Young and old: Do you know what to do?

I was 39 when my stroke hit, and I freely admit that I knew very little about strokes at the time.

And people in that age bracket have strokes every day. And that numbers have been going up.

It's disheartening to hear, then, how most young adults are not stroke savvy:

When asked what they would do if experiencing the hallmark symptoms of stroke, only about one in three people under age 45 said they would very likely head to the hospital.

Hospitals hiring weight-guessers? Or is there a better solution?

Image from Wellness Corporate Solutions via Flickr

Ever seen someone offering to guess your weight at a carnival? It's been a while for me.

Maybe we need to hire some of those folks for hospital work - when knowing someone's weight means administering the correct amount of a drug that could bring you back from a stroke, or put you in danger - at least partly depending on how the accuracy of your weight in its calculation.

Recently, some research shows that weight guesses for stroke treatment are often wrong:

"Relying on our ability to 'guess' the weight of a patient in the acute setting is no longer acceptable and potentially dangerous," Pankaj Sharma, MD, PhD, from the Institute for Cardiovascular Research at the University of London, told Reuters Health.

The recommended dose of alteplase (recombinant tissue-type plasminogen activator [r-tPA]) is 0.9 mg/kg, up to a maximum dose of 90 mg. In the interest of time, clinicians often estimate patients' weights to determine the r-tPA dose. ...

Time to up the game for stroke treatment

Photo by Chris Violette via Flickr

During the last couple of decades, we've seen some upgrade in care for stroke patients.

But this can't stop. Treatment could be so much better.

Check out the story on how experts call for care upgrade:

Patients suspected of having a stroke should be transported to an accredited comprehensive stroke center (CSC) when it is reasonable to do so, they wrote. When a CSC is too far away, patients should be taken to the nearest primary stroke center (PSC) that is linked to a CSC by telemedicine. They also called for the expansion of telemedicine networks linking smaller, non-PSC hospitals in very rural communities to accredited stroke centers.

"The qualifications for these PSCs and CSCs should be upgraded so that imaging technology and the availability of neurologists to see patients 24/7 should be requisites," the editorialists wrote. "Systems for rapid imaging and throughput should be in place at these centers."

The phone number is easy to remember - but who's calling it?

A few posts ago, we looked at the hospital behavior after a stroke patient is hospitalized. And you have seen postings about how hospitals often take patients more seriously if they arrive via ambulance.

But who's calling for an ambulance ride? Here's an interesting look at how race and sex may influence who calls an ambulance for stroke symptoms:

With an average age of 71, half of the stroke patients were women and almost 70 percent were white. Almost 20 percent were black, 8 percent were Hispanic and 3 percent identified as Asian.

Chew your food, or this might happen!

I had the greatest hug last week. But the lead-in event started out deadly.

One evening, after grilling some beef kabobs, I enjoyed one chunk too much – and began to choke. My wife Laura came to my rescue, put her arms around me from behind and squeezed. And at least six more times. The chunk remained, but her moves gave me a tiny bit of an airway. She called 911 while I went to the floor, hacking like a cat with a hairball.

How much priority will you get when it comes to saving your life?

This week's theme: Taking stroke patients seriously. Sadly, we are not always taken seriously.

This is written in kindness - my life was saved by health professionals in a hospital. But we've all seen the other side in hospitals - the hurry-up-and-wait phenomenon. And in my own personal observations, transportation is a big issue for hospitals.

So it's not a big surprise that in those cases in which a stroke patient needs to move to a stroke center, the transfer is actually no faster than driving yourself:

Was your stroke an emergency? Not all that long ago...

Photo by Chris Violette via Flickr

We've gone a long way.

Twenty years ago, a stroke wasn't considered an emergency. No treatment to reverse or limit a stroke's brain damage.

In 1996, the clot-busting drug tissue plasminogen activator was approved to treat strokes. That also caused a great deal of rethinking how health care providers responded to strokes. What was not an emergency suddenly became one. That meant a lot of rethinking of roles and actions of health professionals when a stroke happens.

