Over the past decade, numerous advances have been made in the treatment of stroke patients. During that time, stroke center designations have evolved. Designating bodies across the US generally recognize four stroke center levels. These four levels have been created in collaboration with the American Heart Association and American Stroke Association. Starting with the highest level of care, they include:
In this episode, we sit down with two stroke experts from Ascension Providence Rochester Hospital. Dr. John Whapham, MD, MS, FAAN, FSNIS, the Medical Director of Neuro Interventional Surgery, and Amanda Kalinsky, MS, AGACNP-BC, RN, CCRN, Nurse Practitioner and the Stroke and Neuroscience Program Manager. They are here to discuss what it takes for a hospital to advance its stroke center capabilities and designation. Specifically, their hospital is going through the process advancing from a Primary designation to a Thrombectomy Capable Stroke Center designation.
Both guests have experience with advancing a hospitals stroke center designation. They are currently completing the process of advancing from a Primary designation to a Thrombectomy Capable Stroke Center designation. They’ll help us appreciate what it takes for a hospital to advance their stroke center certification. In addition, they’ll give us their opinion on the use of stroke severity scales by EMS to identify and measure potential strokes. Finally, we list and describe key things that every EMS crew should consider each time they encounter a potential stroke patient.
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.
Over the past decade, numerous advances have been made in the treatment of stroke patients. During that time, stroke center designations have evolved. Designating bodies across the US generally recognize four stroke center levels. These four levels have been created in collaboration with the American Heart Association and American Stroke Association. Starting with the highest level of care, they include:
In this episode, we sit down with two stroke experts from Ascension Providence Rochester Hospital. Dr. John Whapham, MD, MS, FAAN, FSNIS, the Medical Director of Neuro Interventional Surgery, and Amanda Kalinsky, MS, AGACNP-BC, RN, CCRN, Nurse Practitioner and the Stroke and Neuroscience Program Manager. They are here to discuss what it takes for a hospital to advance its stroke center capabilities and designation. Specifically, their hospital is going through the process advancing from a Primary designation to a Thrombectomy Capable Stroke Center designation.
Both guests have experience with advancing a hospitals stroke center designation. They are currently completing the process of advancing from a Primary designation to a Thrombectomy Capable Stroke Center designation. They’ll help us appreciate what it takes for a hospital to advance their stroke center certification. In addition, they’ll give us their opinion on the use of stroke severity scales by EMS to identify and measure potential strokes. Finally, we list and describe key things that every EMS crew should consider each time they encounter a potential stroke patient.
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.
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 January 18 2021. I'm Geoff Lassers and I'll be your host. This episode was recorded on January 4 2021. In this episode, we sit down with Dr. John Whapam, the medical director of Neuro-interventional surgery at Ascension Providence Rochester hospital. We're also joined by Amanda kalinsky nurse practitioner and the stroke and neuroscience Program Manager at Ascension Providence Rochester hospital. They are here to discuss what it takes for a hospital to advance its stroke center capabilities in designation. Specifically, their hospital is going through the process of advancing from a primary stroke center to a thrombectomy capable stroke center designation. Over the past decade, numerous advances have been made in the treatment of stroke patients. During that time stroke center designations have evolved designating bodies across the US generally recognized four stroke center levels. These four levels have been created in collaboration with the American Heart Association and American Stroke Association, starting with the highest level of care. They include comprehensive stroke centers, thrombectomy capable stroke centers, primary stroke centers, and acute stroke ready hospitals. Each certification fills a critical role within its specific region, and each is intended to assure that stroke patients throughout the United States receive the time sensitive care they require. Before we get into our interview with our guests, I thought it would be a good idea to set the stage of how we got here and give you a very brief flyover history of stroke center designations and the treatments they offer. Stroke has been described in medical literature for 1000s of years, literally 1000s of years from the time of Hippocrates until the mid 1990s. Effective stroke treatment options simply did not exist. In fact, stroke was largely considered untreatable until FDA approval of IV ultaplace, more commonly referred to as TPA as a stroke medicine in June of 1996. Following IV alteplase or TPA approval, hospitals began to respond to stroke with greater urgency progressive hospitals began to look at how they could eliminate delays in assessment and diagnostic procedures by streamlining their response to stroke patients, thus increasing their ability to identify candidates for IV TPA treatment within its narrow treatment window. Even though many individual hospitals across the US independently worked on improving their internal stroke protocols, there was a clear need for consensus standard best practices in stroke care. 2003 began the first voluntary certification process for hospitals built around acute ischemic stroke treatment with IV TPA. Shortly thereafter, the primary stroke center certification launched in 2004, stroke systems of care began to develop with a certification of primary stroke centers, which further emphasized the need for field recognition of stroke. Many states and counties throughout the United States began to pass legislation that required EMS to bypass non primary stroke center certified hospitals to allow for diagnosis and treatment at primary stroke centers. In September of 2012, that comprehensive stroke center certification was launched, which is the most advanced level, it is intended to treat the most complex stroke and cerebrovascular disease cases. This includes the initial and ongoing care of LVO as well as severe hemorrhagic stroke patients. In 2015, a third stroke certification program was launched for acute stroke ready hospitals. This certification was developed in response to literature that suggested that many patients having an acute stroke do not have already access to a primary or a comprehensive Stroke