Telemedicine and Acute Stroke Treatment

My community hospital is holding its quarterly physician staff meeting and one of the items on the agenda will be a bylaw change which will permit outside physicians, not credentialed or vetted by our hospital credentials committee, to perform video consults on patients within our hospital. Hospital administration is pushing this bylaw change, and since there has been a quiet coup which has transferred medical staff power from the community’s practicing physicians to the hospital employed and paid physicians, it is a foregone conclusion that it will easily pass.

The bylaw change is being requested because the hospital would like to continue to reap the benefits of being an ischemic stroke comprehensive treatment center and offering the health benefits to the community despite not being able to meet the criteria. If a patient presents to the emergency department within four hours of developing ischemic stroke symptoms they must be offered the administration of a “clot busting “drug Alteplase (t-pa). The patient must not have any bleeding tendencies and no evidence of active bleeding or a mass or tumor on head CT scan and must be examined by a neurologist within 45 minutes of arrival.

The problem is that most community based neurologists with outpatient office practices and hospital staff privileges cannot and will not drop everything they are doing and run to the emergency department to evaluate a new patient each time a stroke protocol patient arrives. When given an ultimatum by the hospital administration, that they must take call and be available within 45 minutes, our community neurologists en masse relinquished their hospital privileges.

The hospital countered by bringing in several research oriented academic neurologists and neurosurgeons to man the beautiful new Neuroscience Institute and provide coverage of the ED for the stroke protocol. Few if any of these physicians were able to develop and maintain a practice within the community and they have since left. The Emergency Department is staffed by employed board certified emergency physicians who are well qualified to diagnose an ischemic stroke and administer t-pa. They refuse to do so citing the liability of a poor outcome as the reason. Despite data indicating the benefits of t-pa administration in these situations, the 6 out of 100 chances of a bleed in the brain plus the 1 in 6 chance of death is enough to deter their participation.

You would think that since the hospital hires these physicians the logical choice would be to fire them and hire a group that will provide the state of the art care in a timely fashion. This has not occurred. You would think that the state legislature would grant the ED physicians sovereign immunity from medical malpractice suits if the patient meets the criteria for the ischemic stroke protocol and the patient is given appropriate informed consent for the procedure but this common sense legislation has not been developed or passed.

The hospital has chosen a different pathway. They are opting to hire neurologists from a university medical center who will provide video consults on ischemic stroke patients from an offsite location. Robots will actually examine the patient and televise the data back to the telemedicine center after an emergency department physician performs a brief initial evaluation. The neurologist off site will then provide the needed neurology consult to proceed with the injection of the clot buster.

I suspect the mechanism will work like this. A patient or family member will call EMS via 911 and be taken to the Emergency Department. A triage nurse will ask all the questions to qualify the patient for the t-pa protocol; a robot will examine the patient and transmit via TV the data to an offsite neurologist while an ER physician does an exam. A CT scan of the head and brain will be performed. If no bleed is discovered or tumor or mass that could bleed, t-pa will be administered by the pharmacy and nursing staff. Further intervention by an interventional radiologist and or neurosurgeon may then occur.

At no point in this protocol does it call for the patient’s primary care doctor or cardiologist or usual neurologist to be called. We will be called once the procedure is complete because neither the ER physician or the neurosurgeon or the interventional radiologist will want to admit the patient to neurology ICU. While our surgical ICU and Medical ICU/CCU are covered 24 hours per day by an outsourced hired intensivist group, the neuro ICU does not have that type of coverage.

I can hear it now, my phone ringing and upon picking it up I hear the voice of a clerk in the Emergency Department, “Hello Dr Reznick, Dr. Whateverhisorhername wishes to speak to you about patient Just Had A Stroke.” I get put on hold for five minutes and then in a flat nasal voice, “Hello Steve your patient came in earlier by EMS with symptoms of an acute ischemic stroke. They met the t-pa ischemic stroke criteria and were treated. Unfortunately, they had a major hemispheric bleed with mass effect and edema and are now unresponsive and intubated on a ventilator. We need you to come in and admit him and care for him.”

