INTERVIEW WITH DR. JOSEPH CLARK
Conemaugh Memorial Medical Center Emergency Department Physician
Q: In the emergency department how many cases do you see of stroke? Is stroke one of the things you see most often?
A: It’s pretty prevalent actually. You know, we see probably --- actually treatable strokes five or six a month that can be treated with tPA. We do see a lot of strokes that don’t meet guidelines for tPA. We actually have a lot of people that come in late as far as warning signs and we see a lot of what they call TIA which is the transient attacks or the mini-strokes that we see actually a good bit of. We see a lot of elderly people who may have stroke symptoms for, you know, eight, ten, twelve hours not really realize the warning signs and then the family bring them in late and we do see a lot of those but actually treatable stroke, you know, probably about five or six a month actually that we can give tPA to and treat aggressively.
So those are the ones that we are really targeting, you know, as far as treatment and options and warning signs and getting the public to know, you know, why they should come to the emergency department early.
Q: Why do you think people suffering a stroke don’t get help right away?
A: Well, I think a lot of it is, you know, they don’t know the warning signs. They, you know --- the inherent thing is to avoid going to the hospital if they don’t have to and, you know, some people really don’t recognize or may have, you know, altered mental status to where they may not feel that they should seek treatment and sometimes it’s the family members who recognize it.
They may be slurring their words or they may be a little bit weaker than they were before or something like that that caused them to, you know, bring them to the emergency department for treatment.
Q: Can the warning signs for stroke vary in as far as intensity?
A: They can be somewhat subtle sometimes. Sometimes they’re very dramatic. Sometimes, you know, the classic symptoms of the facial slur --- or facial droop and the slurring speech and the one-sided weakness and so forth are the very dramatic signs that we see, you know, people do bring them to the emergency department quickly. Sometimes the symptoms can be somewhat subtle, you know, just a little bit of the slurring of the words, a little bit of a facial droop, a little bit of weakness of an extremity, a hand or a lower leg or something like that.
So sometimes the signs and symptoms can be somewhat subtle. If it’s a person who doesn’t walk a lot or do a lot with other people, if they’re, you know, not seen frequently like the elderly that are seen on an occasional basis and then they get them up to walk or something, notice that they can’t walk as well, you know, those are things that we see frequently as far as delayed presentation to the ER.
Q: What would your advice be to people regarding stroke? What do you want them know?
A: The main thing is the recognition of warning signs, you know, things like headache or slurred speech, facial droop, weakness on one side of the body, even just generalized weakness that is more noticeable should be evaluated and seen promptly in the emergency department.
Treatment options are somewhat limited after a delayed presentation and unfortunately with stroke care today, you know, early recognition is the key and getting them to the emergency department to be evaluated quickly so that we can initiate treatment if it’s within a three hour window for tPA. There are guidelines and indications and contraindications but for most cases of tPA --- or stroke that are tPA eligible stroke then, you know, three hours is the window that we’re shooting for recognition signs.
Q: Why the three hour window with tPA?
A: Well, it’s kind of an arbitrary number I guess but it’s a number that’s been derived that the complications in giving tPA rise abruptly after three hours of delay so that if there are --- if there’s more delay than three hours then there can be some serious complications such as bleeding with tPA in the brain and things like that. So, you know, we try to get them here, get them diagnosed quickly by CT scan and by evaluation by an emergency physician and then get the stroke team initiated.
Q: How does tPA work?
A: tPA is an actual inherent chemical in the body that has kind of been captured chemically and mass produced. It’s basically a tissue plasminogen activator. It’s a biochemical that actually breaks clot within our own system that we have on a day-to-day basis.
It’s just used in a much higher quantity when we give it through the IV and basically the purpose of that is to break up clot that may have formed from either heart attack or stroke or what have you but we do use it mostly for stroke here, not that much for heart and lung causes but it is, like I said, it’s an inherent chemical that flows through your body on a day-to-day basis, just used in more concentrated and higher dosing in this sense.
Q: How do you determine if tPA will be used to help a stroke patient?
A: There’s actually a long list of indications and contraindications. Some blood pressure measurements come into play, the severity of the stroke symptoms. If the stroke symptoms are resolving then those are things that, you know, may cause us not to use tPA because we don’t want to cause harm and it is a somewhat dangerous drug. So if the symptoms are improving with treatment and --- or improving without treatment I should say then we may not give tPA but for those cases where they meet the three hour window, there are no contraindications to giving tPA and they have fairly catastrophic stroke symptoms, you know, it can be a real lifesaver and a real improvement to their outcome.
Q: What outcomes have you seen in those cases where tPA has been used?
A: Well, you know, in situations where, you know, you may have a total paralysis of one side of your body, any improvement in that would be a plus and, you know, those people who have improvement of those symptoms can go on and live a more meaningful life, can have less mortality associated with their illness and be a much --- lead a much happier life, you know, if they’re not debilitated. It’s mainly --- the focus of it is to prevent life debilitation which is what we see with stroke, you know, long-term care that is needed if patients don’t have resolution of symptoms, you know, burdens on theirselves and their family, you know, with stroke symptoms.
