(insert name here), M.D., Medical Staff President
(insert hospital name here)
(insert hospital address here)
Dear (insert name of hospital administrator and president of medical staff here):
This WSJ article (below) suggests knowing which hospitals can effectively treat stroke is important. The vice-president of the American Hospital Association (quoted below) agrees "... it would be important for patients to know how well prepared their local hospital is."
Therefore, I must ask you, as recommended by that AHA executive:
1. Does your hospital have both CT techs and equipment available at all hours on all days?
2. Is a neurologist available at all hours?
3. What is the mininum training of your neurologists in dealing with strokes in an emergent setting?
4. What are your ER protocols for stroke treatment?
5. Is tPA available if indicated?
I look forward to your response.
Sincerely yours,
/s/ (your name, mailing address here)
cc: (insert name of your attorney)
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Fatal BlockagesGee, I would, too.
Stroke Victims Are Often Taken To Wrong Hospital
Outdated Ambulance Rules, Inadequate ERs Make Dangerous Ailment Worse
Lessons From Trauma Centers
By THOMAS M. BURTON
Staff Reporter of THE WALL STREET JOURNAL
May 9, 2005; Page A1
Christina Mei suffered a stroke just before noon on Sept. 2, 2001. Within eight minutes, an ambulance arrived. Her medical fate may have been sealed by where the ambulance took her.
Ms. Mei's stroke, caused by a clot blocking blood flow to her brain, occurred while she was driving with her family south of San Francisco. Her car swerved, but she was able to pull over before slumping at the wheel. Paramedics saw the classic signs of a stroke: The 45-year-old driver couldn't speak or move the right side of her body.
Had Ms. Mei's stroke occurred a few miles to the south, she probably would have been taken to Stanford University Medical Center, one of the world's top stroke hospitals. There, a neurologist almost certainly would have seen her quickly and administered an intravenous drug to dissolve the clot. Stanford was 17 miles away, across a county line.
But paramedics, following county ambulance rules that stress proximity, took her 13 miles north, to Kaiser Permanente's South San Francisco Medical Center. There, despite her sudden inability to talk or walk and her facial droop, an emergency-room doctor concluded she was suffering from depression and stress. It was six hours before a neurologist saw her, and she never got the intravenous clot-dissolving drug.
In a legal action brought against Kaiser on Ms. Mei's behalf, an arbitrator found that her care had been negligent, and in some aspects "incomprehensible." Today, Ms. Mei can't dress herself and walks unsteadily, says her lawyer, Richard C. Bennett. The fingers on her right hand are curled closed, and she has had to give up her main avocations: calligraphy, ceramics and other types of art. Kaiser declined to comment beyond saying that it settled the case under confidential terms "based on some concerns raised in the litigation."
Stroke is the nation's No. 1 cause of disability and No. 3 cause of death, killing 164,000 people a year. But far too many stroke victims, like Ms. Mei, get inadequate care thanks to deficient medical training and outdated ambulance rules that don't send patients to the best stroke hospitals.
Over the past decade, American medicine has learned how to save stroke patients' lives and keep them out of nursing homes. New techniques offer a better chance of complete recovery by dissolving blood clots and treating even more lethal strokes caused by burst blood vessels in the brain. But few patients receive this kind of treatment because most hospitals lack specialized staff and knowledge, stroke experts say. State and county rules generally require paramedics to take stroke patients to the nearest emergency room, regardless of that hospital's level of expertise with stroke.
Stroke care is positioned roughly where trauma care was a quarter-century ago. By 1975, surgeons expert at treating victims of car crashes and other major accidents realized that taking severely injured patients to the nearest emergency room could mean death. So the surgeons led a push to make selected regional hospitals into specialized trauma centers and to overhaul ambulance protocols so that paramedics would speed the most severely injured to those centers. Now, in many areas of the U.S., accident victims go quickly to a trauma center, and trauma specialists say this change has saved lives and lessened disability.
Eighty percent or more of the 700,000 strokes that Americans suffer annually are "ischemic," meaning they are caused by blockage of an artery feeding the brain, usually a blood clot. Most of the rest are "hemorrhagic" strokes, resulting from burst blood vessels in or near the brain. Although they have different causes, both result in brain tissue dying by the minute.
Several factors have combined to prevent improvement in stroke care. In some areas, hospitals have resisted movement toward a system of specialized stroke centers because nondesignated institutions could lose business, according to neurologists who favor the changes. In addition, stroke treatment has lacked an organized lobby to galvanize popular and political interest in the ailment.
Doctor Ignorance
A big reason for the backwardness of much stroke treatment is that many doctors know little about it. Even emergency physicians and internists likely to see stroke victims tend to receive scant neurology training in their internships and residencies, according to stroke specialists.
