Survivor gives us a lens into regional systems of care for acute ischemic stroke in North Dakota

I just got back from the North Dakota Mission: Lifeline STEMI and Acute Stroke Conference in Bismark, ND. I had a great time and I learned a lot.

I often get asked to speak in various venues about acute STEMI and 12-lead ECG interpretation, but for this conference they wanted me to talk mostly about stroke. That turned out to be a good thing because it forced me to read the 2013 AHA / ASA Guildelines for the Early Management of Patients With Acute Ischemic Stroke to make sure I was asking intelligent questions during the panel discussion (which I moderated) and also giving accurate information for the class I taught about stroke recognition and treatment.

I also turned to a new source of information about acute ischemic stroke and that is the #FOAMed community on Twitter. If you're not familiar with FOAM or FOAMed it stands for "Free Open-Source Medical Education". I was surprised to learn that giving reteplase (Activase) or rtPA for acute ischemic stroke is somewhat controversial, at least in the emergency medicine blogosphere. That may explain why some of our emergency physicians locally are hesitent to give rtPA for acute ischemic stroke, especially for mild or rapidly improving strokes.

To help explain why rtPA is controversial for acute ischemic stroke I will refer you to a blog post entitled Schrödinger’s Fence at the Life in the Fast Lane blog.

This created some cognitive dissonance for me as I certainly didn't want to come across as a bomb thrower while moderating a panel discussion about acute ischemic stroke. In the end, it turned out that my concerns were completely unfounded because the panelists were happy to acknowledge that the therapy is controversial but well supported in the guidelines and give their reasons why they believed that rtPA is both indicated and underutilized for acute ischemic stroke. The panel discussion was video taped and I will update this blog post as soon as the video is available online.

What I really want to tell you about is a story of survival. But it's more than that. It's a story about love, and caring, and decision making, and even customer service.

As host of the Code STEMI Web Series as First Responders Network I have been priviledged to meet many STEMI and sudden cardiac arrest survivors, including the EMTs, paramedics, nurses, and physicians who  worked together as a team to save their lives. I have always imagined that the holy grail of survivor stories would involve therapeutic hypothermia, and actually being there at the bed side when the patient opens his or her eyes for the first time in the presence of their loved ones. 

At no time did I imagine how powerful a stroke survivor story could be. It simply never crossed my mind. So I was unprepared and deeply moved by a stroke survivor story that was presented on Wednesday.

The patient's name is Scott Onstine and his wife's name is Diane. Scott is a diabetic and the stroke affected the left temporal lobe of his brain. This area is involved in the rention of visual memories, processing sensory input, comprehending language, storing new memories, emotion, and deriving meaning. Scott sensed something was wrong so he contacted his wife by cell phone. This is critically important because as I learned this week, a huge number of stroke patients don't recognize their symptoms as stroke (perhaps because stroke does not cause pain) and it's not uncommon for stroke patients to "lie down" in attempt to "sleep off" the symptoms. This is a huge problem because time-to-treatment is extremely important for acute ischemic stroke and once stroke patients lie down, they usually don't get back up. Once they are found by a loved one it's usually either impossible to establish a timeline or it's too late to treat the stroke with rtPA.

Fortunately for Scott, his wife came home, thinking that perhaps his blood sugar was low. She tried to give him some orange juice but he threw it up. Then he knocked over the glass. She went up stairs and was shocked to see the bedroom completely trashed. Scott had been trying to use the phone, and because of his stroke symptoms, he couldn't figure out how to do it. Diane was getting scared, especially after she measured Scott's blood sugar and found out it was only 130. She contacted 9-1-1 with a certain amount of anxiety because she had called 9-1-1 once before thinking that Scott was having a stroke. On that occasion it turned out to be low blood sugar.

Diane got an awesome dispatcher. She rapidly determined that Scott was probably suffering a stroke due to his difficulty in forming speech. She actually had Diane perform a FAST (Face, Arms, Speech, Time) exam on Scott while waiting for the ambulance.

The test results revealed expressive aphasia. Diane spoke about how much this dispatcher meant to her, how she acted as a "life line" on the other end of the phone, keeping her calm and staying with her until help arrived. She spoke about a paramedic named Gus (who I also met); how kind, caring, and competent he seemed. She spoke about the firefighters who showed up on scene to assist, how professional they were, how they moved the furniture to make room for the gurney, and how they moved the furniture back.

