Deborah Howell (Host): Maybe you've heard the phrase, time is brain when it comes to stroke. In this episode, Dr. May Nour, Vascular Neurologist and Interventional Neuroradiologist at Memorial Care Long Beach Medical Center will tell us about the life-saving impact of the Mobile Stroke Unit and how this hospital on wheels is transforming emergency stroke care by bringing rapid diagnosis and treatment directly to patients when every second counts. Welcome Dr. Nour.

May Nour, MD, PhD, FSVIN: Hello, how are you?

Host: Good morning. I'm great. Wonderful to have you. Why is it so important to treat a stroke quickly?

May Nour, MD, PhD, FSVIN: Well, you ask a very important question. Stroke like many other golden hour emergencies is very time sensitive, meaning that each minute that we can save for the patient in terms of initiating care, directly impacts the patient outcome. So for each minute that goes by, without flow of blood to the tissue of the brain, 2 million brain cells die.

So you can imagine if we can afford time savings of half an hour and more, how that can impact the final outcome of a patient and how they live their life.

Host: Absolutely. So tell us about the mobile stroke unit and how it's different from a regular ambulance.

May Nour, MD, PhD, FSVIN: So unlike any other ambulance that's operated by the EMS system, the mobile stroke unit is a primary stroke center on wheels, meaning that we've brought the hospital to the patient. This is an ambulance, which is equipped with a CT scanner in order to identify whether there is lack of blood flow to the tissue of the brain or bleeding into the tissue of the brain so we can diagnose stroke in the field.

This also has experts who are a paramedic firefighter, a nurse who's a stroke trained nurse, a CT technologist, and a stroke neurologist, either in person or by telemedicine. And we bring all the laboratory equipment needed to make together in accordance with the clinical diagnosis, the imaging And the laboratory, what's the best diagnosis for the patient and how we can treat them.

And in fact, we initiate that treatment and bring time saving to the patient wherever they are.

Host: Absolutely incredible. And why is having that CT scanner on the unit so important?

May Nour, MD, PhD, FSVIN: Well, in order to treat stroke, we must understand whether it's ischemic in nature where there's a lack of blood flow to the tissue of the brain, or hemorrhagic in nature where there is bleeding into the tissue of the brain. That's really basically the fork in the road in which we have to understand and how to start treatment.

And, unlike any other ambulance, we can do that in the field.

Host: Wow. And how does that mobile stroke unit team work with local EMS to activate the mobile stroke unit and the team?

May Nour, MD, PhD, FSVIN: So we work with the fire departments, and EMS services. We are designated as a shared regional resource of Los Angeles County Emergency Medical System. We are an additive resource to the care, so we don't replace the 911 response. We attend with the 911 response. As such, within our geographic operating area, we'll work with the fire departments that serve that area and in Long Beach we're very, very proud of our partnership with Long Beach Fire Department and the surrounding cities to Long Beach with the LA County Fire Department.

Host: Now some people listening might say, why the fire department, someone's having a stroke.

May Nour, MD, PhD, FSVIN: Great question. Actually, that was my thought when I started this program. I didn't understand why when we went on a medical response, a fire engine showed up. I said, where's the fire? But it is such where in our Los Angeles County system, the fire departments are the majority of the 911 or emergency medical response is actually, furnished by the fire department.

So there are 28 different 911 responding entities in Los Angeles County. And the majority, if not, almost all are fire departments.

Host: Okay. Thanks for clearing that up. That was really kind of like confusing to me. Now I get it. What treatments can patients get right away on the mobile stroke unit?

May Nour, MD, PhD, FSVIN: Exact same treatments as they would get in the emergency department when they present to the hospital. So after the scan and understanding whether it's a lack of blood flow stroke or a bleeding type stroke, we carry the clot busting medications that are treatments for ischemic stroke or lack of blood flow stroke.

We also carry hemorrhage reversal agents for patients who are on blood thinning agents that need to be reversed. We carry anti-seizure medications and other medications, and so basically we bring the hospital to the patient.

Host: It really is a hospital on wheels. Who's on the team that works inside the mobile stroke unit?

May Nour, MD, PhD, FSVIN: The team is in our program is composed of four essential people. Number one, a firefighter paramedic, and that is one of the fire department firefighters, again, are, we're very proud of our partnership with Long Beach Fire. We also work with the Torrance Fire Department and we started staffing with Santa Monica Fire Department.

In addition to that, we have a nurse who's either trained in critical care nursing or emergency medicine nursing. We have a CT technologist who operates the scanner, and then we have a physician, a vascular or vascular and interventional neurologist. In our case, there are two of each of our colleagues who cover. And that person is either in person or by telemedicine presence.

Host: That's a lot of people. How large is this van?

May Nour, MD, PhD, FSVIN: It's a very large ambulance. If you look at it, it doesn't look like a fire engine or anything. It looks like a very large ambulance. In our mobile stroke unit one, we can actually carry up to six people on the ambulance with us in addition to the patient.

And we have really, really exciting news that the program has been expanded and we're not only working with one mobile stroke unit now, but a fleet of mobile stroke units, we will be revealing very soon MSU2 and three to the fleet.

Host: Terrific. Congratulations on that.

May Nour, MD, PhD, FSVIN: Thank you. After seven years, it's a huge accomplishment.

Host: I can only imagine. And how has the Mobile Stroke Unit helped patients since it started?