I will vote in protest against this bylaw. I will lobby for recruiting neurologists who are hospital based who will actually see the patient and care for them. I will lobby for a new state law to provide sovereign immunity for ED physicians treating ischemic strokes according to the internationally recognized protocol. I will lobby for our medical and surgical residents on site and in the hospital to be permitted to administer t-pa after meeting the appropriate criteria. I will not support out of the area physicians making the final call and leaving our local physicians to deal with their results.

SPRINT Study Supports More Aggressive Blood Pressure Targets

For several years now there has been a growing controversy over how low to lower blood pressure to reduce health risks. The most recent recommendations were to lower systolic BP to 140 or lower in men and women less than 60 years old, with a higher systolic blood pressure of 150 in those over 60 years older. There has been much recent concern that if we lower systolic blood pressure too much in senior citizens we fail to perfuse the brain with needed blood supply carrying oxygen and nutrients. The end result is a clinical appearance of dementia or cognitive impairment. Researchers recognize that to achieve a systolic blood pressure of less than 140 most patients need to take at least two blood pressure pills. There has been a great deal of difficulty convincing patients to consistently take those two blood pressure pills so the thought of adding a third medication to achieve a systolic BP of 120 or less is quite challenging.

To answer the question of how low to optimally lower blood pressure, the National Heart and Lung Institute instituted the SPRINT study looking at 9300 men and women over age 50 that had high blood pressure. One group was attempting to lower systolic blood pressure to 120 or less. The other to 140 or less. The study was scheduled to run through 2016 and conclude in 2017. The goal was to see if the lower blood pressure reduced the number of heart attacks and strokes. Last week the Federal government announced that the reduction in heart attacks and strokes in the aggressively treated group was so pronounced that they were stopping the study early. With the lower systolic BP the heart attack and stroke risk was reduced by nearly a third and the death risk by 25%. To achieve the desired systolic blood pressure of 120 or less required the daily use of three distinct blood pressure medications per patient.

In the process of cutting the study short to announce the results for the public’s benefit, the researchers were not able to answer the question of whether senior citizens would suffer more falls from getting dizzy with the lower pressure or if the lower pressure resulted in more cognitive impairment and dementia due to hypoperfusion of the brain. The only question they answered is that a lower target blood pressure will result in less death due to heart attacks and strokes. They did not address the issue of whether lower blood pressures would result in less chronic kidney disease either.

There are many academic researchers who hail the SPRINT study as cutting edge in further reducing cardiovascular injury and death. Other researchers are peeved at the failure to look at the effects on dizziness, falls, dementia like symptoms and kidney function with the lower blood pressure in our elderly population. As a practicing clinician I will look at each patient situation individually. I will suggest maximizing lifestyle issues such as smoking cessation, weight reduction, lipid control and sensible exercise before adding additional medications to lower blood pressure even more. We will recognize that many of you are already on two blood pressure medicines, an antiplatelet agent, a lipid lowering agent plus other medications before we add a third class of blood pressure medicine to get your systolic blood pressure even lower. With the side effect profile of most blood pressure medications including electrolyte imbalances, fatigue, effects on frequency of urination and sexual function, we must consider the individual pros and cons of further lowering BP by additional medication very carefully.

Increasing Dietary Fiber Decreases Your Stroke Risk

Fruits and vegetables v2Diane Threapleton, MSC, of the University of Leeds, England, and colleagues reported in the online version of Stroke that eating more dietary fiber may modestly reduce your chances of having a stroke. Additional grams of dietary fiber intake was associated with a 7% lower risk of hemorrhagic or ischemic stroke.  She said a 7 gram per day increase in fiber is easy to achieve being the equivalent of two servings of fruit like apples or oranges or an extra serving of beans.

United States guidelines call for the average man to consume 30 – 38 grams of fiber per day while the average women should consume 21-25 grams.  We fall far short of that with the average male consuming only 17 grams of fiber per day and the average woman only 13 grams.

Researchers note that soluble types of fiber form gels in the stomach and bowels, slowing the rate of absorption of foods and slowing gastric emptying. This slowed emptying increases our feelings of being full so we consume less food. They additionally noted “bacterial fermentation of resistant starch and soluble fibers in the large intestine producing short chain fatty acids which inhibit cholesterol synthesis by the liver and lowering serum levels.”