So the main goal is to improve quality of care and quality of life with tPA use and, you know, it’s not 100 percent treatment. It doesn’t happen and work every time but for those patients that do go onto recovery their improvement is substantial and they’re --- you know, their life is changed for the better.
Q: Does it frustrate you or make you sad when you see somebody that comes in that you know had they come in sooner the outcome might have been different?
A: Yeah, you know, and I think it hurts the families a little bit, too, because they may not have realized or they thought well, we’ll just give it a little bit more time and see if it improves and when it doesn’t and they come in late and we have to kind of say that there’s nothing much we can do, you know, obviously it does impact the families and they do take it hard. We take it hard. You know, it’s nice when you’re able to give someone treatment for a disease that may have an actual meaningful outcome and having that ability to do so but having your hands tied with not able to give it, you know, being able to give, you know, three hours after or more is somewhat frustrating, yeah.
Q: What are some of the warning signs of stroke?
A: The main things are if people have, you know, one-sided weakness, slurred speech, headache. Headache is a large one, you know. If they’re obviously changed in their mental status, if they’re more confused, you know, like I said, you know, inability to walk or ambulate or use hands to pick up an object. Those are things that we want to, you know, key in on and get the laypeople to know. You know, the main thing, like I said, is just early recognition of signs and getting them, getting them to the emergency department quickly.
Q: Symptoms of a heart attack it can be very different for men and women. Is that true with stroke as well?
A: Not really. You know, stroke kind of effects all comers. It’s the number two cause of death worldwide and it probably will overcome all comers as far as cause of death soon and it’s pretty much unilateral across the board as far as women versus men. It’s --- the brain works very similarly, you know, in all human beings. So if there’s, you know, unilateral symptoms that signify a large stroke or slurred speech and such then it’s usually, you know, the same for men as it is for women, you know, and it really isn’t any different epidemiology as far as, you know, men coming in later than women or anything like that. So it doesn’t really discriminate as far as picking either population for disease.
Q: Why are we seeing more strokes today?
A: Well, I think a lot of it is lifestyle right now, you know, as far as obesity, hypertension. Those --- or high cholesterol, smoking. Those are all things that can cause more stroke. Stroke is caused by thromboembolic and thromboplaque that --- or plaque forms in the brain and if there’s more high cholesterol and hypertension and things like that that can contribute to plaque rupture and plaque formation then that’s why I think why we see more of it nowadays than we did before, just more or less the sedentary lifestyle.
Q: Are the risk factors for heart disease and stroke the same?
A: Pretty much. Yes. They do fit together. They fit, you know --- it’s a vascular disease throughout the body. It’s just more or less a different location but it’s pretty much the same mechanism of cause.
Q: Are there different types of strokes?
A: There are two different types of stroke. There’s the ischemic type stroke where tPA would be indicated and then there are strokes where there are bleeding causes in the brain. People who are on anticoagulants and so forth may have bleeding causes of stroke and in those cases we definitely would not want to give tPA; however, they may have a surgical cause that may be fixable such as an aneurysm clipping or something interventional by the neurosurgeon that could be lifesaving or preventative as far as further damage to the brain.
Q: So what is the first thing you do when somebody comes in and you suspect a stroke?
A: Immediately on arrival to the ED, get the person to the CT scanner just because time is of the essence. The CT scan will tell us whether it is more of an ischemic type stroke versus a bleeding type stroke. The blood will show up very brightly on the CAT scan. This will be read by a radiologist on a quick basis and then we’ll institute treatment based on that and --- but yes. If it’s --- if the CT scan shows bleeding on the scan then we would approach more of a neurosurgical approach to the patient.
Q: What is “Stroke alert” and how do you think it impacts care at Memorial Medical Center?
A: Here at Memorial’s emergency department we’re very aggressive with heart cases and very aggressive with some other things like trauma and the point of those cases is to institute care rapidly. We have an approach with the trauma team where, you know, the trauma team takes care of the patient immediately on arrival to the ER. Studies are instituted quickly and results are obtained quickly so that care can be instituted as fast as possible. In the past, patients really didn’t get this with stroke and through study and so forth we know that stroke patients did poorly because care was not initiated quickly and diagnosis was not obtained rapidly.
So we’re trying to be as aggressive with those cases as we are with the heart patients and with trauma patients just because if we can obtain that information to institute care quickly those patients can do much better in outcomes and in the cases where we give tPA it could be a lifesaving measure. So, you know, we do try to, you know, diagnose those problems as quick as possible, determine whether they are eligible for tPA and then move on with treatment and care.
Q: If you had one stroke are you at an increased risk to have another stroke?
A: Your risk does increase with further strokes. If you have one or a TIA or a mini-stroke you are at more risk for other strokes. If you have documented or known vascular disease such as prior heart attack or diabetes, which is a cause of sometimes heart disease and vascular disease, then you are more at risk and your chances do increase with possible further strokes.
Q: Is there anything that you can do to help lower the risk of stroke?
A: Well, pretty much, like I said, lifestyle changes, watching your cholesterol, exercise, watching your blood pressure. Those are all things that can help your risk of decreasing your odds of having strokes. So it’s more or less lifestyle modification.
