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Ep. 204 - LiveWell Talk On...Stroke Care in the ER (Dr. Ryan Sundermann)

episode 204

Ep. 204 - LiveWell Talk On...Stroke Care in the ER

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Ryan Sundermannmedical director, St. Luke's Emergency Department

Dr. Arnold:
This is LiveWell Talk On...stroke care in the ER. I'm Dr. Dustin Arnold, chief medical officer at St. Luke's Hospital UnityPoint Health. When it comes to stroke, time is essential. And today joining me is Dr. Ryan Sundermann, medical director of the emergency department and he's going to discuss signs, symptoms, as well as the essential treatment of treating an acute stroke. What the symptoms are and what may happen after you arrive at the emergency department. Now Ryan, I know typically in the month of May you celebrate national vinegar awareness month and this year stroke's awareness month is also in May. Are you going to celebrate both?

Dr. Sundermann:
I don't know if that was a typo or if that's just your eccentric knowledge of weird facts.

Dr. Arnold:
Yeah. I know how much you enjoy vinegar, and so you're going to do both?

Dr. Sundermann:
Yeah, of course. Why not?

Dr. Arnold:
So good.

Dr. Sundermann:
Maybe at my house, I don't know if we're going to celebrate vinegar here, but yeah.

Dr. Arnold:
Yeah, keep that at home, out of the work place. Well, first let's start, what is a stroke?

Dr. Sundermann:
There's several different types of stroke. Typically when we refer to standard strokes, it's a blockage of a blood vessel, basically. We could get into as many details as you want, but as you know, people have heard of like cholesterol and plaque and things like that. And those exist within your vessels. And typically one of those kind of flakes off and creates an injury inside the vessel and when the body attempts to heal it, it creates a little clot and then that clot then blocks that blood vessel. And then the blood stops flowing. And then when the brain doesn't get blood through that vessel, it starts to die or get damaged. There's another type of stroke, which is when blood vessel breaks and that's called a hemorrhagic stroke, and that's considerably less. The number of those are fewer. But they are still considered a stroke. It's an injury to a vessel in a brain that causes poor blood flow to that area of brain, leading to its death.

Dr. Arnold:
You know, sometimes when I'm asked that question, sometimes I say that it's a heart attack of the brain.

Dr. Sundermann:
Yeah. Sometimes people think heart attacks and strokes are the same thing

Dr. Arnold:
Yeah. But I mean, I think people understand a heart attack. And in a heart attack of the brain, time is important. Now that we understand what a stroke is, for the listeners, at least they have that concept. The next is to diagnose it. And for the general public, there is an acronym, that they can use to at least run through the symptom they may be having and determine whether or not it could be a stroke. But as I know, you say this and I say this, if you think it's a stroke, just come to the ER.

Dr. Sundermann:
Right.

Dr. Arnold:
You know, don't try to second guess yourself. Well, what is that acronym?

Dr. Sundermann:
So it started off with FAST, and FAST was something that was developed for the public to use. You maybe even saw some of the billboards that it used to be on, the paramedics would sometimes use it. And that was just Face, Arm, and Speech were the big ones. And so if you had facial droop, if your arm wasn't working, or if your speech was slurred or you couldn't talk, find words, et cetera. And then they changed it to BE FAST, which is a little bit more in depth. So for example, balance you know, when people come in and say—so B stands for Balance, E for Eyes and then FAST, the Face, Arm, and Speech. The problem with balance is that people come in and say they're dizzy. And that can mean a lot of things: off balance, light headed. You know, we always have to differentiate that.

Dr. Arnold:
Yeah.

Dr. Sundermann:
But you know, for the general public, if you feel like you have new onset of dizziness, lightheadedness, something that you're not accustomed to, then some of those can be signs of stroke, especially balance issues. And so those can sometimes be accompanied by like spinning or, you know, also lightheadedness. But if balances off, incoordination, that kind of is what it gets to. Because in the form of FAST score, that often got left out. And again, without getting into a whole bunch of details, a different part of the brain kind of controls your balance as opposed to what controls your face, arm, and speech. And then eyes also, if you have vision loss that can—sometimes a stroke can be just vision loss.

Dr. Arnold:
Yeah.

Dr. Sundermann:
There's a special word for that called amaurosis fugax, which we don't use very often, but I know you love your Latin.

Dr. Arnold:
I do.

