New Technology Helps Save Stroke Patients’ Lives
 State-of-the-art
videoconferencing system allows doctors at UPMC Passavant and UPMC
Passavant Cranberry to access UPMC Stroke Institute expertise
When a patient is rushed to the UPMC Passavant or UPMC Passavant
Cranberry Emergency Department with symptoms of a stroke, time is of
the essence. The longer a person’s brain is denied oxygen and glucose
as the result of a clot or other blockage, the less chance that the
person will recover. But if doctors are able to intervene and provide
treatment within the first three hours after a stroke, they may
minimize damage to the brain, providing the patient with a better
chance of a partial or complete recovery.
“We have a saying which is ‘time is brain,’” explained Lawrence
Wechsler, MD, director of the UPMC Stroke Institute and professor of
neurology. “We have a three-hour window to give an acute stroke
patient intravenous tPA, and the sooner it is given, the better the
outcome.”
Intravenous tPA, also known as tissue plasminogen activator, is a
clot-busting drug that can lessen, or even reverse, the damage caused
during a stroke. Though it has been available for more than 10 years,
relatively few patients receive the drug after undergoing a stroke.
“Despite the great number of strokes that occur, only one to two
percent of patients end up being treated with IV tPA,” says Dr.
Wechsler. “The biggest problem is the difficulty in obtaining the
neurological expertise needed to diagnose these patients on an
emergent basis.”
When a patient is rushed to a hospital’s emergency room, it is often
difficult for a neurologist to get to the site within 20 or 30 minutes
to determine if that patient is a candidate for IV tPA. “Often,
emergency department physicians are not comfortable giving IV tPA on
their own, without the advice of a neurological expert,” says Dr.
Wechsler.
To this end, UPMC Passavant and UPMC Passavant Cranberry recently
partnered with the UPMC Stroke Institute to implement a stroke
telemedicine system. This system uses state-of-the-art
videoconferencing technology to link experts at the UPMC Stroke
Institute to Emergency Department physicians at both northern
hospitals. These Polycom units, which feature a computer monitor and
remote-controlled camera, have been in place at UPMC Passavant since
March 2006, and for the past month at UPMC Passavant Cranberry.
“It is a great benefit for patients when small community hospitals,
like UPMC Passavant Cranberry, can communicate with larger facilities’
experts on very short notice, on a real-time basis,” says Ravi
Vajjhala, MD, director, Emergency Medicine at UPMC Passavant
Cranberry. “By using telemedicine to evaluate and communicate with
patients directly, these specialists are able to help emergency
department physicians make judgments that better serve the patient.”
How It Works
When a patient enters the UPMC Passavant or UPMC Passavant Cranberry
Emergency Department with symptoms of a stroke, ED physicians need to
determine if that person is a candidate for acute stroke therapy. To
do this, they activate the stroke telemedicine system’s MedCall, which
allows them to connect effortlessly with the stroke experts at the
UPMC Stroke Institute.
“Emergency Department physicians are able to reach us 24 hours a day,
seven days a week, 365 days a year,” says Dr. Wechsler of the
technology that can be used within the Stroke Institute, as well as
from the Stroke Institute team’s homes.
Cameras and monitors, which are set up in the emergency departments’
examining rooms, provide Stroke Institute telemedicine team members
with two-way audio/video communication with ER doctors, as well as the
patient and the patient’s family. Team members can view CT scans,
gather patient histories, and even control the camera to zoom in and
out to more closely monitor the patient’s condition. “We can get all
of the essential information we need from the telemedicine system in
order to determine if the patient is a good candidate for IV tPA,”
says Dr. Wechsler. There is also a telemedicine unit set up in UPMC
Passavant’s intensive care unit, so that the Stroke Institute team can
monitor patients after treatment if needed.
“I think the biggest advantage of the stroke telemedicine system is
that it provides the emergency room physician 24-hour availability for
prompt, and even emergent
consultation with neurologists who are specialists in acute stroke
care,” says William Kristan, MD, chairman, Department of Emergency
Medicine, UPMC Passavant. “With the technology at hand, the
neurologist can evaluate the patient, talk to the patient’s family,
look at the CT scan, and be confident with the results because they
are not relying on someone else’s interpretation.
“Being able to consult and collaborate with a stroke specialist
enables the emergency department physician to feel more comfortable
with treating the patient with tPA since IV tPA can cause potentially
dangerous side effects in some patients,” he continues.
Since the stroke telemedicine program began in March 2006, doctors at
the UPMC Stroke Institute have reviewed 38 patient cases with the
technology, and nine patients have been treated with IV tPA. The
Stroke Institute averages a response time of 5.42 minutes to MedCall,
and those patients who are considered to be good candidates for IV tPA
are treated with the clot-busting drug an average of 75 minutes after
arriving at the hospital. Patients whose strokes are caused by
hemorrhages or who have uncontrolled hypertension do not qualify for
the procedure.
