Imagine having a severe, life-threatening stroke at 5 p.m., being rushed by ambulance to undergo minimally invasive surgery to remove the blood clot from your brain, then walking out of the hospital, symptom-free, the very next morning. That’s what happened to 72-year-old Carleton Golder.
It’s widely assumed that the outcome of a stroke will be one of three options: death, life-long disability, or a long, grueling recovery. As it stands, stroke is the fifth most common cause of death in America and a leading cause of adult disability. It reduces mobility in more than half of stroke survivors ages 65 and older. While these outcomes can’t be completely eliminated, Golder’s experience can be far more common.
When treated quickly and appropriately, even people with the most severe strokes can survive and thrive. The problem is that most stroke patients aren’t accessing the treatment they need, particularly those who are most vulnerable. This is especially true for those patients who first are taken to a lower level center and then need to be subsequently transferred to a higher level hospital for specialized treatment. According to new JAMA study, stroke patients who are female, Black, Hispanic, or 80-plus years of age have a significantly longer delay for inter-hospital transfers. This is unacceptable and demonstrates that the system — even with significant improvements in some regions — is still failing too many people.
Field triage protocols where emergency services personnel assess stroke severity in the field and then, depending on the case, have the option to take patients to the most appropriate center rather than the closest should be standard practice everywhere. This can help close the gap in systemic disparities in care.
Medicine has delivered a groundbreaking treatment for the most dangerous strokes, known as emergent large vessel occlusions. During a mechanical thrombectomy, neurointerventionalists, physicians with dedicated expertise in minimally invasive procedures in the brain, use catheters to quickly reopen blocked arteries in the brain — in as quickly as 20 minutes in some cases. This is a safe and well-established procedure, and has been the standard of care since 2015. However, less than one-third of stroke patients who are eligible receive this life-saving procedure. For most, it comes down to getting to the appropriate medical facility in time to receive treatment. This is where EMS comes in.
Over the past 7 years, physicians, patients, and advocates have pushed forward changes to EMS triage and transport protocols across the country. To date, 41 states have updated local or statewide stroke system policies (such as ensuring severe stroke patients are transported to a Level 1 stroke center), with others poised to make similar changes. The challenge now is to motivate stroke patients or family members to call 911 at any sign of stroke so that they can plug into these improved systems.
Research shows stroke patients and their families hesitate to call 911 for a variety of reasons, such as failing to realize the emergency nature of the situation, wanting to go to a specific hospital, worrying about transport costs, or lacking understanding about the speed and efficacy of being taken in an ambulance.
But the fact is when a person calls 911 for stroke, first responders can assess their condition and start treatment right away. Driving to the emergency department (ED) and waiting in line puts a patient at risk of not recovering. Not only that, the newly updated triage and transport protocols ensure that most patients who call 911 will be taken directly to a facility that is best equipped to treat them.
This unaccessed care is costing us on an individual and societal level. Stroke costs in the U.S. are approximately $56.5 billion. Additionally, for every minute saved in transfer to the appropriate care, there is $1,000 in savings on medical costs for short- and long-term care. So, patients who hesitate to call an ambulance due to the anticipated expense might be costing themselves thousands more in costs related to recovery and lost wages.
Updating triage and transport protocols nationwide was the first step in ensuring patients survive and thrive after a severe stroke. Now healthcare providers, patient advocates, and community leaders all have a role to play in getting people to call 911. Promoting simple tools like BEFAST (balance, eyes, facial drooping, arm weakness, slurred speech, time to go to the ED) can help patients understand the signs and take them seriously.
Golder says he owes his life to the young man that called 911 for him. Golder was conducting a job interview when the applicant noticed that he was rubbing his temples, and at one point “got lost” in the discussion. The applicant recognized the signs of a stroke and immediately called 911. Within 8 minutes, EMS was on the scene.
No one is immune to stroke, but everyone should have access to the best possible stroke care when they need it, no matter where they live. Because when it comes to stroke, calling 911 is essential. The medical system should take care of the rest.
Mahesh Jayaraman, MD, is an interventional neuroradiologist at Rhode Island Hospital and the president of the Society of NeuroInterventional Surgery.
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