J.L. WEBB

The numbers are frightening: approximately 700,000 Americans will suffer a stroke this year. That's one stroke every 45 seconds. Every three minutes, one of those patients will die, making stroke the third-most prevalent cause of death in the United States. And the so-called alleged lucky ones — patients who survive - will become members of the group that is the nation's number-one cause of disability.

But those bleak statistics are in the crosshairs of Central Florida healthcare providers whose life-and-death mission is to beat the clock that is the enemy in emergency treatment of stroke patients.

At Florida Hospital's Orlando and Altamonte campuses, both of which are certified primary stroke centers, "Code Gray" teams rally to respond when paramedics and emergency medical technicians in the greater Orlando area alert them that they are bringing in a patient who may have had a stroke.

According to Deborah Lombardi, administrative director of Florida Hospital's Neuroscience Institute, the Code Gray team includes a computed tomography technician who prepares a CT scanner for the patient, a laboratory technician who facilitates a quick turnaround of lab tests, a charge nurse who makes arrangements for a hospital bed, a patient registrar to admit the patient into the system, and a neurocritical care-trained nurse. An emergency room physician is available and a stroke neurologist is on call, Lombardi said.

Once paged, the team mobilizes in minutes — minutes that are golden when it comes to providing meaningful treatment to a person who has had a stroke. Time can mean the difference between recovery, severe disability or death.

"At a well-run stroke center, everything stops for that one patient. The key factor is getting the CT scan and seeing what is going on in the brain. That's when we know if we still can do something about it," said Dr. Michael Lozano, president of the Florida Association of EMS Medical Directors and chair of the Florida College of Emergency Physicians' EMS/Trauma Committee, with headquarters in Orlando.

"It wasn't that long ago, honestly, that we couldn't do much for (stroke patients)," said Lozano, 44. But since passage in 2004 of the Florida Stroke Act, which requires that paramedics and EMTs transport possible stroke victims to state-accredited Primary Stroke Centers, and the inception of Code Gray or "Brain Attack" teams, Lozano said treatment options are greater and positive outcomes have increased.

"We know with certainty from clinical studies that stroke patients do better if they go to a hospital that is a certified stroke center," Lozano said.

Dr. William David Honeycutt, 47, is a Maitland neurologist who is on call when a Code Gray alert is issued at Florida Hospital. He said the improved quality of care is palpable since the teams were put in place. "And the more you utilize a protocol like this, the better you become at it," Honeycutt said.

Honeycutt gave earned credit to "the medical directors from all surrounding counties who have really stepped up to take an active role in educating their paramedics" about diagnosing strokes in the field.

"They've come a long way in identifying strokes and getting them to the appropriate hospital," Honeycutt said.

Once doctors like Honeycutt confirm a stroke and that it was ischemic (only about 15 percent of strokes are hemorrhagic), they determine if the patient is a candidate for intravenous drugs that may be able to dissolve the clot. Again, time is the critical factor in this attempt to intervene.

If doctors are sure the stroke occurred in the past three hours, it usually is safe to administer the clot-buster drugs. If that cannot be ascertained, the risk of using the tissue plasminogen activators, or tPAs, may outweigh the possible benefit. Unfortunately, only about 3 to 5 percent of stroke patients nationally are candidates for IV clot-busters, but that percentage has almost doubled at some primary stroke center hospitals, including Florida Hospital.

Knowing when to start the clock on stroke treatment is difficult. Victims delay dialing 911 because they are not familiar with the signs of stroke. They fail to recognize slurred speech, blurred vision, confusion and numbness in their extremities and face as symptoms.
"People just don't call 911 soon enough," noted Dr. Charles Sand, a past recipient of the national Stroke Advocate of the Year award from the American Stroke Association.

"Strokes are (odd) like that. You can't see right. You can't talk right. You don't really know what is going on with your body. It's not like a heart attack where you have chest pain," said Sand, 48, medical director for Bayflite at St. Joseph's Hospital in Tampa, one of the busiest emergency rooms in Central Florida and where many stroke patients from rural areas are airlifted. The team at St. Joseph's responded to 677 stroke alerts in 2006.

"Recognition and calling 911 are the two big obstacles to overcome in educating patients" about the symptoms of stroke, Sand said. With acute care teams on call in the ER, "it's a shame when people don't come in right away so that we can treat them."

When treating cardiac emergencies, Sand said it is understood that "time is muscle" and the sooner a patient gets to the cath lab, the better the chances of limiting damage to the heart muscle. When the emergency is stroke, time creates a similar risk to brain tissue.

Lombardi agreed. "Older people tend not to pay attention to the symptoms. They think it's something else and less serious," she said.

Lozano said the key to raising awareness among patients is to raise awareness among physicians, and that approach transcends strokes and applies to all diagnoses. In his role with the Florida Association of EMS Medical Directors, Lozano wants all doctors to remember that "emergency medicine is sophisticated and a vital part of the continuous line of patients' treatment."

Toward that end, Lozano believes it is important for physicians to devote more time outside their clinical specialties to stay abreast of what's new in emergency medicine.



June 2007