Once again, nutritional common sense prevails. Eating healthy, including more fresh fruits, vegetables and whole grain products results in more fiber ingested and fewer health issues occurring.

Unique Stroke Symptoms in Women

Stroke - NIHIn a previous blog I have discussed the need to recognize stroke symptoms rapidly so that an individual can be transported to an approved stroke center quickly and receive treatment within 60 minutes of arrival and hopefully within 3 hours of the onset of the symptoms. The classical symptoms include:

  • Sudden numbness, weakness or paralysis of your face, arm or leg usually on one side of your body
  • Abrupt onset of difficulty speaking or understanding speech
  • Sudden vision change with blurring, double or decreased vision
  • Sudden dizziness, loss of balance or loss of coordination
  • The onset of a severe sudden headache which may be associated with a stiff neck, facial pain, vomiting or pain between your eyes
  • Sudden change in mental status or level of consciousness
  • Sudden confusion, loss of memory or orientation or perception.

New research shows that women often delay seeking help. It is believed this occurs because women often exhibit different warning signs in addition to the traditional ones. Women having a stroke may exhibit:

  •  Loss or consciousness or fainting
  • Shortness of Breath
  • Falls or Accidents
  • Seizures
  • Sudden pain in the face, chest, arms or legs

Time Is Of the Essence in Acute Stroke Treatment

Ambulance at Emergency EntranceWe are fortunate to live in an area where several of the local hospitals including Boca Raton Regional Hospital and Delray Medical Center are certified stroke treatment facilities. What this means is that if you are experiencing symptoms of a sudden and acute stroke then they are prepared to begin lifesaving and permanent neurological damage sparing treatment within 60 minutes of arrival on site. This means we need to transport you to the facility quickly and efficiently if the signs of a stroke occur. Ideally we wish to begin treatment within three hours of the onset of the symptoms if possible, but under some circumstances we can extend that to six hours. At these facilities they have the staff and training to rapidly assess your neurological status and cardiovascular status, perform the necessary imaging studies of the brain and cerebral blood vessels and start you on a thrombolytic medication such as rtPA quickly and safely to save your life and or prevent severe permanent neurological damage.

Our local hospitals have recently reminded their physician and nursing staff of the different options available for stroke management. They all require the same thing. Patients and their loved ones must rapidly recognize the symptoms of an evolving stroke and seek medical attention by calling 911 and being transported to a stroke center. If you or your loved one suddenly develops a drooping face it is time to call 911. Ask the person to smile and if one side droops then the problem needs immediate investigation. If the individual develops sudden weakness in an arm or leg, especially if they are on the same side of the body then you need to call 911 immediately. If the person suddenly develops difficulty speaking it is time to call 911. That would include problems with finding the correct words or just pronouncing the words correctly in a manner that is not garbled. If the patient suddenly develops problems seeing out of one or both eyes or part of one or both eyes it is time for an immediate evaluation. The same can be said for the sudden onset of confusion in an individual who never had this problem. Call 911. We additionally recommend immediate evaluation for sudden dizziness, loss of balance or loss or coordination.

After 911 has been called you may then call your doctor or family to inform them. If you have an aspirin you may administer it. If you have a list of the patient’s medications bring it or the pills in the original pill bottles. Getting to a stroke center quickly may save your life or save you from permanent neurological damage.

Does Marijuana Smoking Contribute to Stroke?

Marijuana LeafMedical marijuana and now recreational use of marijuana are becoming legalized around the United States. Is it safe and can it lead to serious health consequences?

At an International Stroke Conference in Hawaii, reported on in MedPage Today, researchers found relationship between smoking pot and having an ischemic stroke. P. Alan Barber, MD., PhD, professor of clinical neurology at the University of Auckland in New Zealand, told of seeing a 30 year old stroke patient who had none of the traditional risk factors for a stroke. The patient smoked cannabis or marijuana regularly. This led to the doctor reviewing the records of all his younger stroke patients. They found a high proportion of tests positive for marijuana use in younger stroke victims and decided to expand their study.

