Faster Care for Stroke Victims Sought

WASHINGTON (AP) -- They jokingly call themselves commandos, but instead of camouflage gear they wear white coats -- doctors whose mission is to get more stroke victims a clot-busting drug that can mean the difference between permanent brain damage or recovery.

In the handful of cities where these specialists race to emergency rooms at whatever hour stroke victims arrive, patients are up to 10 times more likely to get that drug.

``Usually when we arrive, there's a great sigh of relief'' from overworked ER doctors who are unsure how to treat a stroke, says Dr. Edward Jauch of the University of Cincinnati's stroke team.

More than 700,000 Americans will suffer strokes this year. It is the nation's leading cause of disability and No. 3 killer. Some strokes are caused by the bleeding in the brain, but most are ischemic strokes, caused when arteries feeding the brain are blocked. That's the type that the clot-busting TPA treats.

Yet six years after TPA was named crucial to the treatment of strokes, only two of every 100 ischemic stroke victims receive it.

But in Houston, San Diego, Cincinnati and other cities, the so-called stroke commandos are getting TPA to significantly more patients in time, from 10 percent to beyond 20 percent of patients in some hospitals.

Now the National Institutes of Health wants to spread that success and turned to the commandos for advice. Their recommendation: Within the next year, all hospitals should designate whether they have the facilities for proper stroke care. Then ambulances should begin immediately to carry possible stroke victims to those hospitals that promise state-of-the-art care, even if it requires bypassing a closer ER, just as paramedics now take accident victims to trauma centers.

``Hospitals are not created equally,'' Dr. Anthony Furlan of the Cleveland Clinic Foundation told 400 stroke experts at a meeting convened by NIH last week. ``Either they have to get up to speed, or they shouldn't be doing stroke care.''

Why is it so hard to give TPA?

Partly it's a matter of time. TPA must be given within three hours of the first symptoms, and roughly a quarter of patients get to hospitals fast enough.

But too often the hospital plays a role. Patients arrive in time, only to be cared for by nonspecialists confused about how and when to give TPA, stroke experts told the NIH meeting.

Because TPA can cause bleeding in the brain, a CT scan to ensure the patient isn't already bleeding is crucial. Not every hospital offers 24-hour CT scans.

And the scans can be confusing. For example, one study found 32 percent of patients initially deemed to have a stroke too mild for TPA wound up dead or disabled. Yet stroke ``is a slowly gathering steam engine'' as brain damage builds for hours, so don't rule out TPA just because of an early CT scan, warns Dr. J.P. Mohr of New York's Columbia-Presbyterian Medical Center.

The stroke commandos fight such barriers in different ways. In Houston, for example, University of Texas experts signed up six of 29 area hospitals to offer proper stroke care, with specialists on duty 24 hours a day, and taught paramedics stroke symptoms. Ambulances now are supposed to bring possible stroke victims only to those six hospitals.

In Cincinnati, Jauch assembled a team of experts that 15 area hospitals page for help whenever a stroke victim arrives. San Diego's system is similar.

In Nevada, where patients can be 300 miles from the nearest stroke specialist, a commando team advises rural hospitals on TPA by phone and computer, and flies patients to bigger hospitals for follow-up care.

There are no national guidelines urging hospitals to adopt such programs. But the NIH's National Institute of Neurologic Disorders and Stroke will post the new recommendations on its Web site in hopes communities will follow them.

Meanwhile, patients and families can help themselves by knowing stroke symptoms - weakness or numbness on one side of the body, slurred speech and loss of balance - and seeking help immediately. Call 911, as arriving by ambulance guarantees a faster hospital exam.

Women often have some different symptoms, including confusion, disorientation and pain. Don't focus just on those unusual signs - mention any other symptoms like one-sided weakness, too, because those buzz words speed a correct diagnosis, advises Dr. Lewis Morgenstern of the University of Michigan.

And don't be reluctant to ask the ER doctor if you or a relative is a TPA candidate, the specialists say. The answer might be no, but asking can help ensure the right tests are done.