Air transport of the doctor, rather than the stroke patient, can save time – therefore, lives – while also saving money.
The idea came from organ transplants.
Typically, once an organ becomes available, one surgeon will begin preparing the recipient while another travels to harvest the organ from the donor. That makes for a “nearly seamless connection in the timings,” says Ferdinand Hui, MD, of The Johns Hopkins Hospital in Maryland.
When it comes to one of Hui’s specialties, emergency stroke care, timing is of the utmost importance, too. But one of the hospital’s satellite facilities — Suburban Hospital, which is outside Washington, D.C., and about an hour away by vehicle from the main campus — doesn’t have fully prepared stroke specialists.
With organ transplant in mind, Hui began working on a plan to help Suburban by getting himself there quickly: by helicopter, which takes slightly less than 20 minutes of travel time, shaving off roughly 40 critical minutes.
The alternative — bringing the Suburban patient to him — isn’t as rapid because the patient must be moved to a helicopter, set up in it for monitoring, flown (after already being transported the first time) and then set up again at the new facility.
“If you fly all of the patients into the one center that can do it, you’re probably going to have a lot of patients not treatable by the time they get there,” Hui says. “Whereas if you have a robust helicopter coverage system and a bunch of crazy doctors that are willing to fly, they’ll probably get a better outcome for these patients.”
Another thing saved in this scenario is money. Transporting a doctor is less than half the cost of transporting the patient, Hui says. These savings come from monitoring equipment and a nurse no longer being needed in the helicopter.
“As it turns out, it’s not that expensive,” he says. “It’s just transporting a doctor.”
Hui gave “helistroke” service a try in January, when a severe-stroke patient was identified at Suburban. The findings from his effort were published in May 2017 in the Journal of Neurointerventional Surgery.
The treatment timeline:
11:12 a.m.: Suburban identifies patient as having a severe stroke.
11:46-11:58 a.m.: CT scans performed of patient’s blood vessels and brain. The scans help determine whether a stroke is ischemic or hemorrhagic, and thus the type of treatment.
12:07 p.m.: Hui notified at Johns Hopkins Hospital.
12:13 p.m.: Johns Hopkins helicopter service is notified and then receives weather clearance for takeoff.
1:07 p.m.: Hui inserts catheter for thrombolytics into ischemic stroke patient shortly after arriving at Suburban via helicopter.
1:41 p.m.: Catheterization treatment is completed.
In most cases, for thrombolytics to be effective, they should be given within 180 minutes of a stroke, but best results have been found to come within 90 to 100 minutes. From identification to treatment took 115 minutes. Time between decision to treat and groin puncture was 43 minutes. Time between the decision and the groin closure was 77 minutes.
The decision-to-treat times are comparable with those at systems in which patients aren’t transported, Johns Hopkins says.
As with the preparing and the retrieving physicians for organ transplant, one provider was completing the initial procedures with the stroke patient while Hui was en route.
By the time … the stroke interventionist gets to the patient, you’ll already have done a lot of the logical work that gets them [prepared]. So in fact, what we found is that the timings are actually very similar to no transfer at all.
Dr. Ferdinand Hui
“By the time … the stroke interventionist gets to the patient, you’ll already have done a lot of the logical work that gets them [prepared],” he says. “So in fact, what we found is that the timings are actually very similar to no transfer at all.”
Had the weather forced him to remain grounded, however, it might have been a different story. Hui describes this as the method’s biggest limitation, especially because Maryland’s ambulance regulators say he, as a nonpatient, can’t use the vehicles as a backup for quick transportation.
Whether any new timesaving technique in stroke response can be implemented is highly dependent on a multitude of factors, says Robert Brown, MD, MPH, a neurologist and the chair of the Division of Stroke and Cerebrovascular Disease at Mayo Clinic. Those include the location of the major center and satellite facilities, whether the patient is in a rural or urban area, hospital staffing, transportation options and other available resources.
In the end, though stroke-response technology is quite advanced, there’s no one-size-fits-all solution when it comes to transportation, decision making and administering care, Brown says.
Two other time-lessening methods being implemented at other hospitals are “telestroke” — which uses telemedicine to connect a stroke specialist with an on-site provider and the patient to provide an evaluation, instructions and care directly from a responding ambulance.
Such ambulances are equipped with small CT scanners for patient evaluation and prepared to give thrombolytics through the arm (rather than the groin, which is more targeted but requires a specialist), Brown says.
“It’s an exciting time, to be sure, because we have so many new treatments available,” he says, “and we just want to be sure that patients have access to them.”
Turning attention to logistical maneuvers is positive in a way, Hui said, because it symbolizes that effective treatment is already in place for what he called an “under-recognized disease.”
“Everyone knows [stroke is] bad, but I think still too few people recognize that it can be treated effectively,” he said. “And I just hope every chance I get to tell people that effective treatment exists, and the biggest barrier is actually logistics.”
Michael Stone is a freelance health care writer based in Tennessee.