“Though we’ve only been doing this a short period of time, patients
treated with IV tPA through the stroke telemedicine system have shown
significant improvements, with some undergoing a complete recovery,”
says Dr. Wechsler. Studies show that when treated with IV tPA in the
first 90 minutes after the onset of a stroke, patients are twice as
likely to recover from a stroke, with 33 percent of patients showing
minimal or no disability.
“Even though a person may have had a stroke outside that three-hour
window, it’s still important to get the person to the hospital as
quickly as possible, because there are potential alternative
treatments available,” adds Dr. Kristan. “The biggest obstacle we see
in treating strokes is patients who delay coming to the emergency
department — they wait to see if things will get better.”
Reaching Out to More Communities
As the only health system in western Pennsylvania that links Stroke
Institute experts to community hospitals via telemedicine technology,
the University of Pittsburgh Medical Center plans to expand the
service to reach even more communities. The service, which is
currently available at UPMC Passavant, UPMC Passavant Cran-berry, UPMC
Presbyterian, and UPMC Braddock, will soon be up and running at UPMC
McKeesport and UPMC St. Margaret.
“Efforts are under way to extend the tele-medicine program to all UPMC
hospitals,” says Dr. Wechsler. The technology, which was pioneered by
Dr. Lee Schwamm, director of TeleStroke and acute stroke services at
Massachusetts General Hospital, is currently used at 14 hospitals in
Massachusetts, as well as at hospitals in Georgia, southern
California, and Utah.
“For patients who have a stroke, being able to go to a hospital where
doctors are able to evaluate and treat them emergently with IV tPA
capabilities is extremely important,” says Dr. Wechsler. “Time is
brain, and the sooner these patients receive treatment, the better.”
STROKE TIMELINE
Never ignore the warning signs of a stroke. The faster you get
diagnosed and treated, the better the outcome. Every minute you wait,
you lose almost 2 million brain cells.
Symptoms begin
-
Numbness or weakness of the face, arm, or leg, especially on one side
of the body
-
Sudden confusion, trouble speaking or understanding
-
Trouble seeing in one or both eyes
-
Trouble walking, dizziness, loss of balance or coordination
-
Sudden, severe headache with no known cause
Patient’s brain is not getting enough oxygen or glucose.
Emergency services are contacted. Patient is rushed to the hospital.
For each minute that a stroke is left untreated, a patient’s brain
loses:
For every 12 minutes that treatment is delayed, a pea-sized piece of
brain dies.
Patient arrives at the hospital, and Emergency Room physicians link
with the UPMC Stroke Institute team. Rapid assessment includes:
-
Communication with ER physicians,
the patient, and the patient’s family
-
Gathering of a patient history
-
Results of labs and CT scan
-
Neurological assessment using telemedicine camera
If UPMC Stroke Institute team determines patient is a good candidate,
intravenous tPA is administered within three hours of stroke.
• Blood flow is restored to the brain
• Stroke disabilities may be reduced
• Some patients experience complete recovery
If a stroke is allowed to run its full course without treatment, after
approximately 10 hours, the patient loses:
Brain tissue the size of 1.5 ping-pong balls is irretrievably lost.
*Statistical information from a study published in Stroke: Journal of
the American Heart Association.
Warning Signs of a Stroke
If you notice one or more of these signs, don’t wait.
Call 9-1-1 or get to a hospital right away.
-
Sudden numbness or weakness of the face, arm, or leg, especially on
one side of the body
-
Sudden confusion, trouble speaking or understanding
-
Sudden trouble seeing in one or both eyes
-
Sudden trouble walking, dizziness, loss of balance or coordination
-
Sudden, severe headache with no known cause
Not all the warning signs occur in every stroke. Don’t ignore signs of
stroke, even if they go away.
Courtesy: The American Stroke Association
One Patient’s Story
This past spring, Arvilla Hurt traveled from her home in Virginia to
spend some time with her son, Jerry, and his family, who live in
Franklin Park. Thinking that he had heard her fall in the bedroom,
Jerry went to help her, and realized that there was something more
going on.
“I thought that she might have hit her head when she fell because she
seemed incoherent, and was really confused,” he said. “She was trying
to talk, but couldn’t, so I called an ambulance. One of the paramedics
said that he thought it might be a stroke.”
Arvilla, 77, was taken to the UPMC Passavant Emergency Department,
where doctors linked with the Stroke Institute team at UPMC
Presbyterian using the stroke telemedicine system. CT results were
viewed simultaneously by the emergency department physician and the
neurologist at UPMC Presbyterian, and a decision was made to
administer intravenous tPA for acute stroke.
“The emergency room doctor came and explained the drug and its risks
to us,” said Mr. Hurt. “We agreed that she should have it, and it was
amazing—within two hours, she seemed completely back to normal.”
“When we took her in, she couldn’t even speak coherently; but within a
couple of hours, she could read a book and identify the pictures.
Within three days, she was ready to go home.”
Today, Arvilla is back in Virginia, and Jerry says that she is doing
fine. “We were blessed to have a hospital close enough when we needed
it, and to get her there within an hour of when the stroke happened,”
he said.
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