An interesting take on that history and more ideas evolving, focusing on when stroke care is a statewide effort:

Training stroke patients for the just-in-case scenario

Photo from Thomas Hawk via Flickr

Learning is generally a good thing.

Ever been hospitalized? If so, it's likely you went through a discharge process, received some instructions and signed some papers. In my experience, most instructions are semi-helpful at best. Now, here's an idea that might be an upgrade for in-hospital instructions - educating stroke survivors helps them spot another stroke faster:

Stroke survivors who receive extensive stroke education are much more likely to recognize symptoms of another stroke and seek immediate treatment, a new study shows. ...

Note to self: If you're going to have a stroke, schedule it

This week, I took a friend to a hospital's emergency room after normal business hours. This isn't the only visit that confirmed my belief that health care suffers after hours.

Now, from Denmark, a new study looks at that weekend effect:

Overall, death within 30 days was 15% more common among patients presenting to Danish hospitals on weekend, evening, or night-time hours compared with those admitted during regular business hours, Nina Sahlertz Kristiansen, MHSc, of the Centre for Quality in Middelfart, Denmark, and colleagues found.

Off-hours admissions were associated with a lower likelihood of meeting even eight out of 10 performance measures, but that difference diminished over time, particularly from 2003 to 2011 after a national quality improvement program, the group reported online in Stroke.

The key factor in the mortality difference appeared to be stroke severity, they noted.

If only strokes followed a calendar and time clock - only Monday through Friday, 9 to 5.

Stroke signs and stroke centers

Knowing stroke signs is important - but what to do next is also vital.

A recent article in the Philadelphia Inquirer offered a resource on finding stroke care. A primary stroke center must meet a certification standard that elevates patient care:

A primary stroke center is an acute-care hospital that meets certain criteria for delivering stroke care and adheres to practice guidelines designed to improve outcomes for patients with warning signs or symptoms of stroke.

If you or a loved one may be having a stroke, call 911 immediately and ask for transport to the nearest primary stroke center.

Click here for a map of stroke centers across the United States - sadly, only updated as of 2010. It's not the most user-friendly map. To see a map of stroke centers, click on the button labeled Map Options, choose the tab called Layers and choose the latest-available year of primary stroke centers.

You'll get a map similar to the image, and you can zoom in for more detail. As you can see, west of the Mississippi, they become sparse.

Too often, strokes are missed in ERs

Clearly, more training is needed. A recent study showed that strokes are often missed in ERs:

Every year, tens of thousands of Americans with symptoms such as dizziness or headache are misdiagnosed in the ER in the days or weeks before they suffer a stroke, according to the researchers.

Women, minorities and those under age 45 are the most likely to be misdiagnosed, according to the study published online April 3 in the journal Diagnosis.

"It's clear that ER physicians need to be more discerning and vigilant in ruling out stroke, even in younger people," study leader Dr. David Newman-Toker, an associate professor of neurology at the Johns Hopkins University School of Medicine in Baltimore, said in a Hopkins news release.

That's a scary thought - people under 45, women and minorities are too often misdiagnosed. My own stroke came at age 39, so I feel incredibly fortunate that the right doctors and other professionals were at the right time and right place.

Of course, if a stroke diagnosed is missed or even delayed, it could mean more consequences for the stroke patient: Possibly more likely to suffer more profound disability, or even death.

If you see someone with stroke signs, make sure you make that known to the health professionals. You might save a life that way.

No closing times for strokes

Ever been in a hospital over a weekend? Hospitals are famous for making people show up before dawn during weekdays for a medical procedure so they can sit and wait for hours - and virtually shutting down on Saturdays and Sundays.

Now, from England, is a story on how an elderly man was turned away from King’s Mill Hospital because stroke unit shut at 6 p.m.:

Elderly stroke victim John Mallalieu was turned away by a Nottinghamshire hospital because it was too late on a Friday afternoon.

The ambulance carrying the 89-year-old from Caunton to King’s Mill Hospital in Sutton-in-Ashfield was diverted to City Hospital in Nottingham, where he remains in intensive care.

