New remote technology allows distant neurologists to assess from afar stroke patients in rural parts of the state and make critical decisions about their care.
By Jill Braden Balderas
When Ed Ward didn’t come to the dinner table after his wife Kathy first called from the kitchen that supper was ready, she wasn’t surprised.
“He was watching sports,” Kathy explained. “So I called him again and he didn’t come.”
Still in the kitchen in their house in Lexington, she heard Ed speak with a slur and instantly knew something was wrong. Kathy found Ed in the den on his knees between an ottoman and a loveseat.
“I couldn’t move,” recalled Ed, who was 57 years old at the time.
Kathy, a former nurse, immediately called 911. “I told them I thought he had had a stroke,” she explained.
“Time Lost is Brain Lost”
That Sunday afternoon in September 2010 Ed Ward did suffer a stroke. Paramedics rushed him to Wake Forest Baptist Health-Lexington Medical Center, one of two hospitals in rural Davidson County, North Carolina.
When a stroke patient arrives the hospital, doctors must determine if the condition is ischemic – caused by a blood clot – or hemorrhagic – due to a broken blood vessel. Both quickly starve brain tissue of blood, which is why stroke experts coined the phrase “Time Lost is Brain Lost.” Millions of brain cells die each minute when deprived of oxygen and nutrients.
According to the American Stroke Association, 87 percent of strokes in the U.S. are ischemic. A Food and Drug Administration-approved drug called tPA (tissue plasminogen activator) can treat ischemic stroke by busting up the blood clot, and restoring blood flow to the brain. But tPA will not help patients past 4.5 hours of onset of symptoms.
Fortunately for Ward, his wife’s swift reaction and the brief ambulance ride got him to the hospital quickly. The doctor in Lexington’s emergency department (ED) suspected Ed Ward’s stroke was ischemic and that he was a candidate for tPA. In order to be sure the doctor contacted neurologist Charles H. Tegeler, M.D., of Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.
Evolution in Telemedicine
For years, Lexington’s ED had telephoned neurologists to get a second opinion on a patient’s eligibility for tPA. Like many rural EDs, Lexington does not have a neurologist on staff, so they conferred with neurologists like Tegeler about CT scans and other patient examinations over the phone. But in December 2009, this process became more high tech.
Some patients have called Tegeler “the robot doctor.” It’s no wonder, because the first look they get at Tegeler is when the doctor drives a 5-foot-tall machine into their room, Tegler’s face clearly visible on the monitor. He’s in Winston-Salem; they’re in one of nine North Carolina hospitals that contract with Wake Forest Baptist for its telestroke services.
“Our goal is to improve stroke care and improve access to stroke expertise,” explained Tegeler, who oversees Wake Forest Baptist’s telestroke program.
“Emergency room physicians are expected to know everything,” says Tegeler. “When they’re out by themselves, especially in smaller communities, it could be uncomfortable giving what’s potentially a risky therapy without any backup.”
Other conditions mimic a stroke and neurologists know better the finer points of the distinction. So, out of an abundance of caution, ED doctors can be reluctant to administer tPA. Recent research by the Centers for Disease Control and Prevention shows the extent of their caution. The study found tPA use rose from 6.4 percent of stroke patients in 2005 to only 9.5 percent in 2010.
“You don’t want to give potentially risky and expensive treatment if it isn’t a stroke,” said Tegeler. “There is a 6% risk of brain hemorrhage.”
Set medical criteria help determine which patients are at greater risk for this bleeding.
Tegeler and the other four vascular neurologists at Wake Forest Baptist beam in to the robot through their hospital desktops or the laptops they tote when on call.
“I could be at Harris Teeter or Costco as long as there is wireless [Internet] I can access,” said Tegeler.
Through the camera on the robot, Tegeler performs a complete neurological assessment on the patient. Based on his findings, and the examination of the ED doctor, Tegeler will make a recommendation for whether or not to administer tPA.
Ultimately, the ED doctor makes the tPA call.
Stephen Greer, M.D., has been medical director of Lexington’s ED for just over a year.
Having Tegeler examine a patient via the robot he said, “It’s the next best thing to being there.”
“No matter how many times I see these patients, my neurologic exam is never going to be as good as Dr. Tegler’s because that is all he does,” said Greer.
Because of the risk that goes along with tPA, Greer sees the telestroke program as a way to rule people in who need the drug.
“I’m fairly comfortable not giving tPA,” Greer expressed. “I’m not real comfortable without a neurologist saying ‘give it.’”
Patient Education, Especially in the Stroke Belt
The CDC study, looked at more than 115,000 patients over 5 years, and found that 44 percent of stroke patients arrived the hospital more than 4.5 hours after the start of stroke symptoms. That means they were automatically ineligible to receive tPA. It also demonstrates the major need to educate patients about stroke symptoms and the importance of getting to an emergency room fast.
“The knowledge of stroke in general is dismal,” said neurologist Larry Goldstein, M.D., director of the Duke Stroke Center in Durham.
“Very often patients will consciously deny the symptoms,” he explained. “Or stroke itself – the way the brain works – makes the person not realize they are having a stroke.”
Still, many patients don’t know what symptoms indicate a stroke or that they need to get to the hospital immediately.
Educational campaigns to change this take on further significance in North Carolina because it’s part of what researches have dubbed the “Stroke Belt” – the swath of southeastern states that have higher stroke rates than the rest of the U.S.
According to a North Carolina Stroke Association fact sheet, the state’s stroke death rate is sixth highest in the nation, with the age-adjusted stroke rate – 57.4 per 100,000 – coming in 23 percent higher than the overall U.S. rate.
That same fact sheet reports that in 2007, just 17.6 percent of N.C. adults could identify the symptoms of a stroke, and would call 911.
The state continues to make progress in developing hospitals that are known as nationwide as Primary Stroke Centers, where patients can get the best available care. Twenty-seven North Carolina hospitals have received this designation from The Joint Commission, which includes being able to administer tPA. But these hospitals are mostly located along I-85, I-40 and I-77 leaving many North Carolinians far from comprehensive stroke care.
“There are areas of the state where there are no specific hospitals that are capable of treating with tPA,” said Goldstein.
Ed Ward did receive tPA. For his treatment, doctors followed what’s known as “Drip and Ship.” The drip was the tPA given through an IV, the ship was transferring him to Wake Forest Baptist so the neurologists there could care for him.
All he remembers about the ambulance ride from Lexington to Winston-Salem was asking the paramedics, “Can’t y’all find some more bumps to hit?”
According to Wake Forest Baptist, 248 activations occurred in their telestroke network in 2011. Fifty-three percent of those patients remained at the original hospital, 45 percent of them were transferred to Wake Forest Baptist, and 2 percent got transferred to other facilities. Transfers are recommended when there is no neurologist available in the area to offer continuing care to the patient.
Shortly after he arrived Wake Forest Baptist, Ward started to experience paralysis and several days later life-threatening brain swelling that required surgery. Ward worked hard at physical therapy for months, but still remains mostly confined to a wheelchair.
“They tried me on different kinds of walkers and it just hasn’t worked real good yet,” Ward said. “I still gotta get stronger and get my balance back.”
Ward demonstrates the success of telestroke, said Tegeler, first of all because he received tPA. Secondly, Ward was transferred to receive a higher level of care. “He was in the right spot for the kind of care that he needed to save his life,” Tegeler said.
Looking over at his grandson Madden, Ward said he feels “lucky” to have survived.
“Especially after all I went through, I had good care and people taking good care of me.”