First Strike Against Stroke: Saint John’s achieves recognition as a center of excellence that fills an urgent need.
January 24, 2017
Mercedes Arana’s stroke occurred as it does for so many people— completely out of the blue. The retired certified nursing assistant had no prior medical issues like high blood pressure, high cholesterol or diabetes. She was active, doing Zumba five times a week and had never smoked. But while enjoying a weekend at the home of her daughter and grandchildren in Pacific Palisades this past July, Mercedes, 69, suffered a severe stroke that could have been permanently disabling or even fatal.
“Her stroke came as a total shock to all of us,” says Mercedes’ daughter, Bridgitte Fanous.
The night before, Mercedes felt well except for a slight headache. “When she spoke to my dad on the phone the next morning her voice sounded a little different,” Bridgitte recalls. “And she left the phone off the hook, which I thought was a little weird.”
What happened next set off Bridgitte’s alarm bells. “When my mom started talking, her face drooped to one side and she couldn’t speak right,” she recalls. “Then she said she had a really bad headache and started tapping one side of her head. It took me a little bit of time to register what was going on, but then I thought, ‘Mom is having a stroke—call 911.’ My next-door neighbors are doctors (Sharo Raissi, MD, and Violet Boodaghians, MD), and they helped my son, Michael, call it in and tell the dispatcher that we thought my mom was having a stroke.”
An ambulance arrived within 10 minutes and rushed Mercedes and Bridgitte to the Providence Saint John’s Health Center emergency room, where they were met by vascular neurologist and stroke program medical director Jason Tarpley, MD, PhD, and stroke neurologist, Daniel Franc, MD, who was on call at the time, and emergency room doctor, Sherry Yafai, MD. Right away, Samuel Hou, MD, PhD, an interventional neuroradiologist, who recently joined the stroke team at Saint John’s, was paged along with the rest of the interventional team.
Dr. Jason Tarpley and Dr. Samuel Hou
At this point, Mercedes’ left side was paralyzed and she was unresponsive. Imaging tests were performed immediately, and the doctors determined she had a large blood clot in the carotid artery in her brain (an ischemic stroke). Luckily only about 24 minutes had elapsed from the time 911 was called.
“The doctors came out and told me my mom was having a severe stroke,” Bridgitte says. “They asked if they could administer the IV clot-busting drug tPA (tissue plasminogen activator). The doctors told me about all the potential side effects, and I asked if they would do it if it were their mom. They said yes. So I said, ‘Let’s do it.’” This medication was delivered in a lightening-fast 19 minutes after Mercedes arrived at the hospital.
The tPA didn’t work because the clot was so large; in fact, tPA only works in about one-third of ischemic stroke cases, partly because it is ineffective if given more than 4 1/2 hours after a stroke begins.
“Stroke is the second leading cause of death in Los Angeles County." – Los Angeles County Department of Public Health
The ED nurses and the stroke team quickly transported Mercedes to the interventional suite. Dr. Tarpley and Dr. Hou then immediately performed a thrombectomy, a newer procedure that has revolutionized stroke treatment. A catheter is inserted into an artery in the groin and up into the brain. The stroke-causing clot is then removed with a device called a stent retriever, which is threaded through the catheter into the artery where the clot is attached to a wire so that the stent and clot can be pulled into the catheter and removed. “Thrombectomy is wildly effective,” Dr. Tarpley says. “The results are very dramatic. If they get to us in time, patients often have very significant improvement right in front of your eyes. With Mercedes, we had her on the table getting the procedure 67 minutes after she hit the hospital.”
Mercedes spent two weeks in the hospital, part of that time in the intensive care unit where she was attended to by neurologists and nurses with specialized training in the care of stroke patients. After being discharged, she began receiving outpatient physical therapy and rehabilitation services at Providence Holy Cross in Mission Hills, near where she lives. Her husband cares for her and helps her at home.
“She’s about 75% there in terms of doing all the things she used to do,” Bridgette says. “She still drifts a little to the left side when she walks, but her arm and hand work well and she has full brain function. She takes walks. We are all doing everything we can to get her back to 100%, and we see progress every day.”
The right place at the right time
Not a lot of good can be said about having a stroke, but Mercedes was extremely lucky in a few regards. First, she was lucky that her family recognized the symptoms so quickly. She was lucky that her neighbors knew the importance of alerting emergency medical personnel that she was probably having a stroke. Finally, Mercedes was lucky to have been treated at Saint John’s Health Center. This past June, just before her stroke, Saint John’s was certified as a primary stroke center by the Joint Commission on the Accreditation of Health Care Organizations, an independent, nonprofit organization that evaluates disease-specific health care facilities.
