Five Questions With: Dr. Remle Crowe on Stroke Education for Spanish-Speaking Communities

Timely treatment for stroke relies on swift recognition of symptoms and immediately activating emergency response. Community education is critical in this effort. Research shows that Spanish-speaking communities demonstrate lower awareness of stroke symptoms than their English-speaking counterparts.

To address this deficiency, Maricela Wilson, RN, BSN, community outreach coordinator at Seton Healthcare in Texas, Remle Crowe, PhD, NREMT, senior manager of clinical and operational research at ESO, and Paul Banerjee, DO, medical director at Polk County Fire Rescue in Florida, have partnered to create a Spanish translation of the BE-FAST stroke screening tool. Their hope is to reach a broader segment of the public in order to raise awareness of the warning signs for stroke.

EMS World spoke with Crowe to learn more about the tool and how EMS systems can incorporate it to benefit their communities.

EMS World: Why did you select the BE-FAST scale for translation into Spanish (as opposed to other scales such as RACE, LAMS or VAN)?

Crowe: Research using EMS data has shown that many stroke scales perform similarly. We know that performing a stroke scale is important, no matter which one is used. When designing this tool for broad use as an education and communication instrument, we turned to the BE-FAST for its favorable memory aid characteristics (each letter stands for a symptom). The BE-FAST includes the traditional symptoms of an ischemic stroke in the most commonly affected area of the brain (middle cerebral artery), but this scale also incorporates two signs, changes in balance/gait and changes with the eyes/vision, that are linked to severe strokes and may occur in other areas of the brain.

What steps went into the creation of this resource, and can you outline its primary components?

As a community outreach coordinator who often interviews stroke survivors, Maricela was a strong advocate for creating a Spanish-language stroke screening tool. Having lived in Mexico City and completed my EMT training there, it was surprising to me that a tool did not exist. So, we put our heads together to see if we could create a simple mnemonic and illustration. Dr. Banerjee helped test our iterations and partnered with Spanish-language publications in his Florida community to disseminate the tool.

We started with the acronym “RAPÍDO” which is a direct Spanish translation for “FAST”, but we were unable to match the letters with the symptoms in a way that they would likely be remembered. After several iterations, we found an acronym that would include all the symptoms and possess the same favorable memory characteristics of the English tool: AHORA. AHORA means "now" in Spanish which communicates the sense of urgency like the BE-FAST. The A stands for “andar” meaning walking or gait, H stands for “hablar” representing changes in speech, O stands for “ojos” meaning changes with the eyes/vision, R stands for “rostro” meaning facial droop, and the last A stands for “ambos brazos” referring to the ability to lift both arms (or legs).

What need is this tool designed to address—i.e., what is the importance of reaching this population?

Study after study has shown that Hispanic and Latinx Americans have worse stroke outcomes than their white counterparts. One driver of this disparity may be delays in seeking care. Hispanic and Latinx patients often have longer times from symptom onset to hospital arrival and are then less likely to benefit from time-dependent reperfusion treatments. Recognizing symptoms of stroke is key to seeking care early. Again, studies have shown that Hispanic and Latinx Americans are less likely to know the symptoms of stroke. Additionally, Spanish-speaking Hispanic and Latinx Americans are less likely to recognize stroke symptoms compared to English-Speaking Hispanic and Latinx Americans. We believe that having a simple Spanish stroke recognition mnemonic is a step in the right direction for improving health equity.

You included headache as one of the questions, though it’s not directly included in most stroke scales. Can you explain the reasoning?

This is something we debated quite a bit. In my early EMT education, I remember being taught to ask about the “worst headache of your life, unlike any other headache” as part of stroke screening. Over the years, this question seems to have fallen out of most widely used stroke screening instruments as the focus has been on ischemic stroke. Meanwhile, headache is more commonly associated with hemorrhagic stroke. Hemorrhagic stroke also needs rapid identification and transport to an appropriate facility. Since Hispanic and Latinx Americans are at higher risk for hemorrhagic stroke compared to white, non-Hispanic Americans, we felt this component was key. We included the question about worst headache unlike any previous headache as part of the face (and head) section of the tool.

What future projects or initiatives are you planning in the area of stroke education?

One of our major efforts now is to find ways to share AHORA with as many people as possible. As EMS sits at the intersection of healthcare, public health, and public safety, we see an important opportunity to be part of the change. We are grateful for the EMS community’s help with this public health outreach effort and encourage use of the tool. The AHORA graphic may be reproduced and used freely.

Additionally, data is key and EMS data has the potential to further shape our understanding of healthcare disparities. We are currently working on research related to stroke assessment, treatment, and outcomes for EMS patients taking into account key demographic characteristics, like race/ethnicity, age, and gender. We look forward to keeping this conversation going and are very interested to hear about your experiences using AHORA. Thank you!

For a hi-res downloadable AHORA graphic to print and distribute, click here.

English Translation of the AHORA Tool