She spoke about how Gus advised her that it would be a good idea to bypass the closest hospital and go straight to a Primary Stroke Center. She talked about how everyone kept her informed about what was going on, at this time when her life was spinning out of control. She talked about hearing the overhead page — a Stroke Alert in the Emergency Department — and how she knew it was for Scott, and how that reassured her that Scott was in the right place.

By this time Scott had taken a turn for the worse. He was barely responsive. A pastor showed up at the hospital and they prayed together at the beside. At the end of the prayer the pastor said "Amen" and they were both surprised to hear Scott say "Amen". She leaned over to him and said, "I love you!" He said, "I love you." Something deep in his soul knew that he was being prayed for, and that he loved his wife. He was receiving rtPA but they were simultaneously preparing him for an endovascular procedure due to the location and nature of the blockage in one of his cerebral arteries.

It turned out that the rtPA had worked and that blood flow had been restored to Scott's brain. He was rapidly improving. Before long, and had recovered almost all of his neurological functioning. He was discharged from the hospital and given a Holter monitor that revealed periodic atrial fibrillation. He now takes Coumadin to help prevent another stroke.

The Interventional and Stroke Neurologist Dr. Ziad Darkhabani made this simple observation. "Stroke is treatable and stroke is preventable."

This was truly one of the most powerful survivor stories I have ever heard, perhaps because it was seen through the eyes of the survivor's spouse. At the beginning of her talk, Diane made one of the most poignant statements of the entire conference. She said, "Strokes happen to a patient but they also happen to a family."

I have often thought about how any case study — good or bad — can provide a lens through which we can analyze a system of care from the patient's perspective. In this case we can see the entire stroke chain-of-survival. Scott didn't lie down. He called his wife. She realized it wasn't low blood sugar and contacted 9-1-1. The dispatcher recognized the signs of stroke and stayed on the line to encourage and reassure Diane. The first responders took the problem seriously, treated the patient with caring and competence, and provided excellent customer service by respecting the patient's property and moving the furniture back. Gus has the presence of mind to bypass the closest hospital for a Primary Stroke Center. The overhead page told Diane that the hospital was prepared for patients like Scott. They kept her informed. She was allowed at the bedside. She was treated with dignity, compassion, and respect.

Stories like this remind me why I got into health care. We need to celebrate our "wins" to keep us focused as health care professionals. System building isn't easy. In fact it can be very difficult. Couples like Scott and Diane make me realize that in the end it's all worth it. Although many believe the "jury is still out" on rtPA for acute ischemic stroke, it certainly appears to me that stroke patients do better within systems of care, and in hospitals with highly coordinated expertise at every level of care — prevention, diagnosis, and treatment — and dedicated units with nurses who specialize in neuro care.

We in EMS need to do a much better job in educating patients how to recognize the symptoms of acute stroke, and to encourage them to contact 9-1-1.

Special thanks to Mindy Cook from North Dakota Mission: Lifeline for inviting me to be a part of the North Dakota Mission: Lifeline STEMI and Acute Stroke Conference! Also to Peggy Jones, Coordinator of the Illinois Critical Access Hospital Network (ICAHN), who sat next to me at the conference and taught me a lot about the problem of patient delay. She is also a stroke survivor and an inspiring woman in her own right.

Also, to the EMTs, paramedics, nurses, and even a physician or two who stuck around for the 6:30 p.m. class on stroke and the 7:30 p.m. class on STEMI and 12-lead ECG basics, thank you! You guys totally rock! North Dakota is blessed with a truly dedicated group of health care providers.


  • Russell says:

    Something I always do early in my assessment, take a BSL, had a patient sometime ago who presented just like a CVA with a dense left side deficit. His BSL was 1 mmol, was given IM gucagen back then as we werent allowed to give IV glucose in those days. He recovered completely enroute to hospital, told me how he had taken his insulin then walked to the restaurant to have a meal, problem was it was cooked and placed before him too late, before he became hypoglycaemic. Still time critical though, always a chance for coth conditions concomitantly, and the need for further investigation to rule out a TIA or other coexisting problems.

  • Jon Kavanagh says:

    An excellent reminder that we take care of people, not processes.

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