Helen Dandurand (Host): Welcome back to the Well Within Reach podcast. I'm your host, Helen Dandurand, and today I'm going to be joined by Richard Cain, a Paramedic with Riverside, to talk about how Riverside paramedics respond quickly and effectively to stroke symptoms.

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Helen Dandurand (Host): And we're back with Richard. Thanks for joining us today. Could you start by just telling us a little bit about yourself?

Richard Cain, Paramedic: Yeah, thanks for having me. My name is Richard and I've been a Paramedic for 13 years, with Riverside for over 16. Along with my work as a paramedic I'm also a field training officer where I mentor new recruits and I'm in charge of administering our electronic health records.

Host: That's awesome. That's awesome. That's a long time. Has the job changed a lot in the time that you've been doing it?

Richard Cain, Paramedic: Definitely. When we first started we were doing everything on paper and it's taken about 10 years and we are finally for the first time ever, paperless.

Host: That's awesome. That's really great. Well, I'm sure that all of those new technologies kind of factor in with speed and the things that you're able to do. And that's why we're here to talk a little today. We know that like strokes strike fast and we have to act quickly when responding to them. So I guess just to start with that, what are the key signs and symptoms that someone might be having a stroke, and when should 911 be called?

Richard Cain, Paramedic: Great question. When it comes to a stroke, every second counts. So it's important to recognize the signs early. A simple way to remember the key symptoms is with the acronym FAST. F is for face, ask the person to smile. What you're looking for is if one side of the face is drooping or not symmetrical. A stands for arms. You have them raise both arms. If one arm starts to drift down or they can't lift it, that's another red flag. S is for speech. Ask them to repeat a simple sentence. If their speech is slurred or hard to understand, it could be a stroke. And T is for time. If you notice any of these signs, time is critical. You need to call immediately. And there is no, we don't get upset if we show up and it's something simple or something less than. We're actually happy about that.

Host: Right.

Richard Cain, Paramedic: But if it's not, it's always good to call early.

Host: Yeah, yeah, that's good to know. I feel like sometimes just the idea of calling 9-1-1 is kind of daunting to say, oh, well, I don't know. That doesn't seem like it's that critical, but just knowing you know, you should do it and then you can be assessed and that's much better than the alternative. My next question here is, what role do family members or bystanders play in these situations and how can they best help the patient while they're waiting for paramedics to arrive?

Richard Cain, Paramedic: Family members and bystanders, they play a critical role. One of the biggest things is, we're going to be asking a lot of questions of the patient and sometimes they're not able to answer. They're like the lifeline or the bridge between the patient and us. They will know their baseline better than we will.

But the biggest thing is, is to remind the patient to stay calm. The more composed they are, the more effectively they can assist.

Host: Cool. You said that timing is very important during a stroke. What steps do you take, to ensure a fast response when 9-1-1 is called?

Richard Cain, Paramedic: Well, the biggest thing is we treat everything like it is an emergency already. So once the 9-1-1 call happens, it's going to an emergency medical dispatcher who's going to answer the phone, ask pertinent questions, and then we're going to be dispatched. We respond immediately to all emergencies. We respond fast but safe. So, you know, lights and sirens, we're, we're coming and we're coming ready to go to work as soon as we get there.

Host: Awesome. Well, that's, good to know. Reassuring to know. We're going to take a quick break, to talk about primary care at Riverside.

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 And we are back to talk a little more about strokes and how paramedics respond to them here at Riverside. So can you walk us through the initial steps that you take when someone suspected of having a stroke is picked up by an ambulance?

Richard Cain, Paramedic: Yeah, of course. As I stated before, the first thing is it's going to be answered by an emergency medical dispatcher. They're going to get the pertinent information, they're going to relay that to us, so when we get to the scene, we have a better understanding of what exactly we're walking into.

 And then time is brain when it comes to a stroke, so we're going to seem like we're moving kind of fast, we're going to go through like a Cincinnati Stroke Scale, which is asking the patient different questions to kind of see if they have any deficits. We're going to be asking the family what, when was their last known normal and get a good solid medical history on that patient.

Once that's done, you know, care is initiated at the bedside, so we'll do most of this stuff in the house. And then, you know, it's getting the patient to the ambulance and to definitive care like Riverside ER.

Host: Got it. you kind of mentioned this a little bit in answering that, but what kind of communication happens between you, the patient, and the hospital during a suspected stroke case?

Richard Cain, Paramedic: Getting a solid medical history, getting a last known normal, communicating with the family, because even though the patient is your patient, you have to be empathetic and keep the family informed, explain to them, there's a lot of education that goes in. The difference between a critical access hospital versus a primary stroke center.

 we cover a very large area where the closest hospital may not be the most appropriate hospital. The patients do get a choice at the end of the day, but we do have to educate

Host: Okay. So are there any specific tools or technology, that you use in the ambulance to aid in this diagnosis on the way to the hospital?

Richard Cain, Paramedic: Yes, definitely. And this is probably the part that I'm most excited about because we are, we're putting in new technologies as we speak.

Host: Yeah.

Richard Cain, Paramedic: But obviously we have, you know, the ambulance is equipped. I call it like a mini ER. We have a cardiac monitor. So we would do a 3 lead ECG, a 12 lead EKG, blood glucose because a lot of low blood sugar symptoms mimic a stroke.