Developed in collaboration with the American Stroke Association, the Joint Commission’s certificate of distinction for primary stroke centers recognizes treatment centers that undertake exceptional efforts in treatment of stroke. The centers need to be specially staffed and equipped to improve long-term outcomes for not only stroke patients but also those with cerebral aneurysms, carotid artery stenosis, arteriovenous malformations and other neurovascular disorders. In other words, Mercedes benefited from receiving the highest standard of care available at a state-of-the-art stroke treatment facility.
Meeting a growing need
A stroke occurs when a blood vessel that carries oxygen to the brain is either blocked by a clot in an ischemic stroke, such as the one Mercedes had, or ruptures (a hemorrhagic stroke). “About 75% of the strokes we treat are ischemic, 20% are hemorrhagic, and 5% are a subarachnoid hemorrhage, which occurs when an aneurysm [a ballooning, weak section of an artery] ruptures in the brain,” Dr. Tarpley says.
Strokes are medical emergencies and every minute can make a tremendous difference. If not diagnosed and treated very quickly, death or serious, long-term disability can result. “For an ischemic stroke, the best thing we can do is to get that blockage open as soon as humanly possible,” Dr. Tarpley explains. “We know that about 1.9 million brain cells per minute die behind [the blockage].”
According to the Los Angeles County Department of Public Health, stroke is the second leading cause of death in the county. Nearly 800,000 Americans suffer a stroke every year, and the number of people who are at highest risk—older people as well as those with high blood pressure, diabetes, obesity and other medical conditions—is increasing.
“Data has shown that primary stroke centers like ours have better patient outcomes, but they have to be available locally, as time is of the essence,” says George Teitelbaum, MD, regional director of interventional neuroradiology for Providence California. “Unlike heart attacks, most ischemic strokes cause no pain. If you have one when you’re sleeping, by the time you wake up damage may have been occurring for hours and you may be outside of the window when tPA can be effective.”
In the sprawling, traffic-congested metropolitan Los Angeles area, cutting minutes off the time elapsed between suspecting a stroke and being evaluated and treated for it can be difficult—and dangerous. Since 2010 paramedics in Los Angeles County have been required to transport suspected stroke patients to the nearest primary stroke center. Until July the closest such facility for Westside residents was at the University of California, Los Angeles Medical Center.
Now, as the only primary stroke center west of the 405 Freeway, Saint John’s Stroke and Aneurysm Center fills a void in Santa Monica, Culver City, Pacific Palisades, Marina del Rey, Malibu and other surrounding communities. In August the center performed 36 emergency evaluations for possible stroke, compared to around 10 in March.
Working to raise stroke awareness
Receiving certification as a primary stroke center required meeting strict clinical practice guidelines, not only in treating strokes but in preventing them, and that requires educating the public, according to Dr. Teitelbaum.
According to the American Stroke Association, 80% of strokes are considered preventable. Among the risk factors that people can control are high blood pressure and cholesterol, cigarette smoking, diabetes, physical inactivity, obesity and poor diet.
“We host community education events at places like the Santa Monica libraries,” says Renee Ovando, RN, stroke and neurovascular program manager. “A stroke team, which includes doctors, myself and stroke survivors, takes part in lectures on ways to prevent stroke through lifestyle habits, as well as how to know what the common signs are and, if they’re recognized, the importance of calling 911 immediately and letting emergency providers know that a stroke is suspected.”
Unlike Mercedes’ family members, most people are unaware of the common signs of a stroke. The acronym FAST is an easy way to remember the symptoms, Dr. Teitelbaum says:
F: Face drooping
A: Arm weakness
S: Speech difficulty
T: Time to call 911
Additional signs may include sudden numbness or weakness of the face, arm or leg, especially on one side; confusion or trouble understanding; difficulty seeing in one or both eyes; problems with walking, balance or coordination; dizziness; or severe headache with no known cause.
Taking a team approach
Working smoothly together, the center’s interdisciplinary team, which consists of neurologists, nurses, emergency room doctors, radiologists and other professionals who specialize in diagnosing and treating strokes, delivers the type of care that’s been shown to improve patients’ short- and long-term outcomes. “We even have a spiritual care member on our team,” Renee says. “This person can explain to family members what’s happening to the patient in real time.”