A TIA is kind of like a warning sign. It’s like a warning light on the dashboard of your car that says, you know, something may be coming your way. It’s a transient attack of symptoms meaning that cases of ischemic CVA or stroke the blood supply to that area of the brain is compromised and the stroke symptoms develop and TIA or mini-stroke that compromise is not a complete compromise and therefore the symptoms may come and then go away. In those occasions a patient may have improvement of symptoms within hours or even minutes and sometimes they’ll come to the emergency department with stroke symptoms but have completely resolved within, you know, five to ten minutes. So we usually tell people at that time that, you know, they are at high risk for stroke because they’ve already had stroke like symptoms and that they need some specialized treatment and some changes in their medications and some lifestyle modification to prevent further risk of stroke.
Q: Are you seeing more young people with stroke symptoms?
A: As far as age goes with stroke, like I said before there really is no discrimination but we are seeing a little bit younger of a population with stroke type symptoms. I’ve seen some 40-year-olds with strokes that are legitimate strokes and a lot of it has to do with, you know, the new --- you know, the newer onset of diabetes as younger people, obesity and smoking and such that causes the vascular disease but, like I said, you know, we do see some people that have that as a younger age frame, especially younger females, people that may be on hormone replacement or birth control pills.
There’s more risk for thromboembolic type situations. So those are --- there are some risk factors with that as well but most of it comes down to, you know, early diabetes, high blood pressure that’s undetected or untreated and people who use tobacco or smoke. Those, in combination, can be somewhat dangerous.
Q: How does diabetes impact the risk of stroke?
A: Diabetes basically causes your blood vessels to be more prone to develop plaque and thrombus and it’s just a disease process that can cause just profound vascular disease throughout the entire vascular system. So that, you know, makes you high risk for things such as heart disease, stroke, you know, those kinds of things that are vascular problems.
Q: What is a mini stroke or TIA?
A: Essentially a TIA and mini-stroke are the same thing. Like I said before, you know, even though it’s called a mini-stroke it really is not a full-blown stroke. That area of the brain, even though is temporarily affected, usually in those situations there are complete --- there is complete resolution of symptoms with TIA. So, you know, even though it’s called a mini-stroke it’s really a transient attack meaning that the symptoms come and then go but it is a warning sign that there are, there are some problems there with the vascular circulation to the brain and in areas particularly where your stroke symptoms are developing.
So it’s, like I said, pretty much the precursor to stroke meaning that if you have pre-stroke or TIA symptoms that, you know, your risk of developing a full-blown stroke or a stroke in evolution is quite high.
Q: Do you think Memorial’s “Stroke alert” system will impact outcomes for patients?
A: Yes. I think here at Conemaugh, you know, we’ve tried to improve the care that we give through the emergency department in many ways. You know, I think we’ve done that with our trauma care here. We’ve done that with our cardiovascular care here and this is just the next step in progression as far as develop, you know, developing state of the art care for our surrounding hospitals and surrounding patients and, you know, when I look at what we did three years ago as opposed to now, you know, there’s quite a dramatic improvement in the way we treat stroke here especially and keeping in line with other, you know, tertiary care facilities and larger facilities that, you know, treat stroke aggressively.
I think to have that as our goal I think, you know, the “stroke alert” and the stroke care that we’re beginning to have here is online with that. You know, the “stroke alert”, it’s a new process. It’s stuff that we are doing that we hadn’t done only, you know, months ago. So there are ups and downs but for the most part I think that, you know, it’s delivering care quickly and appropriately to those patients that need it and it’s improving the outcome for patients as far as their quality of life and quality of care.
I think the main thing with stroke and early recognition is the recognition of the signs. You know, some people, you know, feel that they should not come to the emergency department. They feel that it may not be an emergency. This is a definite emergency. This is something that needs to have emergency care, needs to be treated immediately and appropriately and the outcome and the debilitation, if this is not treated appropriately, can be dramatic.
So, you know, it’s very important to recognize the warning signs, headache, unilateral loss of motor function on one side of the body, paralysis, difficulty speaking, difficulty making your words or getting the words out. Those are things that need emergency care immediately and should not be delayed. So anyone who develops those symptoms should seek emergency care right away by calling 911 and having them brought to the emergency department for care.
Q: What would you say to someone who feels embarrassed about seeking care?
A: Well, people shouldn’t be embarrassed to seek emergency care. That’s why we have emergency departments and, you know, I would much rather tell a family that their tests all come back normal and it’s nothing serious than have to tell them that, you know, they have a debilitating stroke that they’ll have to live with the rest of their life because they didn’t seek appropriate care early which sometimes happens.
Unfortunately sometimes people will delay their treatment and feel that it will go away or that they shouldn’t bother us because it may not be an emergency or a true emergency and in those cases where, you know, treatment may not have been able to be given because of that, you know, their symptoms are profoundly dramatic and debilitating and to tell them that there could’ve been an option should they have come earlier it’s saddening to us as professionals in medicine and it’s I’m sure disheartening to the family and the patient.
So if they feel that they have stroke symptoms they should seek treatment immediately and not be afraid to come to the emergency department to be evaluated.