"Surprisingly, you could go through your entire internal-medicine rotation without training in neurology, and in emergency medicine it hasn't been emphasized," says James C. Grotta, director of the stroke program at the University of Texas Health Science Center at Houston.
Many hospitals don't have a neurologist ready to deal with emergencies. As a result, strokes aren't treated urgently there, even though short delays increase chances of severe disability or death. Even if doctors do react quickly, recent research has shown that many aren't sure what treatment to provide.
For example, a survey published in 2000 in the journal Stroke showed that 66% of hospitals in North Carolina lacked any protocol for treating stroke. About 82% couldn't rapidly identify patients with acute stroke.
As with other life-threatening conditions, stroke patients are better off going where doctors have had a lot of practice addressing their ailment. A seven-year analysis of surgery in New York state in the 1990s showed that patients with ruptured blood vessels in the brain were more than twice as likely to die -- 16% versus 7% -- in hospitals doing few such operations, compared with those doing them regularly. A national study published last year in the Journal of Neurosurgery showed a similar disparity.
Another major shortcoming of most stroke treatment, according to many neurologists, is the failure to use the genetically engineered clot-dissolving drug known as tPA. Short for tissue plasminogen activator, tPA, which is made by Genentech Inc., has been shown to be a powerful treatment that can lessen disability for many patients. A study published in 2004 in The Lancet, a prominent medical journal, showed that the chances of returning to normal are about three times greater among patients getting tPA in the first 90 minutes after suffering a stroke, even after accounting for tPA's potential side effect of cerebral bleeding that can cause death. But several recent medical-journal articles have found that nationally, only 2% to 3% of strokes caused by clots are treated with tPA, which has no competitor on the market.
Some authors of studies supporting the use of tPA have had consultant or other financial relationships with Genentech. Skeptics of the drug point to these ties and stress tPA's side-effect danger. But among stroke neurologists, there is a strong consensus that the drug is effective.
One reason why many patients don't receive tPA is that they arrive at the hospital more than three hours after a stroke, the time period during which intravenous tPA should be given. But many hospitals and doctors don't use tPA at all, even though it has been available in the U.S. since 1996. The dissolving agent's relatively high cost -- $2,000 or more per patient -- is a barrier. Medicare pays hospitals a flat reimbursement of about $5,700 for stroke treatment, regardless of whether tPA is used.
Airport Emergency
Glender Shelton of Houston had an ischemic stroke caused by a clot at Los Angeles International Airport on Dec. 30, 2003. In full view of other holiday travelers, Ms. Shelton, then 66, slumped over, and an ambulance was called. It was 4:45 p.m.
By 5:55 p.m., she arrived at what now is called Centinela Freeman Regional Medical Center, four miles away in Marina del Rey. Hospital records show that doctors thought Ms. Shelton had suffered an "acute stroke." But she didn't get a CT scan, a recommended initial step, until 9 p.m. By then, she was already outside the three-hour window for safely administering intravenous tPA. Records also say she didn't receive the drug "due to unavailability of a neurologist until after the patient had been outside the three-hour time window."
Ms. Shelton's daughter, Sandi Shaw, was until recently nurse-manager of the prestigious stroke unit at the University of Texas Health Science Center at Houston. Ms. Shaw says that at her unit, her mother would have had a CT scan within five minutes of arriving, and tPA probably would have been administered 30 or 35 minutes after that.
Today, according to her daughter. Ms. Shelton often can't come up with words or relatives' names, can't take care of her finances, and can't follow certain basic commands in neurological tests.
Kent Shoji, an emergency-room doctor at Centinela Freeman who handled Ms. Shelton's case, says, "She was a possible candidate for tPA," but a CT scan was required first. "The order was put in for a CT scan," Dr. Shoji says. "I can't answer why it took so long."
A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage with our CT scan, and we had to call a technician to come in. That's pretty common with a community hospital." The hospital has since been acquired by a larger health system and now does have 24-hour CT capability.
'Parochial Interests'
A hospital-accrediting group has begun designating hospitals as stroke centers, but that is only part of what is needed, stroke experts assert. They say hospitals typically have to come together to create local political momentum to change state or county rules so that ambulances actually take stroke patients to stroke centers, not the nearest ER. New York, Maryland and Massachusetts are moving toward creating stroke-care systems, and Florida recently passed a law creating stroke centers. But in many places, short-term economic interests impede change, some doctors say.
"There are still very parochial interests by hospitals and physicians to keep patients locally even if they're not equipped to handle them," says neurosurgeon Robert A. Solomon of New York-Presbyterian Hospital/Columbia. "Hospitals don't want to give up patients."