The incident was a timely reminder of the additional problems facing patients who need attention at weekends.

Did this patient choose to have a stroke so close to 6 p.m.? Certainly not.

Ambulance still best choice for stroke transport

This is not a big surprise - ambulance still best choice for stroke transport:

If "time is brain," then patients with ischemic stroke should get to the emergency department by ambulance rather than private vehicle, one study suggested.

Arrival times of 3 hours or less were more likely in an ambulance than in a private vehicle ..., according to Sheryl Martin-Schild, MD, PhD, of Tulane University in New Orleans, and colleagues.

If you read the entire article, you'll see that ambulance patients are more likely to show up within three hours of stroke onset, which means better chances with the only current treatment available for clot-type strokes.

The final outcomes at discharge, interestingly, of both ambulance-driven and private transportation patients are about the same. However, it's also the case that generally more severe stroke patients arrive by ambulance, while the generally less severe arrive by private transportation. So the ambulance-arriving patients generally start out worse but wind up about the same.

The takeaway on this - know stroke signs, and if you think someone is having a stroke, call an ambulance!

Hospitalized stroke patients receive worse care

I've written before about the value of showing up in an ambulance for better care. And you'd hope that once you're in the hospital, you'd be in excellent care. Now, some recently released statistics indicate that stroke patients already in the hospital receive worse care:

Stroke patients receive better care if they have their stroke outside the hospital than in the hospital. These worrisome findings come from a study based on data from the American Heart Association's Get With the Guidelines program.

"Maybe the emergencies we are least prepared for are the emergencies that happen in our very own backyard," Ethan Cumbler, MD, said here at Hospital Medicine 2013. ...

Defect-free care, defined as the proportion of patients who received all of the achievement-measure interventions for which they were eligible, was significantly worse for in-hospital stroke than for community-onset stroke... .

"The gap in defect-free care was larger than I expected," Dr. Cumbler told Medscape Medical News.

This also might show the value of being an advocate for someone in the hospital.

The thing to do: Call 911

Just a couple of postings ago, this blog noted that research showed that there is still often a time issue for stroke patients - they are too often not getting to help in time.

Now, more news along those lines: Stroke patients don't call 911:

Nationwide, only about half of stroke patients arrived at the emergency department via ambulance and that figure hasn't changed over a 10-year period, Hooman Kamel, MD, of Weill Cornell Medical College in New York City, and colleagues found.

"Our findings suggest that national efforts to address barriers to ambulance use among patients with stroke need to be intensified or adjusted," they reported in a research letter in the March 14 issue of the Journal of the American Medical Association.

Thrombolytic therapy improves outcomes after ischemic stroke, but most patients don't present to the hospital in time, which is typically within 4.5 hours of symptom onset. That's despite numerous educational efforts to encourage people to call 911 at the earliest signs of stroke, especially because being transported via ambulance results in quicker arrival at the emergency department."

Thank God - and I mean thank God - someone had the presence of mind to summon an ambulance on the day my stroke occurred. But too often, that doesn't happen.

Now, does calling for ambulance guarantee an ideal outcome? No. Nothing can. But does failing to call 911 reduce your chances of a good outcome? Absolutely.

(Image from Alexander County (N.C.) Health Department)

Ambulance ride can make a difference

I've seen this happen with a family member - once, coming in to an emergency department by regular car, second time, by ambulance. She was seen a lot quicker when arriving by ambulance. That's key in care for stroke patients.

I was taken by this recent story about faster stroke care when patients come by ambulance:

(Reuters Health) - Patients with stroke-like symptoms get brain scans faster when they arrive at the hospital by ambulance than when they use a taxi or private car, a new study suggests.

Such scans are necessary to make a diagnosis, and doing them quickly ensures early care and better outcomes. ...

"EMS (emergency medical services) impact doesn't just stop at pre-hospital care, it can have an impact in the hospital as well," said Mehul Patel, from the University of North Carolina in Chapel Hill, whose findings appear in the journal Stroke.

