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June 24, 2015
Stroke deaths drop in Calif., nationwide
By Courtenay Edelhart
BAKERSFIELD, Calif. — Terrance Minnoy knows the precise moment his stroke journey began. On Feb. 9, he was chatting with a cashier at a department store when suddenly he heard a second, disembodied voice.
It was only then that he realized there were not one but two cashiers at the checkout counter. A blind spot in his right eye had obscured the presence of a second person.
It was a transient ischemic attack, or TIA, he would later learn. That’s a temporary halt in blood flow to part of the brain, and is often a red flag that a stroke is coming. The very next day, Minnoy had two strokes, one at home and one in the emergency room.
Looking back, he attributes the fact that he’s alive today to a combination of divine intervention and superb medical care.
An adult son who had recently moved in with Minnoy is the one who called 9-1-1. But for that, the 44-year-old pharmaceutical sales rep would have been alone when he collapsed in his southwest Bakersfield home.
And Minnoy has nothing but praise for his health care providers.
“From Hall Ambulance to San Joaquin Hospital to the rehab facility, everything was seamless,” he said.
That’s no coincidence. Locally and nationwide, there has been a coordinated effort to boost the quality of medical care for strokes, as well as raise awareness of stroke symptoms so that patients come in sooner for treatment.
It seems to be paying dividends.
Stroke deaths in Kern County fell from 303 to 239, or 21 percent, over the 10-year period between 2004 and 2013, the latest year available from the Centers for Disease Control and Prevention. During the same decade, stroke deaths dropped 18 percent in California, and 14 percent nationwide.
Some of that can be attributed to the U.S. Food and Drug Administration’s 1996 approval of tissue plasminogen activator (tPA), or clot buster medication. It is given intravenously, and is most effective when administered within three hours of the onset of symptoms.
A stroke occurs when a blood vessel in the brain is blocked by a blood clot (an ischemic stroke) or ruptures (a hemorrhagic, or bleeding, stroke). The clot buster clears the blockage of more common ischemic strokes, restoring blood flow to brain tissue that would otherwise die or be irreparably harmed.
The American Heart and Stroke Association has an ongoing educational campaign to get the word out about the importance of getting to the hospital quickly. Launched two years ago, the campaign includes public service announcements and a mobile phone application called F.A.S.T. That stands for Face drooping, Arm weakness, Speech difficulty and Time to call 9-1-1.
Along with listing the warning signs of a stroke, the app can direct users to the nearest hospital participating in the association’s Get With the Guidelines Stroke quality improvement program. Since the program’s inception in 2003, Bakersfield Memorial, Mercy Downtown, San Joaquin Community and Bakersfield Heart hospitals have all signed on.
Among other things, participating hospitals must have a dedicated stroke-focused program staffed by qualified medical professionals trained in stroke care. They also have to collect and report stroke treatment performance data that, viewed in the aggregate, can help hospitals see how they measure up to others providing similar care.
Four local hospitals also have primary stroke center certification from the Joint Commission, an independent, not-for-profit organization that accredits hospitals. They are Bakersfield Heart Hospital, Mercy Downtown, Mercy Southwest and San Joaquin Community Hospital. Offered since 2003, primary stroke care certification requires hospitals to meet a set of core performance measures from multidisciplinary teams, including program management, the delivery of clinical care and performance improvement.
“When we go into an organization, we trace the movement of a patient all the way through their stay,” said Wendy Roberts, executive director for certification at the commission. “We watch a patient from EMS (emergency medical services) to the emergency room through radiology, ICU (intensive care unit) to convalescence and rehab, and even after discharge to assure patients are following their regimens and following up with doctors.”
Complying with research-based protocols has upgraded care throughout the region and improved local outcomes, said Michelle Hartshorn, a nurse who serves as executive director of San Joaquin’s stroke program.
“The evidence shows that when people start to focus on a disease program with consistent procedures and guidelines, the people suffering from these will improve,” she said.
Deaths among San Joaquin’s stroke patients have dropped by more than half from 18 percent percent in 2007, when the hospital opened a stroke center, to 8 percent last year.
The fierce competition in Bakersfield hasn’t hurt things, either.
Nobody wants to be the only one who isn’t certified, and now there’s pressure to scramble for the Joint Commission’s more stringent comprehensive stroke center certification, which mandates that neurological specialists be on-site 24 hours a day.
Starting next month, the commission also will be offering an acute stroke ready certification designed for rural hospitals. To earn that certification, hospitals would have to prove they can provide clot buster medication within that important three-hour window, as well as demonstrate the ability to stabilize stroke patients for transfer, if necessary.
More aggressive treatment methods are another reason stroke mortality is falling, said nurse Michele Shain, director of Bakersfield Memorial’s neurological and cardiac services.
“We now do the same full work up for TIA as we would if they had a full on stroke,” she said. “We take immediate action because essentially it’s an invitation to a stroke. About half of patients who have a TIA have a stroke within 12 to 18 months, so it’s a great opportunity to intervene early.”
There’s also been a slow expansion of the three-hour window for giving clot buster medication, which can be pushed out as far as eight hours in certain instances, Shain said. Barring that, patients may undergo a medical procedure to open up the vessel and break up the clot surgically.
All of that has helped, but we shouldn’t get too carried away with patting ourselves on the back, said Dr. Raffi Kartalian, who directs Bakersfield Heart Hospital’s stroke program.
People are just healthier in general, Kartalian said, because they’re exercising more, smoking less and eating better. Plus, locally, Kern has worked hard to improve its notoriously bad air quality.
“All of these have reduced morbidity across the board,” Kartalian said.
Deaths from strokes aren’t the best way to measure progress, anyway, said USC neurologist Dr. Nerses Sanossian of the American Heart and Stroke Association’s Get With the Guidelines steering committee.
“Stroke mortality is down, but stroke doesn’t kill very many people. More often, it disables them,” he said. “Sometimes, the best outcome for a stroke is death.”
Minnoy is doing well after his strokes. He’s still got some weakness in his left leg, but after weeks of rehab, it’s subtle. That blind spot is getting smaller every day, too.
Minnoy is deeply grateful for the specialized care he received after his strokes, adding that surviving has changed his whole outlook on life.
“Now, every time I’m in contact with people, I’m a little bit more sensitive to our coming together, because this could be it,” he said.