Transcription:
Stroke: The Golden Hour(s)

Joey Wahler (Host): If you, or someone you know, is having a. Time is crucial in helping determine their ability to recover. So we're discussing pre-hospital stroke recognition at emergency care. This is Hello Healthy, a Dignity Health Podcast. Thanks for listening. I'm Joey Wahler. Our guest Dr. Zachary Bowles stroke medical director at Dignity Health, Mercy Medical Center in Merced, Dr. Bowles. Thanks for joining.

Dr Zachary Bowles: Hi there. Thanks for having me.

Joey Wahler (Host): Well first, what are the common stroke symptoms, both those that are noticeable and also those that may not be?

Dr Zachary Bowles: Sure. I think most of us know someone with stroke or will know someone who's, experienced stroke. And so there's a baseline awareness of the classic stroke symptoms. And those are things like droopy face and weakness in the arm. The American Heart Association has come out with, face mnemonic and that's one. I think a lot of people know are FAST, which includes, asymmetry in the face, weakness in the arms as for slurred speech or difficulty finding words. And then the just kind of emphasizing the importance of time, once the things are recognozed.

So I think those are the common ones. Things people may not think about as commonly in regards to stroke or things like balance issues, difficulty with coordination, movements, or just inability to walk. Vision changes that may be one or both eyes, total or partial loss of vision or blurriness. And then other things that are a little bit, more tricky things like confusion, which may be subtle, or things like severe headache, which is one of those concerning finds. We think about in certain types of stroke that involve bleeding.

Joey Wahler (Host): So when a stroke happens, doctor there's a saying, time is brain, which means what?

Dr Zachary Bowles: So, really that saying is emphasizing the fact that, for every minute, seconds passing, there is damage being done to cells inside the brain. And so in regards to the treatments that we now have to offer, earlier that you're able to get to a hospital and get evaluated, means we have more time to potentially provide one of those treatments and make more of a difference in outcome.

Joey Wahler (Host): And then speaking of which that time immediately after the stroke has also been called the golden hour, what's taking place ideally during that time, that makes that period so crucial?

Dr Zachary Bowles: Yeah. So, you hear it called the golden hour and, at a stroke center like Mercy Merced, that hour, that first hour is particularly important. That hour is the time period that we're aiming to complete all of our critical testing, and decision making. And if we're providing treatments, we aim to be able to give that treatment within that first hour, just because everything is so time critical.

Joey Wahler (Host): And so what kinds of things are we talking about specifically there?

Dr Zachary Bowles: So the first thing that's gonna happen, anytime that you, come to the hospital and there's concern for stroke is, is the first stop's gonna be the CT scanner. There are two main types of stroke. Most people have what's called an ischemic stroke. That's a stroke that's caused by an occlusion somewhere in a vessel inside the brain. But there are a subset of people who have what's called a hemorrhagic stroke and that's a stroke caused by bleeding inside the brain. And that's usually a rupture of a vessel somewhere. And the treatment is very different, including our treatment options. And so, the only way for us to know that for sure is to do a CT scan.

Joey Wahler (Host): And then once that's done, what are the next steps in treatment?

Dr Zachary Bowles: So for a long time, we were fairly limited in terms of treatment. We doctors were good. Identifying when a stroke had occurred, our imaging got better and better. We could see specific structures that were affected, but really all of our modern treatment options, have come to use within the last 30 years or so. So in 1996, the FDA approved, medication called the thrombolytic and the commonly used one being TPA. Although there are others now available, So that's an IV medication and it's an enzyme. So what it does is it breaks down blood clots, causing most, of those ischemic strokes that we're talking about.

So that's a medication that's approved right now for use within the first three hours after stroke, which is part of, why that time period is so important, including the hours even before somebody gets to the hospital. and why we really stress recognition, There's been data since then, that's shown that perhaps this medicine's effective even as far as four and a half hours out from when we suspect the stroke started. And so the American Heart and Stroke Associations have approved out, although the FDA has not gone on to extend that, approved time limit.

Joey Wahler (Host): So you're talking there about what, as you said, is known as TPA and because there is something of a shelf life for its usage, as you also said, is it safe to say that oftentimes unfortunately, whether or not that can be used and whether or not you can help someone to greatly recover from a serious stroke, it just comes down to how quickly they're gotten to. How quickly sometimes they're merely discovered because if it's someone living alone, for instance, and they have a bad attack, it might be too late to be able to give them that, right?

Dr Zachary Bowles: Absolutely. Yeah. So, all those things we try to make happen within the first hour after arrival to the hospital. But you think about those things, the time at home spent coming to the realization that maybe you or your loved one is having a stroke, making that decision whether or not to go to the hospital and then that transport time. That all factors in to that, three to four and a half hour goal, that time goes by fast, that clock is ticking.

Joey Wahler (Host): And so let's backtrack for a moment because now that you've described. That crucial period and why it is. So if a stroke is happening either to yourself or someone that you're with, the first thing you should do, am I right, is call 911? And you've gotta be very specific about what you're feeling or witnessing. So what do you want to tell emergency personnel exactly?