A valuable lesson you can take advantage of if you or a loved one is having stroke symptoms, when time suddenly becomes extremely important: Call 911 and get an ambulance.

A story from Kansas - but could be almost anywhere

The story about how a Kansas county ranks high in stroke deaths shows the need of stroke awareness and the need for people to know that if stroke signs are present - even just ONE stroke sign - it's time to get to some help.

From the Morning Sun article:

With either type of stroke, immediate treatment is crucial.

“A surprising number of people wait not just hours but days before they seek treatment,” [Dr. Colleen] Lechtenberg said.

“I know people try to stay out of the ER, but they need to come and get checked out if they have stroke symptoms,” [Dr. Timothy] Stebbins said. “I would much rather tell somebody that they have a simple headache, or that we didn’t find anything wrong with them, than have to say, ‘I’m sorry, we can’t do anything now, but we could have several hours ago’. That is heartbreaking.”

He added that even younger people should get to the ER if they experience any stroke symptoms.

“It’s true that stroke is much more common in older people, but you can have a stroke at any time in your life,” Stebbins said. “The body is a complex machine that surprises us all.”

'Teachable moment' can help stroke prevention

Not really thought about it, but this makes some sense...

Emergency docs on call for stroke primary prevention:

The recommendations also urged emergency physicians to identify patients at high risk for stroke and to consider making referrals, conducting screenings, and beginning preventive therapy.

The American Academy of Neurology endorsed the guidelines for neurologists as well.

Emergency department visits may be a "teachable moment" for patients, agreed Roger Bonomo, MD, director of stroke care at Lenox Hill Hospital in New York City.

Although "a busy ER is not the best place to provide such education," he said in a statement sent to reporters, "it is a good enough place to start."

Good news - but could be much better

Every find news that sounds good but you know it must get better? Recent stories reported just that kind of news.

On one hand, almost 30 percent of stroke patients showed up an an emergency room within the first hour. That's good. But that means more than 70 percent don't show up within the first hour. That's the downside. The downside means fewer treatment options, and, the study shows, fewer people who show up after the first hour receive a clot-busting drug.

There are two other interesting findings: If the stroke is more obviously serious or the patient shows up in an ambulance, then you get a much higher percentage of those arriving at an ER with in the first. Now, the first item is out of your control. However, the second item - how an ambulance can get someone to help quicker - is advice that anyone can follow.

Here's a snippet of one article:

A substantial portion of ischemic stroke patients present to emergency departments within an hour of onset, and they are more likely to receive thrombolytic therapy than those who arrive later, but both factors present room for improvement, according to research published online June 3 in Stroke. ...

The researchers found that onset-to-door time was 60 minutes or less in 28.3 percent of patients, 61 to 180 minutes in 31.7 percent, and more than 180 minutes in 40.1 percent. Characteristics most strongly associated with early arrival included severe neurologic deficit and arrival by ambulance versus private vehicle. Patients arriving in the first 60 minutes more frequently received intravenous thrombolytic therapy than those arriving in 61 to 180 minutes (27.1 versus 12.9 percent), but their door-to-needle time was longer (90.6 versus 76.7 minutes).

After spotting signs: It's about time

Now you know the signs - face, arms (or legs) and speech.

And please remember - don't wait for all of those signs. One is enough to follow the next important word:

Time. If you even think someone might be having a stroke, it's crucial to get help now. No waiting to see if things will get better on their own. No calling a well-intentioned friend or neighbor for advice. No amateur diagnosing. One call to make: 911.

Wise words from the National Institute of Neurological Disorders and Stroke:

Stroke is a medical emergency. Every minute counts when someone is having a stroke. The longer blood flow is cut off to the brain, the greater the damage. Immediate treatment can save people's lives and enhance their chances for successful recovery.

Ischemic strokes, the most common type of strokes, can be treated with a drug called t-PA, that dissolves blood clots obstructing blood flow to the brain. The window of opportunity to start treating stroke patients is three hours, but to be evaluated and receive treatment, patients need to get to the hospital within 60 minutes.

(Image from the Missouri Department of Health and Senior Services)