Host: Oh, yeah. I hadn't put a lot of thought into the different things that could be mimicking that too.

Richard Cain, Paramedic: Yeah. Strokes don't always present like you see on TV or in the movies, so we have to have an array of tools to try to assess and figure out exactly what's going on with the patient. Obviously, we're going to take, like, baseline vital signs, blood pressure, pulse, respirations, pulse ox, and tidal capnography is something new that we've implemented within the last few years.

And what's coming now is we're starting to institute telemedicine in the ambulance. So, with switching to an electronic health record, we got tablets. And we were able to figure out that we can use our instant messaging program Trillian. It's HIPAA compliant. So eventually we're going to have a tablet in the field for the stroke patient.

We're going to be able to show the doctor in real time on a video call; the signs and symptoms that we're seeing, in addition to we've already transmitted that 12 lead to the hospital, so he can see it. And then we do a Cincinnati stroke scale, obviously, as well, and, what's called a RACE score. So, I've already explained the Cincinnati stroke scale.

The RACE score is kind of differentiating the type of stroke, mostly looking for an occlusive or an ischemic stroke.

Host: Could you explain the difference between those?

Richard Cain, Paramedic: Between an ischemic stroke. So you have an ischemic stroke and you have hemorrhagic. An ischemic stroke is a clot. What that is, is somewhere in the brain, there is a clot that has developed that is cutting off oxygen. And remember, time is brain. Because oxygen deprivation is actually what causes the brain deficits. So within, you know, a certain window of time that if we can get that patient to definitive care, the goal is to have them symptom free after they administer the clot busting medications.

A hemorrhagic stroke is a little different. It's where vessels are actually burst. And that becomes a surgical issue.

Host: Got it. So yeah, with all those, the technologies are just crucial and the speed and the safety you guys can get folks to where they need to be is super important and that kind of, after you explaining, you know, the reason that the time is brain and things like that, it makes sense that you want to go to the center that has the advanced care that can care for you right away as opposed to being transferred. It sounds like that would be, could be detrimental.

Richard Cain, Paramedic: Well, exactly, because once you go to Hospital A, and we're lucky we have great hospitals in the area, no matter which one, where you go, but Hospital A may not have a neurologist in the building, and so that person may have to get transferred to a facility that's in their partner region or something like that.

Generally, it's like a three hour window for the clot busting medication, and by the time they get assessed, in that emergency room, the transfer gets scheduled, you're really starting to creep up the time.

Host: Yeah, could be scary. So once you arrive, say like your team, when you arrive at Riverside at the emergency department, how are strokes officially then diagnosed and treated and are there any special technologies that help with that process?

Richard Cain, Paramedic: So today, as we're transporting that patient to the hospital, we have to do a call in to the hospital to give them a report. And what we would say is, you know, this is Riverside Ambulance, we're calling in a code stroke. That is a universal code at Riverside that's saying I'm bringing somebody in that has stroke like symptoms.

At that time, Riverside Emergency Room is activating the code stroke. So we're getting neuro, we're getting pharmacy coming down, all these different departments come together and they're standing, waiting for us to arrive. Sometimes the ER doctor may be waiting outside where the ambulance parks so he can get eyes on the patient immediately.

After that happens, once we arrive at Riverside, we bypass the ER. We go straight to CT, so the patient can be scanned. They become a priority patient, they cut in line, if you will, and they get scanned within minutes of us arriving at Riverside, and that's how the stroke will be officially diagnosed, is off a CT or an MRI.

Host: Got it. Sometimes you have to cut in line when it's important.

Richard Cain, Paramedic: Yeah, you know, it's a, it's a triage system. It works.

Host: Yeah. Well, that's really great. And then it sounds like from there, you know, you can get the care that you need, with the specialists that are needed here at Riverside.

Richard Cain, Paramedic: Yeah. Generally speaking, once we get to CT, we, we have to re-give our report to the physician and the nurse, and then our part of it is finished. It's kind of like, you know, like a football team, you know, you have your special teams. We get as close to the goal as possible, and then the doctor is the quarterback, and we just kind of hand it off to him to finish.

Host: Well, that's awesome, and I mean, that's a lot of important work that you guys are doing to get folks where they need to be safely, and educate, and assess. There's a lot going on, and you guys do a great job.

Richard Cain, Paramedic: We appreciate that. Thank you.

Host: Yeah, yeah. Thanks for all that you do. Is there anything else that you feel like we missed that you might want to add today?

Richard Cain, Paramedic: I think just circling back on the importance of early recognition. You know, a lot of people, you are right, back to your point earlier where people are apprehensive about calling 9-1-1. They think they're, they're being a burden, you're really not, that's literally what we're setting they're being paid for and we would rather put your mind at ease if it's nothing and just bring you over to the hospital to get checked out, but in the time of an, you know, when it's a true emergency like a stroke, we get gratification from that early recognition, getting the patient the definitive care safely, and starting a lot of those treatments and having a positive outcome.

Host: Yeah, so definitely remember if you're listening, if there's ever any question, don't be afraid to call 9-1-1. Well thank you for being with us today, Richard.

Richard Cain, Paramedic: Thanks for having me.

Host: Yeah, and thank you listeners for tuning in to the Well Within Reach podcast brought to you by Riverside Healthcare. For more information, visit riversidehealthcare.org.