The current study looked at 160 stroke patients with an average age of 45.  Sixteen percent (16%) of the stroke patients tested positive for cannabis whereas only 8% of the control patients tested positive. When the researchers used detailed statistical analysis to review the data the only risk factor associated with ischemic stroke, or TIA, was marijuana use. “The study provides the strongest evidence to date of an association between cannabis and stroke.”

This was a preliminary study and it could not account for the tobacco use of the control subjects. Most of the marijuana users were tobacco smokers as well. The study did not delineate the extent of the pot smoker’s use of marijuana in terms of quantity and frequency of use. Barber went on to say that more detailed and extensive studies would be coming. He feels there is a definite link between pot smoking and stroke citing the fact that cannabis constricts brain vessels and can be associated with palpitations and atrial fibrillation which is a risk factor for stroke.

As the political pressure builds on states to legalize marijuana, tax it and use it as a revenue source; it would be nice to find out the consequences of its use and its effect on future illness and health care costs? Is it the marijuana? Is it the method of delivery by smoking it rather than pill form? These questions should be addressed in future studies.

Inflammation and Vascular Disease

Heart, stethescopeI was privileged to hear Bradley Bale, MD and Amy Doneen, MSN, ARNP talk about the development of coronary artery disease and cerebrovascular disease in patients with low or few cardiac risk factors.  They cited American Heart Association studies looking at groups of men and women between ages 45 and 65 who have their first heart attack or stroke despite being in compliance with suggested lipid and blood pressure guidelines. They pointed out that the first Myocardial Infarct or Stroke occurred in 88% of women who met lipid guidelines and 66 % of men.  These are people who do not smoke, do not have untreated or uncontrolled lipid levels, are not diabetics and who lead an active life style.  They asked “why”?

Dr. Bale and Ms. Doneen work with the well respected cardiovascular Center of Excellence at the Cleveland Clinic program in Ohio, and believe that inflammation is the root of the problem.  They believe that soft plaque composed of lipids and other cells lurks beneath the endothelial cells lining blood vessels. In the presence of inflammatory stimulants, this soft plaque ruptures suddenly through the endothelial level into the blood stream. When it comes in contact with the blood flowing through the vessels the body believes we are bleeding and cut and chemical mediators are released that initiate the formation of a clot. When this clot occurs in a small coronary artery we have a heart attack or myocardial infarction or precipitate a lethal irregular heartbeat. When this clot occurs in the blood vessels of the brain, we have an acute stroke or cerebrovascular accident.

The key to prevention in the so called low risk patient is to detect the inflammation in advance, and treat it. They are firm believers in performing B Mode Duplex ultrasounds of the carotid arteries in the neck to look for the presence of soft plaque beneath the endothelial cell lining. This soft plaque is distinctly different from the safe but calcified plaque we can see on CT scans used for cardiac scoring studies.  They couple this imaging study with a series of complex blood tests which identify inflammation. These include a myeloperoxidase level, the Lp-PLA2 level, the urine microalbumen to creatinine ratio, a F2-IsoPs level and the cardiac specific CRP level.

These tests and studies in combination with a traditional history and exam, sugar and lipid levels and EKG can help us identify those “low risk” patients who actually are high risk for a heart attack or stroke. The cause of the inflammation is often difficult to spot and may be in your mouth with dental or periodontal disease or in your joints with inflammatory arthritis.  Patients with excellent dental hygiene and normal appearing gums may harbor specific inflammatory bacteria that put them at risk. While this seems a bit forward thinking, remember we once questioned the research that showed that bacteria (H Pylori) caused gastric ulcers and intestinal bleeding.

I have begun instituting the inflammatory blood marker panels in my practice. Labs are sent to the Cleveland HeartLab for this purpose. I will be initiating periodic carotid ultrasound studies for the appropriate patients in the coming year.

It is often difficult for clinicians to distinguish snake oil sold for profit from cutting edge science. I have tried to spare my patients from worthless but profit driven products. I am convinced the Cleveland Clinic is just ahead of the rest of us in offering these services and I will make them available to the appropriate patients and will do it in a financially structured manner that does not add out of pocket cost to the patient. It’s not about adding another profitable income stream to the practice. It’s about identifying individuals who shouldn’t have a heart attack or stroke before they do.