Article and photos by James Campagna
A patient suffering from a stroke is one of the most urgent types of medical emergencies. Even when the patient survives, an ischemic stroke, a blockage of the arteries in the brain, can very quickly lead to irreversible brain damage, with 1.9 million brain cells potentially lost with every passing minute. The potentially high stakes of emergency medical care are never clearer than when mere minutes mean the difference between paralysis or full mobility, life or death.
“Nine out of 10 stroke patients are not getting the pharmacological treatment for stroke” that they need, says Dr. Mackenzie Lerario, medical director of New York Presbyterian’s Mobile Stroke Treatment Unit, referring to the medications that are typically used to dissolve blood clots that cause strokes. And many patients are not treated quickly enough, she adds.
To speed the treatment of stroke victims, New York Presbyterian launched its Mobile Stroke Treatment Unit in 2016, the first of its kind on the East Coast. This unique emergency service, a collaborative effort among Columbia University, Weill Cornell, New York Presbyterian and FDNY/911, was modeled after a similar program first launched in Hamburg, Germany in 2011.
Currently three units operate out of New York Presbyterian Hospitals in Manhattan, Queens and Brooklyn. The team responds to FDNY/911 dispatched emergencies Monday through Friday between 9 a.m. and 5 p.m., the hours determined to provide the most benefit for patients. The hours of operation are based, in part, on a hospital study of when the most confirmed stroke patients are admitted to the ER. Patients who suffer a stroke during the night are often not aware of their condition until the morning and, therefore, miss the pharmacological treatment window.
Prior to establishing the mobile service, patients would have to travel to the emergency room for treatment on their own or via a conventional ambulance. The very fastest a patient could receive treatment following the onset of a stroke was roughly 45 minutes, not including travel time to the hospital. The new stroke unit, by contrast, can administer life-saving, clot-busting medication known as tissue plasminogen activator, or tPA, before the patient reaches the hospital. Overall, the unit has reduced the time it takes for a patient to receive treatment, following the onset of symptoms, by as much as 40 minutes.
During an emergency, New York Presbyterian’s stroke unit dispatches a specialized team of professionals to treat stroke victims. Each member of the team was chosen from the top of their field and was given further training in emergency response care as well as stroke specific protocols. “Team work is absolutely essential,” said Dr. Matthew Fink, the chief neurologist for the program. “This cannot be done by any single person.”
Fink and Lerario oversee a team of four emergency medical professionals on board the stroke-unit ambulance, including paramedics Chris Bossart and Ashley Lawrence, registered nurse Cinthia Holland and computed tomography, or CT, technician Reimundo Castro. While treating a stroke victim, they communicate via a wireless video network with a neurologist at the hospital. Each morning, the team does “a little huddle,” explains Holland, the unit’s RN who is certified to treat stroke victims. “We go over everything that’s in the ambulance. When we get to the scene we know what needs to be done.”
The specialized ambulance is outfitted with a mobile CT scanner, allowing the imaging technician, Castro, to send the neurologists a precise view of what’s taking place in the patient’s brain via the wireless network. An on-board video link, controlled remotely from the hospital, continuously monitors the neurologists. The communications technology enables the team to make life-or-death decisions in a matter of moments. “All of us collaborate together to get the end result,” says Castro, the CT technician. “From us working together so much it’s a real nice rhythm of how things go from A to B to C.”
When working at its best, the team can evaluate, scan and treat a patient within 15 minutes of arriving on the scene. During the stroke unit’s first year, Fink worked as the neurologist on board the stroke-unit ambulance, fine tuning protocols. “It was very important to learn what exactly was needed before we moved to tele-medicine,” Fink explained. “Speed was of the essence. The earlier and the faster we could identify and treat a patient from the onset of symptoms the better the recovery.”
A study done by the Canadian Agency for Drug and Technology in Health, a nonprofit research organization, found that 253 patients treated by a mobile stroke unit, 83 percent were living without serious disabilities three months later. By contrast, among 260 patients–a comparable number–treated in a traditional emergency department of a hospital, only 74 percent were doing so.
Despite the improved treatment time and recovery outcomes, the team still sometimes loses patients. Following a particularly difficult case, when a young mother of three died, the team did a postmortem—a standard protocol, said Holland. “I wasn’t on scene with that case, but I did get on the call later because it did affect everyone,” Morgan said. “You want to know you did absolutely everything in your power for the patient.”
But, more often, the stroke unit is successful and saves lives. Some patients are so grateful they reach out to the unit after their emergencies are over. For example, when the team was called to Bryant Park on a warm, sunny Monday afternoon in 2018, they found a man in his early 40’s showing the classic signs of a stroke–loss of speech and the inability to move the right side of his body. Within 25 minutes of reaching the scene, the patient was evaluated, scanned and administered tPA, the clot-dissolving medication.
By Wednesday night, two days after his stroke, the patient was out of the hospital and on his way to a baseball game. ”That Friday he invited us all back to the spot where it happened to thank us,” said Morgan.
The program doesn’t just save lives, it also saves “a lot of money in downstream costs,” said Fink. When patients avoid a life-long disability, long-term physical therapy and related hospital care, the savings far outweigh the costs of the program, according to Fink, who estimates the startup costs for one mobile-stroke unit at $950,000 with an additional yearly expense of $1.3 million to operate each of the three units.
For now, the stroke unit’s costs are being fully funded by donations from the WP Carey Foundation and LeFrak Charitable Foundation until a sustainable reimbursement model is developed by multiple U.S. insurance providers. Unlike single payer insurance in Europe, U.S. insurers have been slow to realize that the upfront expenses for the mobile-stroke units will reduce long term costs, Fink notes.
So far, New York Presbyterian has been able to avoid cost-benefit argument that hospital boards and administrators typically have to make. And stroke-unit patients are only billed for a standard EMS ambulance.
No wonder they are grateful. During the holiday season, the stroke victim from Bryant Park tracked down Holland through Facebook, to again express his thanks to the team. That was “one of those cases that remind us why we do what we do,” said Holland.
Correction: May 16th, 2019
Since the article’s publication, Dr. Lerario underwent gender reassignment; her name and relevant pronouns have been edited to reflect the change.