First Mobile Stroke Unit in the United States!

[systemet]

Let's pretend we just gave tPA in the driveway and start making our way to the stroke center. Suddenly a car blows a red light and flips the ambulance. Can you imagine the potential blood bath that could come from an MVA after getting tPA? Even if there is no external trauma, there is going to be a brain bleed.

Well, getting in a collision in an ambulance is almost always a bad idea, tPA or no tPA. Fortunately, it's also quite rare. There's a fair number of systems that are already assuming this risk by giving TNK and similar drugs to STEMI patients. Of course, the demonstrated benefit there is far clearer, and a better argument can be made for it outweighing the potential risk.

One of the possible advantages of EMS is that we like to run with scissors. We have an ability to get a lot of things done quickly, by walking and talking. This seems to take longer in the in-hospital environment sometimes. It seems like the right person from the right union has to come and draw the blood. The right person from the right union has to do the 12-lead. It has to sit until the right physician has time to read it, etc. We 'lysed a STEMI a couple of weeks ago with a 4 minute first medical contact-to-ECG time, and 17 minute door-to-drug (52min symptom onset-needle) time, using 3 people and consulting with cardiology via cell. It can take me 17 minutes on a bad day to get my sick patient registered, with the right wristband and stickers, and on to the ER bed.

tPA in ischemic CVA obviously remains quite controversial.

I wonder if there's some place for using a mobile CT scanner to do rule-outs on low-to-moderate risk head trauma? Does anyone know what European physician-driven EMS systems are doing with similar technology?

Here's an interesting link:

http://www.jove.com/video/50534/prehospital-thrombolysis-a-manual-from-berlin

Ebinger M, Lindenlaub S, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Kellner PA, Kaczmarek S, Endres M, Audebert HJ.Prehospital thrombolysis: a manual from Berlin. J Vis Exp. 2013 Nov 26;(81):e50534. doi: 10.3791/50534.PMID:24300505 [PubMed - in process]

[ERDoc]

I like the idea of mobile CT to r/o clinically significant head trauma. You might be on to something there, systemet. Another difference in the field vs in the hospital is that you are only dealing with one pt. The multitude of things that need to happen within minutes of a "stroke" hitting the door is taxing on even large hospitals. It does take a few minutes to get the pt registered in the computer. Nothing can happen without the pt being registered. This is a JCAHO issue. Tests (radiology/lab) cannot happen without several different ways of verifying pt identity. You also have to hope that the CT scanner is open and not being used. If we get an early enough heads-up this can usually be accomplished. We don't have big union issues so making sure the right person is there is no big deal. We have someone to get access, someone to get an EKG and someone to do the stroke scale (which has to be done within a certain time frame otherwise you get nastygrams from the higher ups who only understand what the regulations say and not how actual pt care works). Reading a head CT is much different than reading an EKG. Almost anyone can get proficient at reading EKGs, CTs are a whole other beast which is why there is a whole specialty dedicated to it. With a STEMI, you look at the EKG and see ST elevations. You make the diagnosis right away. With a stroke, if you are able to see the stroke it is too late. That is the problem. You have to make the diagnosis and administer a dangerous medication on the basis of a lack of evidence. Is this a CVA or a TIA? There are also a lot more contraindications for tPA in suspected stroke so you have to wait for labs to come back and go through their history if they are not good historians. All of this for something that is of questionable benefit and may be more harmful than useful.

[scubanurse]

Well, getting in a collision in an ambulance is almost always a bad idea, tPA or no tPA. Fortunately, it's also quite rare. There's a fair number of systems that are already assuming this risk by giving TNK and similar drugs to STEMI patients. Of course, the demonstrated benefit there is far clearer, and a better argument can be made for it outweighing the potential risk.

One of the possible advantages of EMS is that we like to run with scissors. We have an ability to get a lot of things done quickly, by walking and talking. This seems to take longer in the in-hospital environment sometimes. It seems like the right person from the right union has to come and draw the blood. The right person from the right union has to do the 12-lead. It has to sit until the right physician has time to read it, etc. We 'lysed a STEMI a couple of weeks ago with a 4 minute first medical contact-to-ECG time, and 17 minute door-to-drug (52min symptom onset-needle) time, using 3 people and consulting with cardiology via cell. It can take me 17 minutes on a bad day to get my sick patient registered, with the right wristband and stickers, and on to the ER bed.

tPA in ischemic CVA obviously remains quite controversial.

