Today, stroke professionals at Mills-Peninsula Medical Center (MPMC), including dedicated physicians, specialists, researchers and staff, regularly run a race against time to save people’s lives with their newest tool, the Mobile Stroke Unit (MSU).
Our team is helping pioneer the future of acute stroke care.
Treating Stroke in the Field
The MSU is a specially equipped ambulance that is, in essence, a stroke center on wheels. “We are basically an extension of the emergency department, except we’re out in the field,” says Ilana Spokoyny, M.D., a Mills-Peninsula neurologist who serves as Clinical and Research Director of the MSU program. “The big difference is we’re able to get to patients sooner and treat them faster.”
The MSU program is part of a clinical trial called BEST-MSU. Mills-Peninsula is working in partnership with the City of San Mateo and local emergency services for the trial. Six academic medical centers across the country are also participating in the trial; Mills-Peninsula is the only community hospital involved.
“With the BEST-MSU clinical trial, for the first time in the U.S. we have an opportunity to examine the safety and feasibility of treating patients on MSUs through a national, multi-site study,” says Dr. Spokoyny. The study team hopes to enroll 1,000 eligible patients in the trial in the San Mateo County area and at other participating study sites in Memphis, New York, Denver, Indiana, and Los Angeles.
“With the Sutter MSU being the first and only MSU in Northern California and the only community hospital participating in the BEST-MSU trial, our team is helping pioneer the future of acute stroke care and advanced out-of-hospital approaches to triage.”
Tick Tick Tick
In treating stroke, time is everything. About 87 percent of strokes are ischemic, making it the most common type of stroke. Ischemic strokes are caused by a clot that blocks a blood vessel, preventing blood from flowing to the brain. When this happens, brain cells begin to die at a rate of about two million per minute.
The longer the brain goes without oxygen, the more damage the stroke can do. In fact, every hour a patient goes untreated, his or her brain ages 3.6 years in terms of loss of neuron function. That loss of brain function is why stroke is the fifth cause of death and leading cause of disability in the United States, leaving many patients unable to walk, talk, eat or take care of themselves.
Operational since December 2018, the MSU has a CT scanner on board which allows a neurologist to determine whether a patient is experiencing an ischemic stroke, a brain bleed (hemorrhagic stroke) or something unexpected. If it is determined that the patient is suffering an ischemic stroke, the patient may be a candidate to receive a drug called tissue plasminogen activator (tPA).
The “Golden Hour”
A lightning rod since it was first approved in the United States in 1996, tPA works by dissolving blood clots which helps to restore blood flow, potentially preventing additional brain cell loss. Studies have shown that tPA is most effective if administered within 60 minutes or less from when symptoms begin—what stroke professionals refer to as “the golden hour.”
“We know that patients who are treated within this special window tend to have significantly better outcomes and are more likely to have the blood clot break up from tPA,” says Dr. Spokoyny. “Since the MSU has been operational, we have treated ten patients in the field. Our treatment time from the 911 call to administering tPA to the patient is averaging approximately 42 minutes.”
Lucky Three Times Over
One of the patients whose life was impacted by the MSU and Sutter stroke research is San Carlos resident, Ram Madduluri. An active, 59-year-old tech worker at an internet-based TV service, Ram was at work when he began to experience a very sore throat. “So I went to my manager and told her I wasn’t feeling well, that I was going to go home,” says Ram. “Unbeknownst to me, I was struggling to talk, slurring my speech and my boss said, ‘You don’t look right.’”
Ram’s manager called 911 and an ambulance was dispatched immediately from the Foster City Fire Department. The MSU was activated moments later by the Fire Department.
On board the MSU, the stroke team quickly did a CT scan and Dr. Spokoyny determined that Ram was experiencing an ischemic stroke and was a good candidate for tPA. The medication was quickly mixed in the on-board pharmacy and administered.
As the MSU traveled back to the emergency department at MPMC, Dr. Spokoyny called the stroke neurologist and the on-call interventionalist. Her concern was that the large vessel in Ram’s brain might still have a blood clot and that he might need a procedure to remove it.
“But Ram had received tPA in about 37 minutes from the time of the 911 call, within the golden hour,” she says. “And by time we got to the hospital, scans showed that the large clot had dissolved into smaller clots and his symptoms had totally resolved.”
For safety, Ram reminained for observation in the ICU for 24 hours. “But, overall, Ram made a full recovery," says Dr. Spokoyny. “He had some underlying heart issues which needed attention, but that was not because of the stroke. From a stroke perspective, he returned to his normal, prior level of function.”
Rendezvous System Expands MSU’s Reach
At present, there is only one MSU in Northern California. Driving from MPMC in Burlingame to help patients who live in coastal communities can take precious time.
So the MSU team, in partnership with local emergency services, has established a set of rendezvous points—places that are flat, secure, have ample space for multiple ambulances and are typically not very populated. When the MSU is activated from a coastal community, the local ambulance picks up the patient and meets the MSU at one of these points.
If it is determined that the patient requires the services of the MSU, the person is transferred from the ambulance to the MSU. If not, the ambulance crew continues on to the nearest emergency department. “It’s an efficient way to make more areas on the Peninsula more accessible to stroke care,” says Dr. Spokoyny.