Center. data indicates that at least 50% of the United States population lives more than one hour from a primary stroke center to increase timely access to IV TPA treatment. for acute stroke patients living in these areas, the acute stroke ready hospital certification program was created. This certification program is intended for accredited hospitals that would not be likely candidates for primary stroke center certification, for example, hospitals in rural areas without the resources to achieve a primary stroke center or higher certification. During that same time period and even a few years earlier, the stroke chain of survival grew even stronger for LVO stroke patients thanks to the advent of interventional devices used to perform mechanical thrombectomy which is the physical removal of a clot several recent studies have shown Mechanical thrombectomy is the standard of care for select large vessel occlusion or LVO stroke patients. The process of mechanical thrombectomy with a stent retriever involves inserting an into the femoral artery of a patient and extending the catheter up into the vasculature of the patient's brain, the neuro-interventionalist; The person that performs the 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 distal blood flow to the affected region of the brain by first dilating the vessel, and then simply holding the clot out and 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. As a result, early recognition of LVO stroke by EMS has become a priority for EMS and hospital systems around the world in response to EMS systems have been preparing to adopt the stroke severity scale that best serves their unique set of conditions. Stroke severity 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. This brings us to the final and most recent stroke center certification program that went live on January 1st, 2018. The thrombectomy capable stroke center certification began in response to the need to identify primary stroke centers that meets rigorous standards for performing mechanical thrombectomy and caring for patients after the procedure. This certification program is intended to support timely access to this procedure for qualifying LVO stroke patients. Fun fact the very first certified thrombectomy capable Stroke Center in the entire United States is located right here in Oakland County, Michigan. Shout out to all my Ed and neuro friends at St. Joseph mercy Oakland Hospital in Pontiac, Michigan. To summarize the advent of mechanical thrombectomy for LVO stroke patients, as well as the ongoing use of advanced imaging at stroke centers continues to evolve and make a huge impact on stroke patient outcomes. As a result, many hospitals are working very hard and making huge investments to increase the capabilities and certification of their hospital so that they provide the highest level of care for their surrounding communities. Both of today's guests have experience with advancing a hospital stroke center designation. Dr. John Whapam is the medical director of neuro-interventional surgery at Ascension Providence Rochester hospital. And Amanda Kalinsky is a nurse practitioner and the stroke and neurology Program Manager at Ascension Providence Rochester hospital. They are currently going through the process of advancing from a primary designation to a thrombectomy capable stroke center designation. They'll help us appreciate what it takes for hospitals to advance their stroke center certification. In addition, they'll give us their opinion on the use of stroke severity scales by EMS to identify and measure potential strokes. Finally, we list and describe key things that every EMS crew should consider each time they encounter a potential stroke patient. Please keep email your questions, comments, feedback and episode ideas to the EMS on AIR podcast team by email at QI@ocmca.org. Also, check out our website emsonair.com. For the latest information, podcast episodes and other details follow us on Instagram @ems_on_air. And please whatever podcast platform you use, subscribe to our podcast and leave us a rating and a review. It really helps us to grow this project. I really can't express this enough or ask you enough times please leave us a rating and a review it really helps us to get noticed a much larger scale. Remember the mission of the EMS on AIR podcast is to keep healthcare provider safe, informed and prepared. increasing our ratings and reviews gets us noticed by more listeners and more potential sponsors and that will lead to increasing our reach resources experts and abilities. Bottom line ratings and reviews are currently currency in our world and they're vital to our growth and your contribution will give us what we need to serve those that serve our communities. They only cost us a few minutes giving us a rating and a review on what Every podcast platform you're using right now. Thank you and enjoy the podcast. Dr. Whapam, let's start with you. Can you tell our audience who you are, what you do and where you do it?
Dr. John Whapam:I'm Dr. John Whapam, I'm a regional trained stroke neurologist neuro intensivist and neuro interventional surgeon. I grew up in the Rochester area here spent the last two decades doing predominantly neurocritical care and stroke and neurointerventional surgery. And currently the medical director of the endovascular section here at Ascension Hospital Rochester, helping Amanda with the outlay of primary to thrombectomy capable Stroke Center here in the Rochester branch of Ascension, I made some decisions about largely why to get into medicine a very long time ago, and particularly neuroscience driven by some family experience and personal experience with tragedy and neurocritical care and suberacnoid and hemorrhage in AVM's. And it's been challenging, it's been interesting to watch the field of stroke kind of evolved from not being able to do much and more of an academic field that really now come full spectrum into a procedural field as well. And the discipline of stroke and neuro-critical care as medical entities kind of evolve as well, along with the surgical discipline. And as I'm at the tail end of my career, I've really been excited about the opportunity to be back in the Rochester area where it's kind of began in the late 70s, early 80s, right at this actual very hospital. So it's been kind of a neat full circle thing for me to try to help evolve the ability to do some of these stroke related procedures here now at this point in time.
Geoff Lassers:That's really cool. That's really cool. My first job in the fire service was actually with the Rochester hills Fire Department. So the first hospital I was transporting to was Crittenton to. So we have a little bit of a bond there, sir. And I think that's really special that you've come full circle all the way back home. That's totally totally cool. Amanda Kalinsky. And who are you? What do you do? Where do you do it?
