Recently, CHS Blue Ridge Lead APC, Brent Curry appeared on WBTV News, a North Carolina CBS affiliate, discussing stroke response in rural medicine. Curry has enjoyed practicing as a PA for over twenty years, and also serves as the Assistant Medical Director of Burke County EMS as well as the area Medical Examiner. He and his family live on a nearby farm where he also maintains a successful woodworking studio.
In stroke intervention and treatment, timing is everything. Minutes make the difference as the stroke impact progressively takes hold on the brain. That part of the equation balances clearly. A stroke cuts off blood supply to the brain – the quicker blood flow resumes, the better the outcome for the patient. The math sequence becomes exponentially complex when factoring in access to medical assistance.
STROKE OUTCOMES IN RURAL AREAS
For millions of rural Americans, those numbers won’t add up when driving distances put them at a statistical disadvantage for obtaining help. Brent Curry, PA-C, Lead APC at Carolinas HealthCare System Blue Ridge in Morganton, North Carolina, knows the challenge all too well as his team consistently tackles the calculus.
“At Blue Ridge, our focus is likely no different than every other stroke-ready facility across the nation,” says Curry. “Expedite the patient, get them in front of a clinician — whether it’s local or via teleneurology and specialized nurses — so we can shorten the door-to-needle time, and make sure they get the advanced imaging.”
However, their pastoral location, tucked in the foothills of the Blue Ridge Mountains, narrows the aperture for that focus. “As a stroke-ready facility, our focus has been getting those patients in a rural setting to call EMS to get to the hospital,” Curry implores, “which in our county can range 16-45 minutes [travel]. That’s the rapid-response time, not necessarily when they arrive.”
BE FAST TO NOTICE: STROKE SAFETY AWARNESS
Initiating travel to a facility at the first hint of stroke symptoms is crucial for improving outcomes for stroke patients in rural areas, and often a call to EMS yields the most efficient method of transportation. Identifying the symptoms results from increased stroke awareness.
“There’s been such a delay in rural care getting to therapy and understanding the benefits,” Curry reveals. “That seems to be why rural care and education have really been a focus for the American Heart Association for the last few decades. Our hope is that with the American Heart Association push, as well as community outreach programs and education initiatives, that patients will recognize EARLY the signs and symptoms of a stroke.”
For many years, the acronym FAST has been employed as a teaching tool to convey a simple method for memorizing common stroke symptoms. The letters F-A-S-T designate specific signs indicating the possibility of a stroke event by noting the following markers:
As knowledge of stroke patterns broadens, determining new signs enhances efforts for early diagnosis. “We used to just speak on a FAST acronym,” Curry explains, “but now we’ve extended that to include Balance and Eyesight — so BE FAST — to help patients recognize their symptoms. Stroke symptoms are different for people … we changed the acronym to BE FAST because we did find that a substantial amount of people missed the posterior strokes.”
BE FAST TO ACT: EMERGENCY TREATMENT FOR STROKE
Curry goes on to express his worry about people second-guessing inherent concerns about taking physiologic changes seriously. “I feel like a lot of people don’t understand that they’re having a neurologic event,” he continues, “whether they’re by themselves and impaired neurologically and not thinking correctly or with family that just don’t recognize it.”
He sees the unfortunate domino effect from that lack of recognition. “Frankly, sometimes a lot of our rural citizens are pretty stoic. They feel like time fixes most things, and I think that’s part of the delay,” he frets.
According to Curry, “over the last several decades, there’s been two essential treatments that have evolved — intravenous thrombolytics and catheter-directed therapy. Those therapies really haven’t changed, but there has been some evolution in the management of them and progression of them.”
The first treatment modality of intravenous thrombolytics must be administered within a 4.5-hour window for efficacy. The catheter-directed therapy opens up a 24-hour window, but with limitations. Curry clarifies the subtle, yet serious, exceptions.
“The 24-hour window for catheter-directed therapy is for a special subset of patients who have large events and large vessel occlusions, and those are usually done at tertiary centers,” he notes. “That’s why the rural communities are doing thrombolytics because sometimes your best option is the closest facility. Keeping rural centers stroke-ready is crucial. There would be such a delay if you have to get patients to tertiary, non-rural facilities … we would lose a large portion of those patients.”
BE FAST TO CALL: IMPROVE STROKE PATIENT OUTCOME
Curry stresses that, no matter what the time frame, patients should get to the hospital.
“Our biggest awareness push is that if you feel like you’re having an event, if you have concerns, contact EMS!” he insists. “The patients we’re able to get through the system the fastest are those who come in with EMS. We’ve found the patients that present via pre-hospital care with pre-alerts allow us to shave off more time.”
Curry further explains that utilizing EMS resources also allows the care teams to prepare thoroughly for patient arrival, anticipating whatever immediate attention could maximize positive outcomes.
“When they do call EMS and they do activate a pre-alert,” he details, “we actually have a protocol at Blue Ridge that we institute teleneurology prior to arrival and they are waiting for monitoring which helps a substantial amount… mostly they go straight to advanced imaging from the stretcher with EMS. It depends on the extent of symptoms.”
The American Heart Association stresses recognition and immediate action because of the narrow treatment window. “If we’re within that window we have options,” Curry stresses. “That’s what we want. We want early presentation and early activation, so we have options. The worst thing you can have happen is that you have a neurologic event that will change your life and your delay creates no options.”