I wonder if there's some place for using a mobile CT scanner to do rule-outs on low-to-moderate risk head trauma? Does anyone know what European physician-driven EMS systems are doing with similar technology?

Here's an interesting link:

http://www.jove.com/video/50534/prehospital-thrombolysis-a-manual-from-berlin

Ebinger M, Lindenlaub S, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Kellner PA, Kaczmarek S, Endres M, Audebert HJ.Prehospital thrombolysis: a manual from Berlin. J Vis Exp. 2013 Nov 26;(81):e50534. doi: 10.3791/50534.PMID:24300505 [PubMed - in process]

They're not as rare as you would think. My husband has had his medic unit hit 3 times, twice with patients, and I have been hit once.

[Ridryder 911]

Sniff ..... Sniff...... Smellls like a PR and marketing strategy. Alike UT when they studied and then introduced the EZ I/O with Vidacare. I am always careful, when I hear .."we are joining.. teaming up.." in lieu of true benefits. Alike others have discussed, what time element will really be reduced? I know the traffic is horrible in that area but would the monies be spent in educating the public?

I really do doubt that with even over 1800 stroke like patients; how many of these notified EMS prior? Alike they said, "We have to be bigger, the first" and so happen we build mobile clinics... hmmmm....

Hopefully, we can see a true evidence based report that will either justify or kill this idea.

R/r 911

[systemet]

Sniff ..... Sniff...... Smellls like a PR and marketing strategy. Alike UT when they studied and then introduced the EZ I/O with Vidacare. I am always careful, when I hear .."we are joining.. teaming up.." in lieu of true benefits. Alike others have discussed, what time element will really be reduced? I know the traffic is horrible in that area but would the monies be spent in educating the public?

I really do doubt that with even over 1800 stroke like patients; how many of these notified EMS prior? Alike they said, "We have to be bigger, the first" and so happen we build mobile clinics... hmmmm....

Hopefully, we can see a true evidence based report that will either justify or kill this idea.

R/r 911

The Germans seem to be aiming to reduce the door-to-needle time for fibrinolysis in ischemic CVA. I'm not sure if they're doing any sort of direct to neuro ICU or surgery for hemorrhagic CVA. My immediate guess, would be that you can't just roll into a neurosurgical or intensive care setting the same way you can roll into a cath lab.

I imagine both centers will be publishing. The Germans certainly seem to be planning to.

I'm also struggling to see the benefit here, but don't want to dismiss it without seeing the numbers. CVA patients do seem to get neglected on busy days in systems I've worked in. It's an area where there's a lot of room for patient advocacy when you have an elderly patient with a low level of baseline disability. Every sick 80 year old looks like a sick 80 year old. It can be easy to make the assumption that their baseline level of disability is more severe when they present disabled.

I've given this some thought over the past little bit, and I can't see it being the first resource on scene in many situations -- but in a big city, if it's alerted at the same time as the first-in unit, I could see there being time to intercept, or meet on scene.

Re: rule outs for medium-risk head trauma: I've considered this a little more, and I think one of the problems is that you can't just scan most of these patients and let them go. They're going to sit in the ER anyway for a few hours to allow any occult pathology time to declare. They're unlikely to get turfed as soon as a negative CT comes up, and probably shouldn't.

Re: MVCs in 'lysed patients: I reckon my personal number is 1 collision for every 2,000 transports. Most of my recent MI patients have gone to cathlab, although a few still received lytics. In my system with 100,000 calls/year, we're looking at around 150-200 true STEMIs, with about half getting lysed. The rest are getting plavix and enoxaparin. Mortality benefit from early reperfusion can be quite large, especially in patients 'lysed in the first hour or two, and especially if there's a longer transport time to PCI. I doubt the risk of anticoagulation / thromolysis and MVC collision occuring in the same patient is very high. A very inexact estimate using these numbers would suggest that's a 1 in 1,000,000 proposition. Of course, my numbers are likely inaccurate, and there's an argument to be made that STEMI patients might be more likely to be transported stat, and be at greater risk for collision as a result (* on the other hand --- if you've pushed the TNK, where's the benefit to transporting emergently? The decision for reperfusion therapy has been made, it's been initiated, and we're going to be looking at what percentage ST resolution we've seen at 90 minutes. Unless they're acutely unstable, e.g. CHF, cardiogenic shock -- is there much of a point?). I wasn't intending to minimise the risk of vehicle collisions for EMS providers, but I still think that the scenario described is fairly unlikely.