Dr. Sundermann:
So that's a term we don't use, but that's just sudden vision loss and that can be the sign of a stroke as well.

Dr. Arnold:
And also can be sudden speech loss.

Dr. Sundermann:
Right. Absolutely.

Dr. Arnold:
I saw a patient with Dr. Barnett, the cardiothoracic surgeon, when I was a medical student. So that's like the early nineties, right?

Dr. Sundermann:
Yeah.

Dr. Arnold:
And a lady had a stroke and it was an embolic stroke, right, from an atrial myxoma and her deficit was that she couldn't speak.

Dr. Sundermann:
Yeah.

Dr. Arnold:
So she gets up around her house and she lives by herself and she going all and bought her stuff, and then she goes to call her friend and she realizes she can't speak.

Dr. Sundermann:
Yeah.

Dr. Arnold:
So that was a very unusual presentation. And I think that reinforces that strokes can be an unusual presentation.

Dr. Sundermann:
Absolutely.

Dr. Arnold:
You know and people should have a low threshold. If they're having brain symptoms of any sort, they need to come and be seen.

Dr. Sundermann:
Right, yeah. You know, that's why I tell people, you wouldn't need me for the standard chest pain. Now, if you're having chest pain and you can't breathe and you're sweaty, you could probably just walk up to the cath lab and get your cardiac cath. It's the weird things. It's the unexplained sweating. It's the nausea that you've never had before. It's the really weird left elbow pain, you know, things like that for heart attacks. But with strokes, they can be very sneaky, you know, the vision loss and sometimes the vision loss, people just, they can still see straight ahead. They don't realize that it's actually kind of out in their periphery. And that's why some more detailed testing just on physical exam is important because they can tell something's wrong. They just can't put their finger on it. But then when we come in and put them through an organized stroke screen, we'll pick up some of those subtle details that once you point it out, then they're like, oh yeah, that's it. And then you can really pick it up and then that's when you got to get them to the care that they need.

Dr. Arnold:
Well, speaking of getting them to the care they need, we mentioned that time is essential, or of the essence.

Dr. Sundermann:
Right.

Dr. Arnold:
So how much time, talk about the time factor here.

Dr. Sundermann:
Yeah, so obviously every minute counts. I mean, the clock really is ticking. As a general rule—so I'll start off by saying, you know, the time that we figure as when it starts is your last known well. So unfortunately people wake up a lot of times with stroke-like symptoms, and so their last known well was when they went to bed. So that's why it's important, like if you wake up in the middle of the night and you feel like something could be going on, don't go back to bed hoping it's gone by morning because that's just more time, you know? So if you really feel like something's going on, come in. But ideally, we get people in here within three hours because most of the research that's been done that looks at the use of some of the medicines we use to break up the little clot that blocks an artery in stroke, the evidence that is out there really best supports that the medicine to break up that clot is given within the first three hours. They've stretched it out to about four and a half hours, and so we'll still do it in cases. But once you get to about four and a half hours, there's not a lot of great evidence support in giving any kind of medicine to reverse the effects of that stroke. So that's kind of the timeframe. But I don't want people to say, you know, oh, I'm going to wait around 90 minutes because I know I got three hours. That damage is being done, so every second counts.

Dr. Arnold:
And also, each case is unique.

Dr. Sundermann:
Yeah.

Dr. Arnold:
I certainly have given it at six hours depending on what the situation is, you know?

Dr. Sundermann:
Yeah, right.

Dr. Arnold:
You know that the risk is starting to outweigh the benefit at some juncture there. Now when you talk about medicines, for the listeners, that's a clot busting drug that dissolves clots. And not only does it dissolve clots in the brain, it dissolves it head to toe.

Dr. Sundermann:
Right.

Dr. Arnold:
And so there's the risk of bleeding.

Dr. Sundermann:
Yep.

Dr. Arnold:
And there's criteria that you follow, evidence based criteria to give that. But one question I want to ask for myself, is age still a contraindication?

Dr. Sundermann:
So that's the thing—

Dr. Arnold:
At one time it used to be really hard and fast. Like, okay they're 85, nope. They're 72, nope.

