made sure that They did that very important finger stick, that they looked for things like the exclusion criteria, and then they greeted the exam. But remember that there were more than 5000 EMTs, and paramedics who had to be trained on this. And so that's how it was rolled out to the entire system. In the fire department itself, each of the EMTs, and paramedics was brought in for an in person training as well. New York City Fire Department does about 60% of the EMS. In New York City, the other 40% are provided by private ambulances, volunteer ambulances, and by hospital based ambulances, all the people on those other non Fire Department type resources. They were trained using those videos and using whatever in person training those separate agencies put together, we plan to implement the protocol in April, we implemented the protocol in April of 2019. Training began in October of 2018. So there was a six month training period before we actually rolled it out. So we had to make sure that we had sufficient amount of time to really get everybody on board and make sure that all the questions that needed to get asked were asked before it was eventually implemented. And at that same time, we're also developing the system and getting more hospitals to provide the services so that the decisions were much easier. To give you an idea. There are 48, I believe, acute care hospitals in New York City. And now I think there are 44 of those 48 are primary stroke centers. And I think there are now at least 20 thrombectomy capable centers, not necessarily comprehensive stroke centers, but thrombectomy capable.

Geoff Lassers:

What's interesting is the biggest thing I've seen in geographic areas that have tried to install or upped the game of their ems providers with stroke severity scales is you start to see all the hospitals increase their certification skills, personnel capable of doing these things. So there's some byproducts that cascade that really benefit the whole community in an expansive way that we didn't plan on, we thought we were just installing, you know, stroke severity scales and making it better. Well, we recognized a bunch of hospitals in our area, like yours are stepping up their game. And so when you're installing this, to those 1000s of people, six months seems like a fair amount of time to really work it through the process with how many EMS provider?s remind me.

Dr. Ethan Brandler:

over 5000. OVER 5000!

Geoff Lassers:

and how many square miles you guys cover?

Dr. Ethan Brandler:

It's New York City, it's only about 40 or 50 square miles.

Geoff Lassers:

But with 5000 employees, 50, hospitals ish, you got quite a bit, obviously New York City, everybody knows is one of the most densely populated places on the planet. So that's a lot of people to get the information into affecting a whole lot of people in your vertical time that can have an impact. There's a lot there. And I'm glad to hear that even though we're using different scales, it sounds like we're using them for the exact same reasons. We're applying them to the best interest of our communities and what works for them. And we're learning what needs to happen in communication to get the people the right treatments on time.

Dr. Ethan Brandler:

The last thing I want to talk about actually is something that we should have talked about really at the beginning of his notification, there were studies that go back to 2003 or 2004, I think that we're done that show that the fact that a paramedic picks up a stroke in the field, and pre-notifies the hospital improves the fluidity and gets patients to treatment faster, and they're more likely to get treatment. If the paramedic is astute and picks up that stroke in the field and notifies the hospital, they're much more likely to get to TPA, they're much more likely to get to the cat scanner early. And in our current situation, we're trying to decide which hospital they get to, sometimes they're going to be able to go to the primary Stroke Center, sometimes they're not going to be able to go to the thrombectomy capable center. But if they start wailing the machinery of the hospital before the patient arrives in the hospital, regardless of which hospital they arrive at, they're much more likely to get to the treatment that they need sooner. When people think about large vessel occlusion early, they get their game on, and they're able to move the patient through the system, whether that means bringing that patient to the cat scanner and giving TPA in the CAT scan room, and then bringing that patient to intervention sooner in that same hospital or whether that means getting that patient to the cat scanner, maybe giving them TPA, maybe not giving them TPA, but getting them back in an ambulance and going off to the place where they can do that endovascular intervention sooner is extremely important and pre notification calling the hospital the paramedic in the back of the ambulance, calling the hospital and mobilizing those resources as early as humanly possible is exceedingly important. And the more information that's in that notification, the last known well time the physical findings, whatever scale you're using, those pieces of information, when they're complete, really are helpful in getting the hospital to mobilize the resources so that they potentially can get somebody moving sooner. I can't say enough about that particular piece because aside from the fingerstick that's probably the most important thing that we do. We've Recognize the stroke. Now we have to communicate that piece of information to whoever is going to receive the patient so that they can get their act together to receive that patient and rapidly process them through whatever process is going to happen for them.

Geoff Lassers:

I agree. Dr. McGraw. In closing, do you want to comment on that?

Dr. Steve McGraw:

