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Diagnosis via technology

Wilson Daily Times (NC) - 9/1/2015

Sept. 01--Carlton Tedder was never in the same room with the neurointensivist who quickly diagnosed and treated his stroke this spring. They did communicate face-to-face, sort of. But he was in Wilson, and she was more than 70 miles away at Duke University Medical Center.

Tedder, 76, was the first patient at Wilson Medical Center to use telestroke technology, arriving in the emergency department just 15 minutes after telestroke went live here on May 14.

The physician at Duke was able to connect with Tedder and the emergency room staff here through telestroke. A two-way, video and audio connection is established with the moveable telestroke robot, so the patient and doctor can see each other and communicate. The neurointensivists, who are also neurologists, can even zoom in to look at the patient's pupils.

Tedder's doctor, Vani Chilukuri, was able to ask Tedder questions and give him commands before making the stroke diagnosis and deciding on treatment that Tedder believes saved him from permanent paralysis.

Early detection is key

At home that morning, Carlton Tedder got up and went to the bathroom. On his way back to the bedroom, he fell and couldn't get up. Tedder insisted he would be OK and told his wife, Romona, that she was overreacting when she called 911.

The EMS crew gave Tedder a series of tests that give a good indication of stroke. For instance, they asked Tedder to hold out his arms, then touch a finger to his nose. He couldn't do it.

Early stroke detection is essential for a good outcome. According to the American Heart Association, a stroke happens when a blood vessel is either blocked by a clot or bursts. The stroke stops the blood and oxygen from getting to the brain, and the brain cells die.

The quicker the patient is treated, the better the outcome.

Once EMS has an idea that the patient could be having a stroke, as happened with Tedder, Wilson Medical Center is alerted that a possible stroke patient is being transported, and a stroke alert is issued. Back at the hospital, the CT area is cleared so the patient can be taken there quickly, said Donna Beaman, chest pain/ stroke center coordinator. Duke is also alerted as part of the stroke alert.

A CT scan can rule out a hemorrhagic stroke, which occurs when a blood vessel ruptures and blood spills in the brain.

A physician at Duke was alerted once Tedder gave his OK. She looked at his CT scan and wondered if perhaps he had a less serious TIA or mini stroke because he was getting better. But an hour after he arrived, he got worse again. He was unable to speak and could not move one side of his body.

He was given more tests while Chilukuri watched his responses back in Durham. The tests routinely include such things as pressing your hands together to gauge strength, answering basic questions including your age, holding out your arms for 10 seconds, and saying words that would indicate slurred speech, such as tip-top, fifty-fifty and huckleberry.

In a typical exam, the neurologists at Duke can also put up pictures on the computer screen to identify and ask the patient to read a few things. The patient and medical staff in Wilson can watch through the Super Telemedical Access Robot, named STAR for short.

Patients are constantly being assessed, said Chris Brown, director of cardiopulmonary neurodiagnostics and sleep disorders at Wilson Medical Center, to see if there are any changes.

In Tedder's case, by assessing his response to questions, Chilukuri was able to diagnose an ischemic stroke from a clot and prescribe the clot dissolving IV drug tPA. Once the clot dissolves, blood flow can be reestablished in the brain. In order for tPA to work, it must be administered within three to four hours of the stroke.

Brown said as time passes, more tissue dies around the clot.

IMPROVING STROKE CARE

Before telestroke was implemented here, a Wilson neurologist would be called to come in and assess the patient and read the CT scan to determine if transport to a larger hospital was needed, Brown said. There is not as much of a need to transport now, and that's a major goal. By keeping the patient in the community, there is less stress on the family, he said, and transport costs are also eliminated.

There is immediate availability with telestroke; usually 2 to 4 minutes after the initial call is made a neurologist has made the first contact. Beaman said sometimes they hear back from the Duke neurologist who has viewed the CT scan, even before the emergency room provider here sees the scans.

Dr. Brad Kolls is one of the neurointensivists at Duke who answers calls for Wilson and several other hospitals while on call in ICU at Duke.

With telestroke, it's possible to improve local stroke care, he said, by getting tPA to the patient as soon as possible. The program also leverages local resources.

"It's a win-win on every front," he said.

Kolls said the doctors like to be called as the patient is going for a CT scan. That way they can formulate a plan based on information they have been given. The ultimate goal is to "improve outcome."

"That's why we are all here," he said, "for the best outcome."

The key is to be as rapid and quick as possible with the testing and diagnosis, he said, re-iterating a phrase that is often used: "Time is brain." The patient loses millions of neurons in the brain for every minute that is wasted.

CALL 911

Tedder's wife did the right thing to call 911 right away. Brown said it's important to call an ambulance and not to rely on family to take a patient into the emergency room.

EMS staff can call ahead and alert the hospital that a possible stroke patient is on the way, and the prep work can begin before the patient even arrives.

Brown said not everyone will see the same outcome as Tedder, who is back working parttime at Food Lion as a butcher, playing golf and going about his normal routine. Tedder said the only difference is that he is slower now.

Other stroke patients may not be as lucky, Brown said, and may not be able to go back to work or to even go home.

Telestroke has been put to good use in Wilson since May. Beaman said it has been used around 25 times a month.

Stroke is the third leading cause of death in Wilson County, behind heart disease and cancer and is the leading cause of disability in the United States.

The AHA says most strokes are preventable if certain risk factors are avoided, including high blood pressure, cigarette smoking, atrial fibrillation and physical inactivity.

lisa@wilsontimes.com -- 265-7810

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