Dr. Sundermann:
Nope. Yeah, but now, you know, every case is unique, like you said. But anymore the thing is, there seems to be a lot of benefit, especially with like heart attacks, for example. Like cardiac cath, it used to be, oh, if they're over 80, we're not going to take them to do a cardiac cath. And now we've learned that those patients actually benefit most from it, you know? And so I think every case is unique, but there's really not a lot of age limit except we have to really— On the stroke scale, there is something, I think it's 85, right? It's not an absolute contraindication. So there's a lot of discussions that have to go on with the family about what they are willing to take on. You know, I think, I believe the number is still 6% risk of bleeding for any time that you administer TPA. But if you've had other bleeding risks, like if you've had a recent gastrointestinal bleed, if you've had recent surgeries, things like that, those are all important to take into consideration prior to giving the medication.

Dr. Arnold:
I'll say, in my clinical experience, I find patients would rather take the risk of having bleeding and dying, than having a stroke and be left with a deficit.

Dr. Sundermann:
Yeah.

Dr. Arnold:
They don't want to be a burden on their family, and they're like, yeah, let's do this.

Dr. Sundermann:
Yeah.

Dr. Arnold:
Now, the patient's arrived to the ER, you suspect a stroke. How do you confirm that?

Dr. Sundermann:
So confirmation is actually kind of relative. So the thing is, a lot of times when people come in and we do the CT, that's the most important thing is we get the CT scan. And so people are assuming that we're confirming there's a stroke on that CT scan. And what the general public may not realize is what we're really doing with that CT scan is confirming that they don't have a bleed. Because if you've bled into your brain, you definitely can't get something that makes you bleed more. So if you've had a hemorrhagic stroke, that's an absolute contraindication to getting TPA, obviously. And so that's the biggest thing. However, with someone–I don't know if you're going to get into this maybe a little bit later—but with some of the newer CT scans we can do what's called the perfusion scan that fills the vessels with some dye, or they call it contrast, and that helps us get a better idea of how large the stroke might be. But as far as—

Dr. Arnold:
Now, I'm familiar with that technique.

Dr. Sundermann:
Yeah.

Dr. Arnold:
But I'm not, I haven't looked at a lot of them and I know you have, is it pretty definitive?

Dr. Sundermann:
It when it's definitive, it's definitive. The problem is when it's not.

Dr. Arnold:
Okay, it's like nuclear medicine test. Like when it's definitive, it's obvious.

Dr. Sundermann:
It's obvious, right. So the thing is, that when we get the regular CT scan, most of the time it's not going to show much of anything. Sometimes in a big vessel, they can actually see a large clot or hemorrhage or something within that actual vessel. And so, that person needs to get intervention immediately. But then they can also do some of these perfusion scans. And what they do is they look at the actual area of infarct, which is the area of like true damage. And then they look at the area around it that might have a little bit of blood supply coming from some vessels surrounding it, and they look at the ratio of that true infarct to the area around it, called the penumbra, and they'd look at that ratio. And that ratio helps them determine the total size, but then also the ratio. Because if you have a small area of infarct, but then a lot of area that's being damaged, but isn't dead yet, that's an area that's amenable to further treatment. And so that's why it's important to get in here, because that's what's salvageable at that point. And so that will show up on these perfusion scans that we do now. I would say more of the confirmation is actually an MRI that they would do the following day. But really, we're doing those initial scans to help know whether or not this person is eligible for TPA, and then it's based off their signs. So if they don't have a bleed and everything else about it says stroke, then they're eligible for TPA. So it's more of the exclusion of the hemorrhagic stroke and the confirmation based on your physical exam.

Dr. Arnold:
And then once the diagnosis made, then they come to the hospital medicine service with the neurologist. Do most strokes end up in rehab, or how do most people do?

Dr. Sundermann:
Yeah. You know, I guess unless they turn quickly around. So, and that's the other thing about TPA. The studies that showed its benefit, are actually people kind of assuming you give this TPA and the next day you wake up and you're tons better because you get the TPA. Actually the evidence they collected from that looked at 30 day outcomes. So people, if they get better in the next 24 hours, they assume that's the TPA. Well, it could just be that your body broke it up itself.

Dr. Arnold:
Yeah.