Amanda Kalinsky:I'm Amanda Kalinsky. I'm a nurse practitioner. I am the stroke and neuroscience Program Manager here at Ascension Providence, Rochester. I am a critical care nurse practitioner and critical care nurse by background, I also have experience with a comprehensive stroke center within our Ascension system experience taking a primary stroke center to a comprehensive level of designation. And I also have a similar background of tragedy within my family. And in the last few years, I recently lost my mother-in-law through a stroke and the quella of After Effects. And so I have lived this first line from a provider and basically the nightmare of seeing this happened to your loved one in the ICU. And unfortunately, she did not have a positive outcome. So this is very near and dear to my heart.
Geoff Lassers:Yeah, unfortunately, stroke is still the fifth leading cause of death in the United States. It takes away too many people. And that is the bad news. But the good news is in the last 5-10 years, there's been a massive amount of science and techniques that have been produced to help give those people a better chance for survival. And a lot of these things come from thrombectomy capable comprehensive stroke centers and even some primary centers that offer comprehensive services. And oh Amanda, you have a history of advancing like you said primary stroke center to a next level of care to a comprehensive doc you have similar experiences as well. And that's really what we're here to talk about today is what that really takes in a previous episode, I spent time talking to New York City Fire Departments Dr. Ethan Brandler who's been very integral in updating their stroke protocols, the use of S-LAMS stroke severity scale, and one of the biggest offshoots, the byproduct of introducing stroke severity scales into EMS systems seems to be hospitals upping their stroke game, getting their available treatment options in the hospital increased at all of the various the hospitals that we have available. So you guys are actually going through that in Oakland County right now. Can you guys tell us what it takes for hospital to advance their stroke certifications.
Amanda Kalinsky:Really it takes a large dedication to our community as far as resources, staffing and really wanting to take the best care of our patients, we already have that groundwork with providing excellent care as a primary Stroke Center. But we really got a need within our community to move forward with thrombectomy capabilities here at our hospital. So with the start of a neuro-endovascular program, really looking to open our services with the use of our advanced equipment that we already have, and utilizing some of our services that we already have in place. We have a pretty robust drill program with nurse practitioners already staffing the service, which is amazing. I had a primary Stroke Center. also bring in Dr. Whampam to partner with us here to grow and start offering those services. And I'll let him talk about more about the full service neuroendovascular program. But going from a primary Stroke Center. You know a primary Stroke Center is amazing at treating our stroke patients administering TPA, but really, we're at that barrier of when you can't provide a thrombectomy service to on site. When that patient has a large vessel occlusion, your only option is to transfer out so we really want to bring that service to the community here to avoid the delays of transferring out. We know that time is brain and getting the patients who are Our lab, our neuro IR lab timely instead of transferring them out is really our goal here to be able to get them to a better and meaningful functional recovery. And especially with the data that we've been seeing in the past several years from American Heart Association, how thrombectomy especially in the extended stroke window is best practice.
Geoff Lassers:mechanical thrombectomy is becoming the standard of care for select LVO stroke patients. Dr. Whapam, can you give us a little bit more background on that and how the stroke centers as they increase their capabilities, really what that's offering for the people around those communities?
Dr. John Whapam:Yep. So a lot of working part is that the key thing I would say it's around having gone from primary to comprehensive structures as well like Amanda, the changeover while simply mechanical, in some ways, adding another piece of the stroke puzzle to the mix, there's a lot more to it than that a lot more working parts than you think and part of the devolves kind of a medical discipline that's sort of one dimensional to multiple disciplines, all converging on a patient in unison in a very time dependent fashion. And that's I think, what's so complex about the transition over from a primary medical side with TPA and basic medical care of strokes to a comprehensive style or thrombectomy capable designation, where places can not only see that, and also the surgical patients as well. And then Amanda would probably add take care of them long term as well in the ICU setting afterwards, which I tell people all the time the ICU care after even these large vessel from back to me cases is 50% of the outcome. In other words, you could do everything right in the cath lab, but the eventual outcome and somebody's home with limitations and disability that are better than when they came in. And are often those are battles fought in the ICU after a stroke case as well. And so they all become important, I think, to answer the one question is that where have we come as far as abilities with devices over two decades to do the extended windows and the people with more proximal occlusions And the answer to that is a very, very long way, haven't kind of been involved in it. Since this has been going on when the first stroke devices really came out in 2003, or four with the mercy retriever and things like that. It's gone from being two hour cases that were horribly fraught with all sorts of complicating issues and limited recanalization of vessels due to devices that at the time were not the best and not handmade and finely crafted for this individual use in medical and surgical character devices now, where we're getting three recanalization rates of 90% plus and 10 minute 15 minute cases, and more often than not what you see in the literature, when you look at pre hospital screening, the throughput in the ER into the cath lab, the biggest determinant now in all the literature is really what we've always known, and that is time. And so when you look at a comprehensive or thrombectomy, capable center, I think the single biggest hurdle and it's a big one, it's an intellectual one moreso than a physical one in many ways, but it's getting all sorts of disciplines to converge with the right staff, the right personnel round the clock, right, because strokes don't just happen at noon, they happen at midnight, and they happen on weekends, and Christmas Eve and holidays, it's getting all that manpower together, at the same time, able to do the same things on the same physiology, sort of like the analogies like a pit stop and racing, where everybody just knows their individual role. they converge on the patient, keeping time, awareness of the time sensitivity of this kind of illness to get an eventual outcome. And that's the big hurdle today. And the other thing is we're now and I we're going to talk about this in a little bit. But the idea about what can we do on the pre hospital side, I think if you went back 10 years ago, it wasn't a huge amount of thought to pre hospital it was when the patient got there, what are we going to do next? Now that we're in really good windows for large vessel thrombectomy, the burden really is not on the hospital side anymore, provided you've got the infrastructure to execute on some of these surgical cases. It's really on how quickly can we recognize identify transport, get a patient into a building that's capable of doing full service stroke, because that's really the hurdle timewise and major determinant of outcome functionality wise on these patients. And so that's really the next big hurdle i think is America's infrastructure, unlike trauma, unlike cardiac has lagged for 20-25 years and infrastructure specifically for things like stroke in populated areas of the country, as many as 40% of populations in relatively populated country don't have infrastructure to do thrombectomy or provide neurosurgical coverage or vascular neurology or critical care. And that's a very big number for a sophisticated medical world that we live in today, when you compare it to trauma or cardiac disease.