The University of California at San Diego runs one of the leading stroke hospitals in the country. It and others in the area that are well prepared to treat stroke patients have sought for a decade to set up a regional system, but there has been little progress, says Patrick D. Lyden, UCSD's chief of neurology. "Some hospitals are resisting losing stroke business," he says. "We have the same political crap as in most communities. Paramedics still take people to the local ER."
Among the opponents of the stroke-center concept during the 1990s was Richard Stennes, then ER director at Paradise Valley Hospital south of San Diego. In various public debates, Dr. Stennes recalls, he argued that many apparent stroke patients would be siphoned away from community hospitals even if they didn't turn out to have strokes. Also, he argued that tPA might cause more injury than it prevents. And then there was the economic issue: "Those hospitals without all the equipment and stroke experts," he says, "would be concerned about all the patients going to a stroke center and taking the patients away from us." Dr. Stennes has since retired.
"All hospitals and clinicians try to deliver the right care to patients, especially those with urgent medical needs," says Nancy E. Foster, vice president for quality of the American Hospital Association, which represents both large and small hospitals. "Community hospitals may be equally good at delivering stroke care, and it would be important for patients to know how well prepared their local hospital is."
Stroke experts aren't proposing that every hospital needs to specialize in stroke care but instead that in every population center there should be at least one that does. In Atlanta, Emory University's neuro-intensive care unit illustrates the special skills that make for top care. Owen B. Samuels, director of the unit, estimates that 20% to 30% of patients it treats received poor initial medical care before arriving at Emory, jeopardizing their futures or even lives. Brain hemorrhages, for example, are commonly misdiagnosed, even in patients who repeatedly showed up at emergency rooms with unusually severe headaches, Dr. Samuels says.
The Emory unit has 30 staff members, including two neuro-critical care doctors and five nurse practitioners. A team is on duty 24 hours a day. The unit handles about two dozen patients most days, keeping the staff busy. On the ward, nearly all patients are unconscious or sedated, so it's eerily silent. Patients generally need to rest their brains as they recover from stroke or surgery.
After a hemorrhagic stroke, blood pressure in the cranium builds as blood continues to seep out of the ruptured vessel. Pressure can be deadly, cutting off oxygen to the brain. Or escaped blood can cause a "vasospasm," days after the original stroke, in which the brain reacts violently to seeped-out blood. In the worst case, the brain herniates, or squeezes out the base of the skull, causing death. To avoid this, nurses at Emory constantly monitor brain pressure and temperatures. They put in drain lines. They infuse medicines to dehydrate, depressurize and stop bleeding.
Since Emory launched the neuro-intensive unit seven years ago, 42% of patients with hemorrhagic strokes have become well enough to go home, compared with 27% before. Fewer need rehabilitation -- 31% versus 40% -- and the death rate is down.
Damica Townsend-Head, 33, gave the Emory team a scare. After surgery last fall for a hemorrhagic stroke, her brain swelling was "really out of control," Dr. Samuels says, raising questions about whether she would survive. The staff put a "cooling catheter" into a blood vessel, which allowed the circulation of ice water to bring down the temperature in her blood and brain. They intentionally dehydrated her brain to lower pressure. A month later, she woke up and recovered with minimal disability. She still walks with a cane and tires easily, but her speech is normal and she hopes to return soon to work. "I consider her what we're in business for," Dr. Samuels says.
Public Awareness
The public's low awareness of stroke symptoms -- and the need to respond immediately -- can also hinder proper care. Ischemic strokes, those caused by clots or other artery blockage, cause symptoms such as muscle weakness or paralysis on one side, slurred speech, facial droop, severe dizziness, unstable gait and vision loss. People with this kind of stroke are sometimes mistaken for being drunk. In addition to intense head pain, a hemorrhagic stroke often leads to nausea, vomiting or loss of balance or consciousness. Still, many people with some of these symptoms merely go to bed in hopes of improving overnight, doctors say. Instead, they should go immediately to a hospital and demand a CT scan as a first diagnostic step.
The well-funded American Heart Association, established in 1924, has made many people aware of heart attack symptoms and thereby saved many lives. In contrast, the American Stroke Association was started only in 1998 as a subsidiary of the heart association. The stroke association spent $162 million last year out of the heart association's $561 million overall budget.
Justin Zivin, another University of California at San Diego stroke expert, says the stroke association "is a terribly ineffective bunch. When it comes to actual public education, I haven't seen anything."
The stroke association counters that it is buying television and radio ads promoting awareness, similar to ones produced in 2003 and 2004. The group also sponsors research and education, including an annual international stroke-medicine conference.
