AcuteCare Telemedicine Blog


Stroke Treatment Gets a Boost

Fifty years ago, the only advice medical textbooks gave physicians for someone suffering with a stroke was to put him to bed and keep him comfortable, hoping that with time, the brain would heal as best it could. For 30 years, promising techniques preceded disappointing trials. First, heparin was going to be the savior, and for most of the 70s and 80s, it almost served as a standard, but better studies eventually showed that the treatment was not just worthless, but in reality dangerous, causing more brain hemorrhages than no treatment at all. Later, drugs that were intended to clear out “free radicals” were going to save the ischemic penumbra, part of viable brain tissue around a central core of dead cells, but all studies showed that either the medication didn’t get to the target, didn’t work, or could even be toxic to the brain.

In the mid 90s, tissue plasminogen activator (TPA), long used for heart attack victims to break up the clots inside arteries of the heart, was shown to be effective in doing the same in arteries of the brain. For the first time, physicians had something to offer patients that actually made a difference. About a third of patients who received TPA had better three month outcomes than those that did not. This success rate was quite good, but patients with severe strokes still did not respond as well because, in most cases, thrombi in the large arteries were not effectively dissolved.

Only in the last few years have studies been done to consider the effectiveness of a thrombectomy, the process of physically pulling out a thrombus inside an artery in the brain or neck, The early devices available to physicians are fairly good at the task, but a substantial number of patients continue to suffer from residual blockages of the arteries following the procedure.

A report of clinical trials using two new types of thrombectomy devices, called Solitaire and Trevo Retriever, show both of these new devices as being up to five times more effective than their predecessors in opening up arteries. Advances this drastic are rare in medicine, but physicians should be optimistic about the potential for these instruments in improving outcomes. Provided that patients can have access to skilled practitioners in time, within eight hours or sooner, the treatment of stroke may be about to enter a dramatic new phase.

Stroke is the most serious disabling condition in adults, resulting in hundreds of thousands of permanent injuries and deaths every year. This decade may witness the greatest advances in the history of stroke treatment. There are still further trials to run, but with these exciting new prospects, the importance of stroke neurologists like the doctors of ACT being present in every emergency room, either in person or by remote presence, cannot be overstated.



Good Things Come in Small Packages

As the fall approaches and we reach the third anniversary of AcuteCare Telemedicine, we have spent some time reflecting on our company and personal growth over the last three years. From simple beginnings, serving one health care facility in the metro Atlanta area, ACT has expanded to include facilities in rural communities of both Georgia and Tennessee. We have developed alliances with Emory University Hospital and the Georgia Partnership for Teleheath, two partners who enable us to provide the highest quality of acute neurologic care where it may otherwise be lacking. Turning our attention forward, ACT continues to push to ensure that every emergency department is staffed with adequate 24/7 neurology coverage, whether in person or via remote presence.

ACT has always believed that our successes are primarily due to the quality of services we offer. Despite our expansion over the past three years, ACT has remained a small, intimate company, still owned and operated by its four founding physicians. We find unique value in our size; it allows for outstanding continuity of care, frequent “meetings of the minds,” and quick, effective identification of problems and subsequent solutions.

Weekly meetings with all four physicians cultivate innovative ideas, enable problem identification, and facilitate the creation of solutions in a timely and efficient manner, advantages rarely possible in larger corporations. Thanks to the size of the company, each physician of ACT has a specific role, but can be flexible and share duties when needed, strengthening the consistency of the quality care we provide.

Being smaller has other rewards. In the world of acute neurological emergencies, there is little time for complex communication and red tape. When problems or concerns arise at any of our serviced facilities, an ACT physician can immediately make contact remotely and work directly with a facility member on issue resolution. Try calling up the CEO of your car’s manufacturer when your check engine light comes on.

The four physician-owners of ACT continue to practice neurology in a group that has been caring for patients for more than 65 years combined. We are highly trusted neurologists in our own community, and we are committed to bringing our expertise to other communities in need. Our small size ensures that we will stay focused on keeping our standards high and our integrity intact along the way.



Acutecare Telemedicine Discusses The Benefits Of Telestroke Services In Georgia At Kiwanis Club Of Northside Atlanta

Michael Woodcock, Sales Executive for AcuteCare Telemedicine (ACT), spoke at the Kiwanis Club of Northside Atlanta on April 13th  discussing the benefits of ACT’s teleneurology services for residents of rural Georgia who lack access to emergency neurological expertise. The presentation was delivered to the membership of the Club, a civic organization comprised of business leaders in the metro Atlanta area.

Woodcock’s presentation, sponsored by Club President Daniel Shorr and Vice-President Joel Isenberg, was entitled “Telestroke in Rural Georgia: Bridging the Gap Between Doctor and Patient”.

The presentation presented the statistics for stroke mortality in the U.S., focusing specifically on the “Stroke Belt” of the Southeast, which includes the state of Georgia.  Georgia’s mortality rates for stroke are among the highest in the nation, and providing expert stroke care to rural Georgians via telemedicine can be a key factor in reducing those mortality rates over time. Woodcock discussed the importance of promoting stroke awareness among the general public, and how crucial it is for individuals to recognize the warning signs for stroke (Face/Arms/Speech/Time).

“It is a well-known adage within the neurology community that “Time is Brain”, and that granting patients immediate access to expert care is crucial to preventing potentially severe disability or even death.” said Woodcock. “AcuteCare Telemedicine can provide that expertise to hospitals that enables them to better care for stroke patients in areas of Georgia that are traditionally underserved.”