Geoff Lassers:Yeah, at the very beginning of this when I started doing, you know, my own research on it, you know, from any ems perspective, when I started to hear about advancements in stroke, I'm like, okay, I haven't heard anything since I got my license back in the very, very early 2000s. So what happened here in 2010 2015? So when I started doing research, I'm like, I feel like I've seen this movie before. I've seen this with cardiac and trauma. I feel like we're going through something we've already experienced in the hospital and pre hospital community as we've advanced technologies, resources and capabilities, and how do we bring all those in for structures together logistics funding, tell me if I'm wrong, I feel like strokes just now catching up to this because of the deluge of data and resources that have come out to really help stroke patients last five to 10 years.
Dr. John Whapam:Yeah, you're actually right. I mean, what we're doing right now is playing catch up infrastructure wise, instrumentation wise to literature that has been sort of under the radar for 20 years, we really haven't had to deal with the absolute need for a lot of this infrastructure because there wasn't database evidence based systems in place for stroke or neurocritical care hospitals to triage small vessel versus large vessel. And then the additional step of surgical stroke cases that was just off the radar, and all of a sudden, 2015 with some of the literature that dropped in that year, here we are in America is playing catch up right now,
Amanda Kalinsky:especially as we're talking about, it's a partnership between multiple disciplines, especially behind the scenes to be able to get this program up and running and safe for our patients really. As our ems, our paramedics pre-arrival, partnering with our emergency department providers, our stroke team, our advanced practice providers, neurologists, our neuroendovascular, and then also our anesthesia providers, our IR team, our nurses and our IR techs, you know, they're critical to us to have them available for our patients, and then providing that after level with our intensivist in the ICU and ensuring that our residents in our ICU nurses, they're already caring for these patients, but being able to continue advancing our game to continue to care for these advanced and complex stroke patients here on site. And there's also a level of partnership with neurosurgery as well. So this is a lot of things that are happening infrastructurally behind the scenes, there's a lot more to it, like Dr. Whapam was saying,
Geoff Lassers:yes, there's massive amounts that happens there, right. There's this huge amount of things where people just assume like, oh, the hospital bought this new tool, and they got a person that knows how to use it. And now you can go there. It's not quite that easy, because just like Dr. Whapam said, you can quote unquote, save a life with mechanical thrombectomy. But the next 50% of their outcome is going to be based on the ICU care. So you might have unclogged it. But you still have to deal with the damage that was incurred, and then try to get them to the highest degree of health possible, which takes neuro teams, ICU's, everything, everything, including ems, to some degree, right? Because what we're seeing is not only catch up in the logistical aspects of all the hospitals and the infrastructure, we got to get ems to catch up. The last time ems had an update in stroke education was 1996-97 with the introduction of the Cincinnati pre-hospital stroke screen, because TPA was available. Since then, it wasn't till like 2010-13, somewhere in there, education really started to change because the data was trickling out about mechanical thrombectomy for large vessel occlusion stroke patients. So logistically for EMS, we're catching up in the majority of cases on the use of stroke severity scales. So number one, we're introducing people to that stroke is a spectrum. It can be severe ischemic, it could be severe hemorrhagic and we use stroke screening tools to identify patients with potential neuro-deficits, then if we identify a potential neuro-deficit, we then use a stroke severity scale to either measure it or use it to identify predictors for a severe stroke or LVO stroke. Can you guys kind of give me your take on the use of stroke severity scales by EMS currently, as it stands as a center like yourself.
Amanda Kalinsky:I think that stepping up your game to use a stroke severity scale in the field is crucial. Like you're saying, right now, I know that agencies in our area, we're using the Cincinnati and while that does provide some level information, I think that the most important thing is to use the stroke severity scale, get that stroke education, and then also do a really good job of communicating the patient's symptoms. So if it's not measurable on that scale, we need to know about those symptoms, but also the LVO scales that are being tested in the field. Those are crucial for our departments to know what we need to activate for your arrival and kind of have us on standby. Your communication of the stroke severity scale from the field to awesome emergency department is how we get our teams on standby ready and waiting for the patient. This is incredibly crucial to get that care started and activated. So utilizing the scales, becoming familiar and gaining that additional education. And I think partnering to be able to start utilizing I know that the FAST-ED scale was being tested and I think that's a great scale to use.