You know, I think it harkens back to when we evaluated some of the data of field produced 12-lead EKGs in STEMI, time to the cath lab. Ironically, it was almost better for a patient in my waiting room with chest pain to call 911. I used to joke and have their 12 lead performed by a paramedic than it would be to get through the triage system and get their 12 Lead done up front. Now, that's obviously different because there's transport time and they're the only patient that the paramedic is dealing with. So there's a lot of sort of idiosyncratic variables there. But I think that that Dr. Brandler's point of view is field suspicion leads to better outcomes. I work at a comprehensive stroke center. And when the paramedics call and tell us that the patient has the following findings that make them suspicious for a patient to have had a stroke, and they arrive to our department and go directly to the CT scanner fully dressed with their IV established by the paramedics onto the scanner for their initial plane CT. We don't even take them off the table till it's been viewed by the radiologist. And they're administered the contrast material in order to have a profusion and a CT angiogram done, still, again, fully dressed, the paramedics are allowed to get back into the service of their community. And we have an ER team that actually retrieves them from the scanner that brings them back. But it is phenomenal to me just anecdotally, but also in data that we've harvested from our own system that when paramedics tell us what they've determined pre arrival, the time to the first slice of a CT angiogram and the first slice of their plane CT is virtually half that if they roll up to our triage desk and say, I'm having trouble moving my arm and I can have the same ability to speak like I used to this, the process of the front end of the hospital really gets up there. But it gets in there a lot faster. If we're notified prior to time zero, if you will, we're ready for them and the scanners cleared before they even arrive to our back door. That's rather what you guys are doing is genuinely inspiring. And I really tipped my hat to you. We are in a sort of similar way, are trying to determine the best way for our medics to identify these patients notify us before they arrive and doing everything we can to expedite their care. And I do have the similar experience to you. I have primary stroke centers that have comprehensive stroke centers in our county, we have hospitals somewhat smaller that in many cases haven't done either of those. Do you feel that having engaged in a system where you do stratify these patients prior to arrival and even considered bypassing a non thrombectomy capable hospital that would be closer but still not able to do the things necessary to treat a large vessel occlusion patient? Do you think that has gone a long way towards getting hospitals to invest in the resources necessary to become themselves thrombectomy capable?

Dr. Ethan Brandler:

Definitely, I think that what we did in terms of trying to develop the system in New York City where we got the stakeholders together and said, Hey, listen, we're doing this you want to play, you want to be a thrombectomy capable center? Well, now's the time to do it, because we're not going to bring you patients who are eligible for it. Unless you are. New York City has basically as I said, 48 acute care hospitals, but the majority of those hospitals are part of one large system or another. So the hospitals have an interest in centralizing their resources in their mothership hospitals. And that was a big problem for us in developing this system, until the hospitals understood that the patient was going to go to some other networks hospital if the closest hospital wasn't theirs. And so they readily started to play ball and ramp up the capabilities of those non flagship hospitals and get them to a point where they were capable of providing services that our patients needed. So yes, the answer, in short is yes, the process of implementation improved services at lots of different places, because hospital systems recognized that they were going to lose out on patients if they didn't provide those services, in perhaps some of the more for lack of a better word remote hospitals. Now, that's not necessarily going to work in places like critical access hospitals with 25 beds, that's going to only be possible in more moderate to larger communities, which can support having such a capable interventionalist available and having the equipment and so on those places that are more remote, that are more rural, where the separation between the patients and the receiving hospitals is much larger, those types of systems are going to have a much, much more difficult time in developing a system that is helpful to the stroke patients. It's very, very hard in rural areas to put bypass protocols in place because you have very limited resources spread out over very large areas. And some of these patients just they're not going to get thrombectomy in a timely fashion. And that's an unfortunate consequences of the realities of the situation and out of figure out how to maybe employ some more advanced transportation like helicopters and so on to some of those patients is essential. in Suffolk County, New York, which is the place where I practice medicine primarily, you know, we've had a couple of real saves when providers in some of the more remote areas have recognized that this is not the patient who should go to the local hospital to maybe get TPA. This is somebody who should get flown to the big house, in spite of the fact that they're not acutely traumatized, or have no major vital sign abnormalities etc.

Geoff Lassers:

Yeah, you're going into the the rural setting, we're actually going to do episodes on the rural setting for stroke. You know, you talk about the constituency of people, you talk about the resource available. You talk about the space between people, there's New York City, and then there's, you know, like farmland, like we have up north Michigan and like upstate New York. So Dr. bandler, I wanted to say thank you very much for being with us. Today, we're going to have you back, I'd love to do a presentation with you to present all the various data, you've been published a number of places, I think there's a lot of value to bring to the table. Obviously, you're an EMS provide first, only because you've ha the license longer, and the your physician and like normal We're going to use you as muc as we can to get that knowledg to EMS providers. We appreciat it very much. Dr. McGraw you go anything before we go

Dr. Steve McGraw:

I'm just so grateful to Dr. brandler. H brings us a very specia perspective, he helps e to understand exactly what e're going to have to do to tak the next big step in Oakland Co nty. I'm excited to d

Dr. Ethan Brandler:

My pleasure. And you can reach out if you have questions or you need help with something. I'm happy to help you.

Geoff Lassers:

Thank you very much. That is all for the show today, everyone. Thank you for listening. Thank you to Steve and Dr. Ethan brandler for oming on the show and spreading our knowledge. If you want to et a hold of Dr. brandler. You an find his contact information n the episode description. lease keep emailing your uestions comments feedback and episode ideas to the EMS on AIR odcast team by email emsonair gmail.com. Also, check out our updated website emsonair.co . For the latest inform tion, podcast episodes and ot er details. Follow us on Instag am @ems_on_air and please w atever podcast platform you use, subscribe to the podcast nd leave us a rating and a re iew. It really helps us grow the podcast. Thank you for listenin to the EMS on AIR podcast Stay safe and have a great d y.