Dr. Sundermann:
And most of the evidence would suggest if you get better in 24 hours, you probably would've gotten better anyway. A lot of it looks at functional outcomes at 30 days from the TPA and those are better if you give the TPA. But that is, you know, so you don't just wait around to see if you're going to get better from the TPA. You need to be doing everything to make sure that if you have ongoing symptoms, that you're— The brain is fairly plastic and it has some ability to kind of restructure itself and make new connections, you can retrain the brain. And that's a lot of the therapy that goes into place. So whether it's speech therapy, functioning with vision loss, functioning with a balance problem and learning what you got to do. And some of it's safety issues, some of it's swallowing, for example. You know, so one of the first things that we do in the emergency department before we give you any medications, is a swallow study.

Dr. Arnold:
Yep, that's right.

Dr. Sundermann:
To make sure you're not choking on things. Because that can be very subtle and that can lead to unforeseen problems. You get a pneumonia because you had a stroke, people don't think of that. And so a lot of the therapy begins right there and physical therapy isn't jumping jacks and pushups, it's things like balance and walking with a walker and, you know, stuff like that.

Dr. Arnold:
So yeah. You know, this is this just kind of an observation. I used to say, people don't die from the stroke, they die from the pneumonia, the GI bleed.

Dr. Sundermann:
Hip fractures are the same thing.

Dr. Arnold:
Yeah. Hip fractures, they die from the complications, not necessarily that. Now, one thing that I've observed and you maybe have seen this in the ER. But okay, so you get in, let's say your right side's paralyzed, you get the TPA and it gets better. And you're like, awesome.

Dr. Sundermann:
Yeah.

Dr. Arnold:
So I make rounds in the morning, it's better.

Dr. Sundermann:
Yeah.

Dr. Arnold:
Well then the nurse comes in and the patient demonstrates to the nurse that it's better. And then therapy comes in and they demonstrate it. So by late afternoon, those muscles are fatigued, and the patient's like, oh my stroke came back.

Dr. Sundermann:
A new weakness, yeah.

Dr. Arnold:
I always try to educate people on that when we first put them in the hospital, that you may see that happen. And then it's not as such a shock. Then the next morning's back to where it was. Well, prevention is the key to everything. And we can do a whole other podcast on how we miss the opportunity to prevent things quite often in healthcare. But what are some of the risk factors and risk factors that can be modified for having a stroke?

Dr. Sundermann:
Well, smoking, smoking, smoking. Those are one, two, and three. I mean, absolutely do everything you can to quit smoking. Just as a side, kind of my strategy if anybody needs a strategy for quit smoking. The first and 15th, quit. People need to practice quitting smoking. Don't do it the first of the year every year, when people tend to. And like, ah, I started smoking again. Quit as often as you can, you know. So twice a month, quit smoking and go as long as you can. So, if it's one day, two days, don't get discouraged. If you start smoking again, two weeks later, you do it again.

Dr. Arnold:
You know what I used to do with patients? So you smoke, let's say, a pack a day, 20 cigarettes.

Dr. Sundermann:
Yeah.

Dr. Arnold:
I'd say, okay, you smoke 20 for three days. Then you smoke 19 for three days.

Dr. Sundermann:
Taper down, yeah.

Dr. Arnold:
So even if you are getting ready to go to bed and you're supposed to smoke seven, but you only smoked five. You got to sit there and just drag them just until it's done.

Dr. Sundermann:
You got to make your eight in.

Dr. Arnold:
Yeah, so it's get to the point—I'm getting this medicine, this drug I'm addicted to out of my brain.

Dr. Sundermann:
Those are definitely—and I think it's all trial and error, you know. Because if there was one proven system that worked, it'd be out there and that's what everybody would do.

Dr. Arnold:
Yeah.

Dr. Sundermann:
So yeah, that's a great way to do it. And you know, I tell people, quit smoking, change the way you drive to work, because people are very habitual about their habits. They drive the same way, they take the same walk, they have their coffee. Change up your whole pattern during that day, you know, take a different route to work, so you got to be paying attention to road signs and things like that, hopefully not looking at your phone. Then do the, you know, chew the Nicorette gum and the lollipops, chew on pencils, suck on lollipops, all that stuff. Go as long as you can, if you start smoking again, don't be discouraged. Just do it again, over and over and over and over again. And over half the people that try that method will succeed in smoking cessation in about nine months, I think.

Dr. Arnold:
And I would say that if you're trying to lose weight and you're adjusting your diet and you fall off.

Dr. Sundermann:
Yeah.