It's not just the general public that fails to recognize stroke symptoms. Often, emergency-room doctors and nurses don't, either. Gretchen Thiele of suburban Detroit began having horrible headaches last May, for the first time in her life. "She wasn't one to complain, but she said, 'I can't even lift my head off the pillow,' " recalls her daughter, Erika Mazero. Ms. Thiele, 57, nearly passed out from the pain one night and suffered blurred vision. When the pain recurred in the morning, she went to the emergency room at nearby St. Joseph's Mercy of Macomb Hospital. Ms. Mazero says that during the six hours her mother spent there, she was given a CT scan, but not a spinal tap, which could definitively have shown she had a leaking brain aneurysm, meaning a ballooned and weakened artery in her brain. After the CT, Ms. Thiele was given a muscle relaxant and pain medicine and sent home, her daughter says.
Two months later, the blood vessel burst. Neurosurgeons at William Beaumont Hospital in Royal Oak, Mich., did emergency surgery, but Ms. Thiele suffered massive bleeding and died. Ali Bydon, one of the neurosurgeons at Beaumont, says a CT scan often is inadequate and that her condition could have been detected earlier with a spinal tap, also called a lumbar puncture. "Had she had a lumbar puncture and perhaps an operation earlier, it might have saved her life," says Dr. Bydon. "In general, a person who tells you, 'I usually don't get headaches, and this is the worst headache of my life,' is something that should alarm you."
In addition, he says Ms. Thiele "absolutely" was experiencing smaller-scale bleeding in May that foreshadowed a more serious rupture. If doctors identify this kind of bleeding early, he says, chances of death are "minimal." But when a rupture occurs, he says, "25% of patients never make it to the hospital, 25% die in the hospital and 25% are severely disabled."
A St. Joseph's hospital spokeswoman says the hospital has "very aggressive standards for treatment, and we met this standard," declining to elaborate.
Determined Nurse
Paramedics did the right thing after Chuck Toeniskoetter's stroke, but only because of some extraordinary intervention. Mr. Toeniskoetter, then 55, was on a ski trip Dec. 23, 2000, at Bear Valley, near Los Angeles. He had just finished a run at 3:30 p.m. when, in the snowmobile shop, he began slurring his words and nearly fell over. Kathy Snyder, the nurse in the ski area's first-aid room, quickly diagnosed stroke. She called a helicopter and an ambulance.
Ms. Snyder says she knew the closest hospital with a stroke team was Sutter Roseville Medical Center in Roseville, Calif. The helicopter pilot was planning to take Mr. Toeniskoetter to a closer ER, but Ms. Snyder says she stood on the helicopter runners, demanding the patient go to Sutter. The pilot eventually relented. Mr. Toeniskoetter went to Sutter, where he promptly received tPA. Today, he has no disability and is back running a real estate-development business in the San Jose area. "Trauma patients go to trauma centers, not the nearest hospital," he says. "Stroke victims, too, require a real specialized sort of care."
One-third of all strokes are suffered by people under 60, and hemorrhagic strokes in particular often strike young adults and children. Vance Bowers of Orlando, Fla., was 9 when he woke up screaming that his eyes hurt, shortly after 1 a.m. on Jan. 8, 2001. Malformed blood vessels in his brain were bleeding. He was in a coma by the time an ambulance delivered him at 1:57 a.m. to the nearest emergency room, at Florida Hospital East Orlando.
Emergency-room doctors soon realized Vance had a hemorrhagic stroke. But neurosurgery isn't performed at that hospital. A sister hospital 14 minutes away by ambulance, Florida Hospital Orlando, did have neurosurgical capability. But in part because of administrative tangles, Vance didn't get to the second hospital until 4:37 a.m., more than two hours after his arrival. Surgery began at 6:18 a.m. "This delay may have cost this young man the possibility of a functional survival," Paul D. Sawin, the neurosurgeon who operated on Vance, said in a letter to the hospitals' joint administration.
Florida Hospital, an emergency-medicine group and an ER doctor recently agreed to settle a lawsuit filed against them in Orange County, Fla., Circuit Court by the Bowers family. The defendants agreed to pay a total of $800,000, court records show. Monica Reed, senior medical officer of the hospital, says the care Vance received was "stellar" and that any delays weren't medically significant. Vance's stroke, not the care he received, caused his injuries, she said.
Vance, now 13, survived but is mentally handicapped and suffers daily seizures, his mother, Brenda Bowers, says. Once a star baseball player, he goes by wheelchair to a class for disabled children. He speaks very slowly but not in a way that many people can understand. "He remembers playing baseball with all of his friends," his mother says, but they rarely come around any more. "He really misses all that."
Here's a list of Oregon hospital mailing addresses, and in some cases, some names of execs.