The team gets patients the imaging or medications they need as quickly as possible. “Our nurses can even give patients tPA as soon as a specialized stroke neurologist deems it appropriate, usually when the patient is still in the CT scanner,” Renee says. Nurses are required to undergo extensive training in every aspect of patient care, from when a patient arrives to when a patient leaves the hospital, and to receive annual stroke education.
There’s a non-human stroke team member, too: the telestroke robot, which can observe and evaluate patients as well as their imaging, from an outside location. This allows for videoconferencing among on- and offsite clinicians, which saves precious time.
Improving life after stroke.
Being treated promptly for a stroke is essential, but what happens afterward is critical too. “We treat people from the prevention to the rehabilitation phase.” Renee says. Having an on-site outpatient clinic for follow-up treatment makes continuing care easier for patients and their families.
Preventing repeated strokes.
“Every hospitalized stroke patient is given specific, individualized education to help avoid future strokes,” Dr. Tarpley says. “We try to figure out why they had their stroke—for example, do they have high blood pressure or blood sugar or carotid artery stenosis? Having a stroke can be an eye-opening experience for a lot of people, so we do want to capitalize on that opportunity for education to avoid future strokes.”
Providing emotional and practical support.
“Recovering from a stroke can be a long and difficult process,” Renee says. “A stroke can be devastating emotionally as well as physically, but our patients are helped—and help each other—after the acute phase of their treatment is over.”
Monthly support group meetings are open to the entire community and cover topics that stroke survivors, their family members and caregivers need to know about. Speakers in the fields of neurology, nutrition, rehabilitation and other areas provide practical resources and a forum for learning new physical and emotional coping skills. “We’ve had an expert on mindfulness meditation, and we’re featuring a yoga instructor who specializes in stroke recovery,” Renee says.
Restoring lost function.
Many stroke patients suffer residual physical deficits after their strokes and require various forms of rehabilitation. “It’s part of the Joint Commission’s mandate that every stroke patient be evaluated for physical therapy, occupational therapy to help with performing daily tasks, and/or speech and swallow therapy,” Dr. Tarpley says.
“Considering that my mom had a massive stroke, it’s a miracle that she is walking and talking so well today,” Bridgitte says. “Our whole family is grateful to God that we had great neighbors, a great hospital, and great doctors and nurses. It was a miracle that put her in the right place where everyone did the right thing at the right time.”
To learn more about how you can support Saint John’s stroke program, please contact Jeanne Goldsmith at 310-582-7344.
TAKING THE NEXT STEP
Being designated a primary stroke center is a great step forward for local patient care. The next goal is to become accredited as a comprehensive stroke center, and this is anticipated to happen within a year or so. “The Los Angeles area probably needs 10 to 15 of them, and we want to be there to help people have the highest quality stroke care in this part of the city,” says George Teitelbaum, MD, regional director of interventional neuroradiology for Providence California.
“We already have met some of the criteria, including the most important one: the ability to offer thrombectomy services 24/7,” he adds. “But we need to add more neuro-critical-care doctors and other personnel available around the clock, including people who can perform thrombectomies as well as neurosurgery procedures like craniectomies (removal of part of the skull to allow a swelling brain to expand).”
Being granted comprehensive stroke center status would also require expanding the Providence Saint John’s Stroke and Aneurysm Center’s advanced imaging capabilities and creating a dedicated facility where patients can receive advanced rehabilitation care after their stroke.
WHO’S MOST AT RISK FOR STROKE?
According to the American Stroke Association, the following groups are at highest risk for stroke:
Risk approximately doubles each decade after age 55, though younger people also suffer strokes.
PEOPLE WITH A FAMILY HISTORY
A person’s risk is greater if a parent, grandparent or sibling had a stroke.
African-Americans have a higher risk of strokes than Caucasians, partly because they have a higher incidence of high blood pressure, diabetes and obesity.
Females have more strokes (and more fatal strokes) than males. Possible links include pregnancy, having preeclampsia/eclampsia or gestational diabetes during pregnancy, smoking, use of birth control pills or post-menopausal hormone replacement therapy.
PEOPLE WHO’VE HAD A PRIOR STROKE, HEART ATTACK OR TIA (TRANSIENT ISCHEMIC ATTACK)
A TIA is caused by a temporary blood clot and is known as a “mini stroke” or “warning stroke.” A person who’s had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and sex who hasn’t.