Dr Zachary Bowles: 911 is Always the place to start. that way you can specify, and I would always use the word stroke if you're suspicious. Our emergency medical services dispatchers are in contact with hospital facilities and they know, wish facilities have the best capability to treat stroke, where they have the imaging that's needed, the specialists that are needed. And they can get that process started from the get go, kind of ready the hospital personnel. The other benefit being that you already have, professionals arriving at home or wherever this is occurring, and they're gonna start gathering that crucial information.

Things about medical history, details of time course and, symptoms, we'll check things, that can mimic stroke. And, and we always wanna do that. The treatment's very different, and they'll be able to check for things like high or, low streams of blood sugar or blood pressure. And so by the time that you get to the hospital, we already have all that information in place and the doctor and other members of the team are already ready.

Joey Wahler (Host): And so if you are having a stroke and you're able to, or if you're with someone that is, it's a good idea to also take notes if at all possible so that you can provide certain information to the professionals when they arrive, what should you be keeping track of?

Dr Zachary Bowles: Absolutely. The critical thing is, if you're having a stroke or you're with somebody who is, you'll know, when you get to the emergency department, you're gonna be asked repeatedly, what the time of onset was? We want to know exactly when those symptoms started, because that kind of starts our clock for consideration of giving medications like TPA, like thrombolytics, and we really wanna confirm that. And so having that detail, and if that's unknown, maybe nobody was there to witness when it started, the next best thing is if you're able to tell us when that person was last seen by somebody to be normal, we can kind of go by that time as a surrogate.

So that's definitely important. Other things that we take into consideration are, factors like medical history, has this person had a stroke before, have they ever had a hemorrhagic stroke bleeding inside of the head? Those things factor into our decisions as far as whether or not this person's even a candidate for thrombolytics, other things like there are other medical problems? Are they diabetic? Do they have a history of high blood pressure? Are they on any blood thinners? things like aspirin or other platelet medications, can all be important.

Joey Wahler (Host): Gotcha. Now we also hear about mini strokes. What are those exactly? How do they differ from a full blown one? And how are those dealt with?

Dr Zachary Bowles: So those can be very similar in onset to a stroke. And when we say mini stroke, usually what we're referring to is something in the hospital, you're here called a transient ischemic attack with TIA, which is basically a temporary stroke syndrome. those symptoms may completely go away, or they may recur repeatedly. But we use that to describe symptoms that aren't lasting yet. And, they're concerning just because we know that people who experience many strokes or TIAs are at higher risk to go on and experience permanent strokes, as well as other bad outcomes.

That may happen as soon as within the next few days. And so, one of our concerns is that, somebody's symptoms go away and they decide they don't need to come to the hospital. We would always urge you to come be evaluated just because there's testing and, other risk factor modification that we can do to help prevent more permanent disability.

Joey Wahler (Host): If someone's having a stroke, are there also certain things that shouldn't be done until medical people arrive?

Dr Zachary Bowles: Absolutely. Along the lines of those mini strokes, That's one of the things that commonly tempts people to wait. And, so I think waiting is one of the big ones. people decided, rather sleep it off, see if symptoms go away and they feel better in the morning. And by that time they're already out of our window for consideration for possible treatments in the emergency department, drowsiness sleepiness may even be a part of a stroke symptom at onset. And so you may be dealing with a family member or a loved one who's telling you, they, they just feel like they need to go to sleep. and it's really important to, urge them to come and be evaluated.

Another one I would say is, giving anything by mouth, is a temptation sometimes to give water, maybe make me feel better, have them eat something, or to give a medication like aspirin, which may end up being part of stroke treatment. But because we don't always know upfront which type of stroke somebody's experiencing, whether it's, hemorrhagic caused by bleeding somewhere, in which case aspirin may make things worse.

Joey Wahler (Host): Understood. So finally Mercy Medical Center is actually nationally recognized by the American heart association for its commitment to providing high quality stroke care awarded the 2022 Gold Plus, Get with the Guidelines, Stroke Quality Achievement award. So tell me, Doc, what makes your team so effective at treating strokes would you say?

Dr Zachary Bowles: I would say, we really emphasize, rapid action as soon as we're suspicious that a strokes occurred. We have a very streamlined process, as part of being a stroke center for doing all these evaluations, when you show up to the emergency departments, you're gonna have a whole team of personnel, immediately rushing to be part of this. So you'll have nurse, you'll have the physician, you'll have a radiology tech, ready to walk you to our CT scan. Really all focused on the goal of, identifying a stroke and identifying somebody who may benefit from the treatments that we have to offer. We hold ourselves to a high standard. We do a lot of work as far as case review, trying to identify places where we could beat up that process and improve in any way possible to help people get the best outcome possible.

Joey Wahler (Host): And the proof is in the pudding. You're obviously doing a very effective job at it. Well, folks we trust you're now more familiar with pre-hospital stroke recognition and emergency care. Dr. Zachary Bowles. Thanks so much again.

Dr Zachary Bowles: Thanks for having me. It was a pleasure.

Joey Wahler (Host): Same here. And for more information about Mercy Medical Center Stroke Program. Please visit dignityhealth.org/Merced/stroke. Again, dignityhealth.org/merced/stroke. If you found this podcast helpful, please do share it on your social media. And thanks again for listening to Hello Healthy, a Dignity Health Podcast. Hoping your health is good health. I'm Joey Wahler