Dr. John Whapam:I'll give you a clinical example. So I work with EMS for 10 or 15 years or more around the country all over the place in the deep south, Michigan on a huge scale and I'll give you an example of what's helpful to us and what helps us be aware. So EMS in the field and medics and firemen and police and first responders those are our eyes and ears to be able to react to clinically and set up for as Amanda indicated. That's our early warning system. That's our best weapon being situationally aware and knowing what to expect and shaving time off on the hospital while all of you shave off time on the pre hospital side. So while there are varying amounts and numbers and types of scales, including Cincinnati, and NIH and 1000 other ways to try to numerically categorize patients in the field, all of which are helpful, don't get me wrong, they all provide a level of data in a number in some cases that comes with it a high predictability of things like large vessel cases based on how high the number is or how severe the disability is, but what's often clinically more helpful to us to try to differentiate between people that are metabolically disturbed or have encephalopathies, or have non-focal non-lateralized neurologic deficits from those that have lateralized, or specific deficits that involves speech that involve one arm, one leg, sensory, lack of sensation of one arm, one leg, one side of the face, things in the brain that are collateralizing. And that are in vascular distributions, there is a footprint, if you will, to people that are having vascular problems in a distribution, it has a very characteristic footprint that is often foretold by their exam. So I'll give you an example. So about 10 minutes ago, Amanda and I got a stroke code marked from the field that came across as weakness, time unknown. So to us that says there's somebody 80 years old in the field, it's kind of weak, we don't know if they woke up that way, we don't know if they're just a little weaker and tireder than normal. We don't know if that's collateralizing. We don't know if they had speech trouble. We don't know if was both arms, both legs, one arm, one leg, whether they were the same side with a person who has pain, whether it's pain related, it's very little information other than somebody weak out there. As you can imagine, that can be 1000 things from a urinary tract infection to back problems, to elevated glucose to 100 other metabolic things that are unrelated to a vascular distribution or stroke. But I can turn that around. And if I had somebody in the field that told us, hey, we've got a lady we just picked up, she's 80 years old, her daughter came over to see her at exactly 8am because they have coffee together and found her to be unable to walk. In addition, she couldn't speak or understand her daughter, even if somebody didn't give me the scale and said to her NIH was blank or Cincinnati stroke scale was blank. That is enough for Amanda and I in the field to know we're going to receive somebody who is aphasic. somebody that's got probably left hemispheric frontal or temporal lobe issues, who's also got a large enough proximal vessel problem to be unable to use the right leg or arm at all. We know they're probably not going to be a medical TPA candidate just from that little vignette, because they were found and woke up that way. So there wasn't a clear time of onset. So a little vignette, one sentence, 80 year old lady found by her daughter this morning, unknown time of onset, weak unable to talk, weak in the right leg and arm, that tells us there's already high probability of a large vessel occlusion without even a number attached to it. That this is somebody who's going to be screened for viable tissue for large vessel get things like CTA and CT perfusion that we'll talk about in a minute. But also beyond the radar for potential left hemispheric thrombectomy just from a firefighter or medics saying they're aphasic. And they can't move their right arm and right leg or even telling us they can't talk. And if they were found that way. That's a good example of some of the clinical stuff that's super helpful to us. It gives us a ton of download information, and actionable things to do just from a little fine tuning of what you physically see, we're not asking folks to be stroke specialists in the field, we're asking you to describe what you see. And that helps us differentiate a ton from a confused person, somebody that's got non-lateralizing symptoms, somebody that can converse and follow commands, somebody that can ambulate, big difference.
Amanda Kalinsky:And I think especially as I'm a response member on the code stroke team, when I'm there and getting handoffs from our paramedics, it's incredibly important for me to get those symptoms and also describe how you found that patient on the scene. You know, was it the patient that you found down? Or is it the patient they were arousable alert talking had some stroke symptoms, and when completely obtunded and comatose? Those are all pieces of the story that help us figure out what was going on, especially for those patients who were possibly a fall and stroke. You know, what came first? What are we having deficits and neuro-symptoms because of that fall, or was it because of the stroke and then they had the stroke, then they fell, you know, kind of that age old story of what came first. So really of what you're seeing on the scene and providing that And in addition, call in to the hospital pre-arrival, but during the handoff to your team at the bedside. It that's crucial what you're seeing, I think we'll talk a little bit more about that later about how we're really partnering to do a handoff and take the patient directly to the CAT scan if they're stable. You know, if their ABCs are stable, we're going directly to the CAT scan to avoid delays for our patients because we know that this patient needs to at least get the noncontrast ct of their head to start their treatment workup. So we know that getting that patient directly on the stretcher directly over to the CAT scan. It is incredibly helped when we partner with you guys. That's the best thing
Geoff Lassers:I think those are both great examples. What we need to Do at every level, EMS needs to identify what happened, when it happened and what it looks like. I mean, if you just do those things, and Dr. Whapam you so elegantly put together one sentence that conveyed a list of neuro-deficits a last known Well and a time of symptom discovery, that was literally if we could get every EMS provider in the nation to do that our acuity acuity increase, so much.