May Nour, MD, PhD, FSVIN: I can give you an example just from yesterday, believe it or not. So I was covering the mobile stroke unit by telemedicine yesterday and our first job is because we bring expertise to the field; not only can we help in treating patients fast, but also recognizing signs and symptoms of stroke differently than anyone else trained in the EMS system.

Because this is our job. This is what we do. And when we arrived on scene, we were attached to a call that came out on the radio as an altered patient. It was not even a stroke dispatch. We know that there's some inaccuracy in dispatcher impression and it's not surprising.

The dispatcher, the 911 call taker, has about 60 seconds to make an impression of what the person is experiencing. And it's all based on what somebody tells them on the phone. And so if somebody tells them the wrong information or different information, then they should know, then it could come as altered, not a stroke.

So we were attached to this altered call. And when we arrived on scene, in fact, the fire crews had evaluated the patient and downgraded, meaning that made it a less intense resource Call. However, our nurse and medic were already there and they wanted to just evaluate the patient while they were there.

And when our nurse evaluated the patient and when we discussed it on telemedicine, they said, you know what? I just have a bad feeling about this, that something here is missing. The patient came to the recreational center, usually plays guitar, and for about 15 minutes, unable to understand how to open his guitar case.

And just looked very confused and it wasn't something, very big that we expect of stroke. Like somebody's paralyzed on one side or somebody can't speak or somebody can't, sense something. He was just confused about how to do things. And our nurse, because trained in stroke neurology, in fact, our nurse used to be one of the Long Beach Memorial stroke nurses before and we have actually two of our mobile stroke unit nurses are veterans of the Long Beach Stroke Nursing Program that's run by Andrew West, which is a phenomenal resource at Long Beach Memorial.

And, Brian, our nurse, said, I think we should admit this patient. I think something's happening. And sure enough, when the patient got to the unit and we examined them, I immediately knew that this patient was having a stroke and I knew exactly where the stroke was, depending on the exam. And we said, okay, this is for us.

Let's take this patient. And the patient was outside of the window for IV clot busting medication. Because as you may know, there's only about four and a half hours from the last known well time. Somebody last known normal, and when I spoke to his wife, the amazing subtleties of this, she said that he was having difficulty. She didn't notice anything different other than when he was leaving the house before arriving to the recreational center. He was looking for his wallet.

He couldn't recognize where his wallet was. Well it was in his left back pocket and he couldn't recognize to put his hand there even though it was there. And

then when our nurse saw him, he was ignoring the left part of his space and that syndrome we call the syndrome of neglect. And that's always in the right parietal lobe of the brain. And sure enough, that's exactly what our scan showed. He was having a stroke of the right parietal lobe. And not only that, we were able to identify on the mobile stroke unit, a blockage of a large blood vessel in his brain, in the middle cerebral artery. And I, myself, as you know, I'm also interventionalist at Long Beach Memorial, but in my role yesterday, the hat I was wearing was the stroke neurologist on the mobile stroke unit. And my colleague, Dr. Victor Zader, was the interventionalist at Memorial and I called Victor immediately.

Victor, I want you to look at the scan. I think we should take this patient for potential clot retrieval. And sure enough, he did take him for clot retrieval at Long Beach Memorial. Imagine had the mobile stroke unit not been there; number one, this was not recognized as a stroke call by the dispatcher.

Number two, it was not recognized by the field team as a stroke. And imagine this patient would've not gone to even a stroke center. And meanwhile, this altered his care to be able to recognize this and direct him to the appropriate site.

Host: And please let us know he's doing okay.

May Nour, MD, PhD, FSVIN: He's doing wonderful.

Host: I'm so glad to hear that. So all of this people, it starts with a 911 call and with the best information you can give them on that call, correct.

May Nour, MD, PhD, FSVIN: That's one. And the thing I really want to emphasize, it's all about community and public education, about the signs and symptoms of stroke and the fact that stroke is time sensitive. even for this patient, after these confusing episodes, he still drove himself to the recreational center because it wasn't recognized that this something emergent needs to happen.

And so I want to emphasize, and this is a great opportunity for education of our community members, that there are certain signs and symptoms of stroke. Some are very obvious and some are subtle. But a good acronym to remember is called BEFAST. And the B stands for sudden loss of balance, E stands for sudden changes in the eyes, meaning that blindness in one eye could be a stroke. Double vision could be a stroke. F stands for facial weakness. A stands for arm or leg weakness. S stands for alteration in speech or language. So somebody can have a slurred speech or they're confused. They're saying different words or making word salad. And T stands for time to call 911. So not only should we recognize the signs and symptoms, but also we know stroke happens suddenly. Stroke is not something that happens over weeks and days. It's a one moment grandma is doing okay, and the next moment she has symptoms and it is time sensitive. So let's not sit on it.

Let's not wait and see how her arm works in a few hours. Immediately call 911 because this is the only way they can get treatment.

Host: And you can learn more about the Mobile Stroke Unit by going to memorialcare.org/lbcmsu. That's memorialcare.org/lbc-msu. Thanks so much Dr. Nour for your time and your expertise today. We learned a lot and really enjoyed having you on the podcast.

May Nour, MD, PhD, FSVIN: It's my absolute pleasure.

Host: That's all. For this time. I'm Deborah Howell. Have yourself a terrific day.