Dr. Arnold:
And you have the cake. And then you say, well, I fell off it today, I'm just going to eat the rest of the day. I always say, okay, if you drop your cell phone, do you jump up and down on it? Or, do you pick it up?

Dr. Sundermann:
Yeah, right. Right.

Dr. Arnold:
And, you know, just stay with it.

Dr. Sundermann:
Don't beat yourself up.

Dr. Arnold:
Yes, absolutely.

Dr. Sundermann:
Because nobody's perfect, it's hard.

Dr. Arnold:
Nope. No smoking.

Dr. Sundermann:
Yep. Diet and exercise, obviously those are big ones. You know, there's a genetic component to it. You know, if everybody's seen like, George Burns he smoked cigars this whole life and he lived to be 103. Nobody knows who George Burns is anymore, but there's those guys that lived a lifestyle that was not conducive to, you know, stroke health and things like that. Then there's the 40 year old guy who runs, you know, six miles every day and he has a stroke just because he was born that way.

Dr. Arnold:
Right.

Dr. Sundermann:
So you can't get away from your genetics. You can get genetically screened for it, but the things that are easy are, you know, you don't smoke, you eat right, try and avoid saturated fats and all that. And actually carbohydrates, I know carbohydrates are the new fat, right? You know, so there's a lot of evidence that suggests especially processed sugars are very inflammatory. And the thing about plaques that rupture that cause heart attack and stroke is the mechanisms the same, that little cholesterol shell inside a blood vessel has got, they call them spongey macrophages. And all it is, is a bunch of really inflammatory cells that make that plaque amenable, like it ruptures and it flakes off. And when that does, that's what creates the injury inside the vessel. So you got to stabilize that plaque. And so one of the best things you can do and the simplest things, is limiting your sugars, because they've found that simple sugars create this inflammatory—from insulin and things like that. And by cutting your sugars, it helps stabilize that plaque. But then also things that stabilize plaques are like statins, for example. And the thing about statins, you probably know more than I do, is that statins aren't just normally, they don't just lower your cholesterol, but they're actually anti-inflammatory. And so that anti-inflammatory component is a big deal. So if your doctor says that you should take a statin and you can, you don't have any side effects—because there are some people that statins don't work for them for one reason or another—but if you can be on a statin, those statins are critical to prevention. And that's one of our inpatient goals is making sure we get them out of here on a statin. I don't do inpatient medicine, but—and then exercise, you know. And so prevention, either before or after a stroke, talking with your doctor and making sure you're clear and it's safe for you to be in a program, but then doing that regular exercise. Which not only is like weight control and things like that, but it's actually anti-inflammatory. But it also, when you exercise, you cause your heart rate to go up, your heart beats harder, and what it does is it creates more flexion. So if you normally just walk around and your heart beats your vessels kind of pulse, just like you can check your pulse. When you exercise, you know, your heart beats harder and that actually creates more and that stimulates elasticity or stretch of your vessels. And so it makes your vessels actually healthier simply by exercising. And so there's a lot of benefits to exercise other than simply like weight loss and calories restriction, you know, things like that. So yeah, smoking, good diet, and exercise are critical.

Dr. Arnold:
Yeah. I always use the analogy of an unloaded revolver. That's your family history, right?

Dr. Sundermann:
Yeah.

Dr. Arnold:
Then you start putting in smoking, high blood pressure, diabetes, high cholesterol.

Dr. Sundermann:
Yeah.

Dr. Arnold:
Now you have a loaded gun that's very dangerous.

Dr. Sundermann:
Yeah.

Dr. Arnold:
And so we want to keep that proverbial gun unloaded.

Dr. Sundermann:
Yeah, I love your analogies.

Dr. Arnold:
Yeah, I know.

Dr. Sundermann:
Full of them.

Dr. Arnold:
I am full of them, I'm full of something that's for sure.

Dr. Sundermann:
Yeah.

Dr. Arnold:
Ryan, this has been great information. Once again, this is Dr. Ryan Sundermann, talking to us about strokes and preparing to celebrate national vinegar month.

Dr. Sundermann:
Yep.

Dr. Arnold:
As well as national stroke awareness month in the month of May.

Dr. Sundermann:
I'm not sour on vinegar month.

Dr. Arnold:
Again, this is Dr. Ryan Sundermann, St. Luke's emergency room medical director. For more information on stroke care or any other medical topics visit UnityPoint.org. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers, about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.