Dr. John Whapam:volume of information from a descriptive assessment that anyone can do even lay people as to what you see when you look at or interact with that patient. And it doesn't have to be super sophisticated or very clinical.
Geoff Lassers:Agreed. And that's exactly what I try to get across. But it takes so much effort in articulation to get people to understand how simple it really is. And that's really a big hurdle for us. And if I may just kind of interject a few things, our checklist that we include in our stroke protocol in our stroke education, and that we try to share with as many people but the first thing we try to get ems to do is to convey the stroke screening and or strokes severity findings to the hospital during their communication with a list or description of their neuro deficits. And all of that is a fancy way of saying, What did you find? And what does it look like? Is it left side of weakness? Can they talk? Can they understand speech explained to the people you're talking to? And then you also got to remember, check your stroke mimics and like you guys were saying, Is that another metabolic issue? hypo or hyperglycemia? Is it tod's paralysis? Is it a trauma? Is it a seizure? Is it all sorts of other things? And then your last known Well, your stroke sign and symptom discovery, those two different times are very, very crucial so that you guys can keep a list of what treatments are still on the board and applicable to this patient vital signs, including blood glucose is the patient on any type of anticoagulant medication. These are all very, very easy things that ems already is doing that we can simply convey. And what I'm hearing from you guys is keep it simple. Whether you use a stroke severity, scale or not. Keep it simple. Keep it clear. What do you got? What does it look like? When did it happen? 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 care while drastically reducing or eliminate the cost associated with ems training. Americans 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 American CME.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 the 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 CME's got you covered on those courses to the EMS on AIR podcast. We'll 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 EMS on AIR podcast logo. Right now. There's a total of 16 episodes of the EMS on air podcast available on American cme.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 cruising to work kicking back and engaged in an EMS on AIR 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 CME's content for free? Yeah free. And now back to the show.
Dr. John Whapam:The one thing I wanted to add from a medical perspective coming from a background in neurocritical care and doing a lot of in-field medicine. in one stroke and injuries and patients, and I think I can add is what can be done in the field? And I think we're getting to that. And that question of is there more information medically about the patients, it's relevant to provide like blood pressure level of anticoagulation, glucose, that sort of stuff becomes actually really important. I think people really forget that stroke is a very medical disease as well as a plumbing problem. And so when a vessel in the brain is plugged up in brain begins to not get oxygen and blood supply, a series of events start to occur. My original background in graduate school was in molecular biology and cellular biology of stroke, and some of the mechanisms of communication in the cells in the brain when there's ischemia or lack of oxygen. And there is a cascade of events that occurs that are very, very medical that flip a bunch of switches in the body when somebody is having a lack of flow to the brain. And they're not all just vascular and plumbing related. So yes, there's no question you get lack of blood flow or oxygen to an area of tissue in the brain when a vessel is plugged up. But in addition to that, it kicks off all sorts of cellular and molecular changes in that brain tissue that have a secondary effect in elicit a cascade of inflammatory response program, pre-programmed cell death of parts of the brain that are not originally injured, neuro-cardiac dysfunction, neural renal dysfunction, dysregulation of pulse, blood pressure, sometimes even respiration, all of which are directly tied to the event and the plumbing problem mechanically, if you will. And so two things one, some of those other medical parameters that surround the exam neurologically become really relevant glucose, blood pressure, etc. And number two, the reaction if you will, by ems, or the first responder to those medical pre-programmed scenarios in the brain are really important. Taking advantage of correcting glucose, we know from the literature can extend the life of neurons in the brain taking advanced control of reversal of anticoagulation, sometimes even with direction in the field, or immediately at the hospital can reverse and extend some of the window in stroke. And we also know that taking advantage of collateral circulation, the way the plumbing of the brain work with volume loading, and pre hospital hydration, and play with some of that physiology and extend time for viable tissues. All those things become really, really important in the field. They're not little things. They sound simple, like glucose management, or hydration or volume expansion or blood pressure control, if people are have unmitigated hypertension, but they can really they're the 50% of the cases that doesn't involve getting TPA or work we do in the head in the lab.
Geoff Lassers:Yeah, that's so important. Just because getting a blood glucose is easy. You can't minimize its importance.
Unknown:I use this example all the time of if you're a firefighter and you go to the extraction scene in a roadside car, bad car accident, and somebody's got a half severed limb, you wouldn't simply just transport the patient to the nearest hospital, you would look at blood pressure, make sure they weren't in shock, you would hydrate them put a tourniquet on stop bleeding that you could at acompressible site. Those things would be lockstep in pre-programmed in automatic for a trained responder in that medical scenario. What we lack right now is the same for stroke in the field.
Amanda Kalinsky:And I think part of the things to the technical aspects when you're getting your vital signs and checking that blood glucose, also the patient's telemetry, so that EKG that also can help us tell you know a little bit about that patient story and what to expect when this patient arrives to our doors. The other thing is placing an IV, it seems sometimes menial, but like we were saying pre-hydration and addition to it is a crucial step for us to be able to take the patient directly to CAT scans and be able to start that back to back advanced imaging that we're doing on our patients. So not only are they getting a noncontrast ct, that exam does not require an IV, but the CT angiogram does require an IV access. So a large for IV we need 20 guage or higher for that patient to be able to quickly be able to run the CT angiogram, it really helps us and shaves a few minutes off of our time to be able to get this patient treated as quickly as possible, especially if it's a TPA candidate. This patient needs two IVs at this point for us to be able to start the bolus and give that thrombolytic and then also proceed with advanced imaging.
