When it comes to a stroke, as the saying goes, “Time is brain.” That means, the longer the brain is without oxygen due to a lack of blood flow from a stroke, the more likely a patient will suffer brain damage or die.
Therefore, when EMS shows up, acting quickly for a patient with a suspected stroke is important. Previously, that has meant bringing the patient to the closest hospital, but, now, this protocol is changing, and saving lives.
In November 2021, Hackensack Meridian EMS implemented a bypass protocol for the most severe suspected stroke patients. This means EMS can bypass the nearest hospital to bring the patient to a hospital that is considered a comprehensive stroke center. A comprehensive stroke center is the most demanding stroke center designation, given to those able to treat the most complex cases.
Endovascular thrombectomy is a breakthrough intervention for stroke that allows physicians to pull blood clots from the veins of stroke victims. Endovascular thrombectomy involves inserting catheters through the groin or wrist, moving them up to the brain, and retrieving the blood clot, allowing blood flow to return to the brain. The intervention has been shown to save lives and reduce disability, with some patients achieving full recovery. U.S. Sen. John Fetterman (D-Pa.) underwent this procedure last May while campaigning, and has since gone on to serve in the Senate.
“We take a plastic tube in the artery in the left leg and advance it to the brain and we give clot-busting treatments or tPA, we can suck out the clot through the plastic tube, or we can mechanically pull out the clot through a stent retriever,” said Dr. Pinakin Jethwa, endovascular neurologist at the Hackensack Meridian Neuroscience Institute at Jersey Shore University Medical Center. “Many times, we can reverse the symptoms of stroke and the patients return to normal.”
In central and southern New Jersey, there are a limited number of comprehensive stroke centers. Jersey Shore University Medical Center is the only one in Monmouth and Ocean counties. Therefore, it was important to implement the new routing procedure in Monmouth and Ocean counties, diverting severe stroke patients from primary stroke centers like Bayshore Medical Center, Riverview Medical Center, Ocean University Medical Center and South Ocean Medical Center to Jersey Shore University Medical Center.
EMS crews make the decision to divert to the nearest comprehensive stroke center in the field. The decisions are based on a patient’s score on the Rapid Arterial Occlusion Evaluation (RACE) Stroke Severity Scale, one of several nationally recognized stroke severity scale options.
The RACE scale is determined by asking the patient to perform certain tasks, including checking for facial palsy by having patients smile or show their teeth, checking patient’s arm and leg motor function, gaze and other factors.
Like all stroke severity scales, the purpose of the RACE Scale is to help EMS identify patients whose symptoms may be due to a large vessel occlusion and may therefore benefit from mechanical thrombectomy — an endovascular therapy shown to improve outcomes for select LVO patients.
Since implementing the new routing protocols in November 2021, the new protocols allowed 83 patients to be routed to a comprehensive stroke center, rather than a primary stroke center. Of those patients, 46% did have an LVO and nearly all have gone on to have an mechanical thrombectomy.
“We have seen many patients with severe strokes helped by this change in protocols. When a patient suffers a stroke, it’s not only important to act quickly, but to get to the right place in the right amount of time,” Robert Bauter, clinical manager, Southern Region, Hackensack Meridian Health JFK EMS, said. “Now patients are able to be treated quickly. In most cases, these patients are returning home days later without any deficits after quick access to a mechanical thrombectomy and updated clot-busting drugs like tenecteplase.”