For more information about AcuteCare Telemedicine, visit www.acutecaretelemed.com



Yes America, Time IS Brain

“Time is brain” is such a frequently repeated mantra of stroke neurologists that it seems almost to have become cliché. For more than a decade, fliers, lectures and even billboards have been admonishing us to get to the hospital immediately when we develop symptoms of stroke such as speech trouble or weakness. The longer a stroke victim goes without treatment, the more brain damage accrues and the greater the likelihood of permanent disability or death. Using the latest methods to restore flow to blocked arteries, neurologists can improve the outcomes of stroke victims beyond anything imagined before the “Decade of the Brain.” 

It was distressing to be called recently to see Sam, a 55 year old, via teleneurology consultation. Sam had fallen at home around midnight. When his wife noticed his complete paralysis on the left side, she wanted to call the EMS. However, he refused to let her do so and dragged himself to bed. When he was no better by the morning, they came to the ER more than 12 hours after the stroke started. Sam’s arrival to the hospital was far too late; the damage was complete. He was unable to even wiggle his toes or fingers on the left side, and was suffering severe left facial weakness.

Unless clot busting medicine is given or a clot is physically removed from a blocked artery within a window of just a few hours, brain cells die without exception. The struggle against time to save brain capacity is an uphill battle. Rather than facing a prospect for a good recovery and being able to walk or dance again, Sam is now likely to remain under nursing care for years to come.

Contrast Sam’s story with that of Britt, a young college student who suddenly found himself unable to move or speak while at home. His family also immediately recognized the signs of stroke, but unlike Sam, Britt was brought to the ER quickly. A study of his brain revealed the blocked artery and Britt soon underwent a procedure to open it. Within a day’s time, he was back to normal, his brain cells recovering when oxygenated blood returned after the artery was opened.

Today, Britt can look forward to decades of normal living. Sam? His fateful decision to ignore serious symptoms and go back to bed has cost him his freedom. Regardless of clichés, Time is Brain. The urgency of timely diagnosis and treatment in cases of stroke cannot be understated.



What Stroke and Heart Attack Have In Common

Because brains and hearts are highly dependent on oxygen-rich blood to survive, current guidelines from the American Heart Association call for treatment in under an hour for both strokes and heart attacks. The phrase “Door-to-treatment” refers to the time it takes from a patient’s emergency room arrival to the initiation of treatment.

In heart attacks, “door-to-balloon” more specifically refers to the use of an angioplasty balloon to relieve a constricted or obstructed blood vessel. In cases of stroke, the key phrase is, “door-to-needle,” referring to the administration of the intravenous medication tPA. The two different organs, with different vascular beds and dealt with by different teams of specialists within a hospital, remain subject to very similar constraints in time and quality measures.

The care of these patients requires a team approach with emergency room nurses and doctors rapidly initiating the process. At all hours, parallel specialized teams must stand ready to reverse critical brain and heart ischemia. Telemedicine technologies have proven to be an efficient solution in allowing very rapid access to quality care.

As leaders in the fight against the morbidity and mortality of these emergencies, AcuteCare Telemedicine (ACT) leads the stroke team at several hospitals, ensuring that proper treatment is available to patients within the critical hour. In addition, ACT monitors stroke care and provides important feedback to the hospitals it serves, because constant evaluation of the timeliness and quality of treatment is a crucial component in reducing the “door to needle” time to help save lives.



Stroke Care Requires a Change in Behavior

More than 2 million brain cells die each minute during a stroke. Reducing the time from a patient’s arrival in the emergency room to the administration of the clot-busting agent tPA, the so-called “door to needle” time, is paramount. A major obstacle to treatment outside the direct influence of the physician is when individuals with stroke symptoms delay seeking treatment.

The public is not without knowledge of stroke. Multiple websites and sources help people recognize stroke symptoms. These include academic sites such as the Mayo Clinic, commercial sites like WebMD, and government resources from the NINDS (National Institute of Neurological Disorders and Stroke). Public service announcements have been used to improve the awareness of stroke symptoms. More importantly, the time sensitive nature of stroke treatment has been brought to the forefront as a focus since the 1990’s. Education does help; the percent of patients arriving to the ER within 24 hours of stroke onset nearly doubled following a 1992 campaign stressing the need for early treatment.

However, in 1996, following FDA approval of tPA use with a 3 hour time limit, the role of timeliness in stroke treatment became even more crucial. Whereas public awareness of stroke symptoms had improved, education campaigns had not sufficiently decreased the time to respond. Even today, many patients are still missing the benefits of immediate treatment with tPA. Education has achieved its goal, making the risks of stroke and the availability of treatment understood, but changing behavior is not as easy. The public is not unafraid of stroke; people may simply be too afraid of the diagnosis. Delays result from the inability to accept that a stroke is actually occurring. Furthermore, previous unfavorable experiences in receiving care or suboptimal outcomes can influence future behavior.

This concept is supported by data in patients with myocardial infarctions (heart attack) which suggest psychological factors may be at play. The extrapolation of this behavior to stroke is not difficult given the typical presentation of stroke is not painful and often not immediately disabling. Society must reinforce the immediate use of the 911 system and healthcare providers must endeavor to give every stroke event the best possible outcome. Otherwise, patients who “wait and see” if it is really going to become a problem suffer as brain cells die.