Geoff Lassers:Yeah, a lot of protocols in EMS nationally. And we redid our protocol here in Oakland County in the last few years. And we made certain that EMS providers specifically paramedics understood that getting a three lead is part of your initial vital signs with a stroke and a lot of times are like Hey, don't waste time on an EKG when you have a stroke patient and specifically what that means is get the four lead or three lead to identify what the patient's in this rhythm is because what if they're in a-fib and they don't have a history of a fib? That is huge pieces of information. However, we do not recommend to our providers doing a 12 lead on scene, you can do that and route to the hospital. We just don't want to delay transport for that 12 lead but if you got time get her done, Also, with the IV we've been recommending in our protocol in 18 in either or both. anticubital veins, because of the exact reason you go to a CT you can sit in a CT. But what happens when the doc wants now a CTA CT angiogram? And for those of you who don't know what that is, is a really cool machine that basically can make a model of the arteries of the brain and show the exact location of the clot. Correct?
Dr. John Whapam:Correct. Yep. Today in modern stroke surveillance, where we do something called a CT perfusion at the same time, that gives us a map, kind of like a functional PET scan type of color image that gives us a rough and dirty idea about tissue that's already infected or dead. And that which is still stunned or alive and potentially salvageable all done really a line of sight right in the CAT scan immediately on the entry. So that's important. The other thing is that maybe 30% of these folks statistically are headed for anesthesia in a procedure. And so knowing that any additional field information as to their medical history that a family member if there have been conveyed to ems, any additi nal idea when they last ge, anything like that, that w uld be germane to general anesth sia can sometimes become impor ant to know because these people 30% of them statistically wil be headed into a case ith potential anesthesia. If the've ever had a reaction to somet ing ever had a problem ith inhalational anesthetic or any kind of other thing like hat reduction agent, it's re lly important to know some of t eir medical history and ai way history
Geoff Lassers:So we talked about the the anticoagulant medication use a little bit more about their history, giving you that background and cutting off that time. One of the big things that's been made very clear to me in the last few years by our neuro experts here locally has been obtaining the information for the next of kin, which makes total sense because sometimes people having a stroke have aphasia, either receptive or expressive aphasia, and getting them to consent to a treatment may be difficult. So they're going to need to contact immediately the next of kin. In your experience, how important is this information to get from the field to the hospital?
Dr. John Whapam:Yeah, it's absolutely critical if available. And we've worked under the premise that people with a lethal occlusion under best practice and with the intent to try to salvage anybody in the assumption that they want life saving measures, we usually proceed, you know if there's a lack of any documentation or contact whatsoever, but it's always a major benefit to have some identified decision maker in the family. For those that you described, who are confused, obtunded aphasic that cannot verbally or written form consent to a procedure, we have to make some very quick decisions on folks based on the imaging in a matter of 30 seconds and CAT scan to then pull them to a procedure that saves time. And so if we don't have a family member readily at the bedside or an emergency room that can be complex to document in the best interest of the patient, it's always great to know their wishes, we can run into scenarios where we have somebody that may have other existing medical problems that we don't know about like a stage four cancer diagnosis where they would not want other things done. Or we occasionally run into somebody with a documented DNR status that would never want an airway or would never want life prolonging measures. And all that's really critical so that we don't end up working on folks that have deliberate wishes already made clear in advance directive or with family.
Amanda Kalinsky:And I think the biggest thing is the documentation of all of these elements that we were talking about, we know that you might be giving this to us in verbal handout, but to have it documented and available on your run sheet and having it immediately available for us to use and hand off while we're in the hospital as we're transitioning from point of care is often telephone game, right? Things get lost in translation. So having that documented written piece of information to go with the patient, it's crucial, we use this run sheet to reference back to and look at the story of the patient pre arrival and to know exactly what was happening. And like you were saying that next of kin info that might be the only place documented where we have this info as patient as transitioning to so many locations so quickly and so rapidly that this is crucial for us.
Geoff Lassers:We have three points of communication that we have a checklist for that we assure that our EMS providers are conveying to the hospital. Number one is in the stroke alert notification to the hospital, whether it's by radio cell phone, either way, they should have a checklist that gives that information, that same information should be delivered at the face to face patient handoff right there at the hospital. But there's a lot of things that happen. What if I give the face to face to one doctor or nurse or other stroke team member and then they have to go to another case. And then somebody else steps in, they might not have heard the last known well by the second or third set of hands that touched them, right? So it's important that in the third checkpoint, my patient care report, the conglomeration of all that information about that patient is right there. So it can be referenced immediately. And it's kind of expressing the really, really big part of this is that no matter what we do, we have to collect very simple, very basic information and that it is sure that it gets to the hospital with the patient or ahead of time of the patient so you guys can get prepared. Is that a good summary of that?
Amanda Kalinsky:Yeah, exactly. I think that's the correct summary. Having that immediately available within our hands. It's crucial.
Geoff Lassers:That's awesome. So one of my big goals for your hospital because you are in the county of which I serve is to try to get as many life support agencies around You using stroke severity scales or at a minimum increasing acuity of identifying stroke patients, bringing them closer together with your stroke program at your hospital. So Rochester hills, Rochester, who else is around you? All those agencies around that area? Look out, you're gonna get a phone call from me and Amanda and Dr. Watson probably Glenn Garwood. And we're gonna try to get you guys involved or at least get you increased education over there. And if any agency, listen to this once into our study, or any of our education, just get a hold of us. One more question for you guys. What are your thoughts on what ems and stroke care look like in the next five to 10 years, based on what you currently know, you guys both have a background and bringing it up the level and up the game of a stroke center, you're watching what's happening from a 30,000 foot view, what's your take on the next 5 to 10 years of what stroke care looks like by ems?
Amanda Kalinsky:I think tapping into virtual platforms is going to be where it's going to be going in the next five to 10 years. I think we're lagging behind right now and playing catch up on that infrastructure. And I really think utilizing our virtual platforms and being able to connect, there should never be a barrier, you know, if I'm taking my patient to the hospital or a neighboring hospital, we should be able to connect on a similar platform. So we don't have that disconnect. I really think that's not only for stroke, I think that's for all care of where it needs to go in the next five to 10 years. And I think that the research and the outcomes of our patients are only going to show us that being able to quickly treat our patients with thrombectomy level care and taking that patient to that designated facility is likely what's going to be best practice.
Dr. John Whapam:Yeah, I agree. I think one of the things I hope to see that I'm seeing maybe the kindling or start of is the extrapolation of modern electronics and social media for connectivity that we use in our private lives all day long. You can talk to your family member on the other side of the earth, like we're doing now and live real time share data, information, anything you want documents, you know, written things, consent, you can do all that remotely. So I think getting over the I like to call it with folks that know me the HIPAA barrier where the common sense treatment of the patient trumps some of the medical legal concerns at some point where we use or extrapolate some of the HIPAA compliant forms of social media and electronics to be able to be in the rigs with ems as their places already doing it. I've done some of that in my career, looking at the pre hospital exams, looking at exams, a patient in the aircraft flying, you have done that having the data to make good decisions as to who's going to get intubated. The minute they hit the ground after imaging or pre imaging and who's a likelihood of a procedure I think we're going to see extension of the imaging into the pre hospital field that's already happening as well in some techniques using remote ambulance CT and remote ultrasound and everything including, you know, heat, metabolic sensing helmets and things that go on patients in the field to try to help pinpoint occlusions or large vessel scenarios that will take the selection process out of the ER into the pre hospital field arena, I think you're going to see that with stroke just because of the nature of the kind of illness it is. And I think you're going to see the continued evolution of a lot of the awareness that mimics today what you see in you know, trauma or cardiac.
Geoff Lassers:I'm waiting for Elon Musk to make a CT helmet.
Dr. John Whapam:Don't laugh, I've actually been approached by folks looking at I can't get into too much specifics, but to be able to sense occlusions based on flow and physics of blood flow and vessels with a device that anybody can place on a patient like you do a defibrillator in a mall. So that world is opening up right now as far as some of the capabilities where a responder could pull out a device that goes on a patient's head that will give you a best estimate as to the likelihood of large vessel occlusion based on certain metabolic factors or imaging or ultrasound or heat, that sort of thing. We're at that point, believe it or not, the infrastructure is really the hurdle right now. It's not our awareness or ability to do something about the physiology. We're over that hump literature wise, we're over that hump mechanical thrombectomy wise, specifically designed devices. I guess the best way to sum it up would be that we've met the enemy and it's us to quote wall Kelly. I mean, it's us it's not the physiology or hurdles to doing something about it. It's us. It's our awareness and infrastructure. Our grasp is beyond our reach me, right?
Amanda Kalinsky:I'm excited to see in the next five to 10 years what research will show us about thrombolytic treatment for patients who don't have large vessel occlusion outside of our traditional thrombolytic window currently. So I'm really excited to see what the literature will come forward with that.
Geoff Lassers:Yeah, because we can treat an LVO. It's like, Oh, we have mechanical thrombectomy, I'm like, Hey, guys, we still have like, most of them aren't. So what are we doing about them? Are we improving that? So that is cool, too. Yeah, like new drugs, new techniques, maybe targeted TPA, stuff like that. There's some really cool, cool, cool stuff. And like you guys are pointing out that the infrastructure is catching up. I hope we use that as an opportunity to learn a lesson from that and really, really enhance way past. Don't just build the infrastructure we need today. Let's build it for 50 to 100 years from now.
Amanda Kalinsky:Completely agree we really need to be looking ahead and partnering together. And I think looking at the best practices, what we're doing with other service lines, like we were talking about with trauma and cardiac already existing there, so we really should be stepping up our games together for the best care of our patients.
Geoff Lassers:That's all for the show today, everyone. Thank you for listening. thank you to Dr. Whapam and Amanda Kalinsky. for coming on the show and spreading your knowledge. 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@ems_on_air and please whatever podcast platform you use, subscribe to the podcast and leave us a rating and a review. It really helps us to grow this thing. Thank you for listening to the EMS on AIR podcast. Stay safe and have a great day.