Helistroke: Flying doctors to stroke victims may improve outcomes

Dr. Ferdinand K. Hui received the call as he headed to his Harbor East home after working out at the gym.

A patient at Suburban Hospital in Bethesda had suffered a stroke and needed a specialized procedure in which a catheter is used to clear the clogged artery in the brain. Dr. Hui doesn't have long. The longer a patient goes without surgery, the more damage to the brain.

About 45 minutes later, Hui, an interventional neuroradiologist at Johns Hopkins Hospital, was aboard a medical helicopter — delivering the specialist to the patient rather than the patient to the specialist.

The approach, which Hopkins doctors call helistroke, is unusual in medicine. Normally stroke patients are transferred to other hospitals for advanced treatment. Johns Hopkins and Suburban are testing whether whisking the doctor to the ailing patient leads to better outcomes.

It is one of the many ways that hospitals are trying to increase the use of catheters to treat certain kinds of severe strokes.

Strokes occur when a blood flow is interrupted to part of the brain, either by a clot of a rupture of a blood vessel. They are the fifth leading cause of death in the United States, killing more than 130,000 each year, according to the U.S. Centers for Disease Control and Prevention. They afflict about 800,000 people each year and are a leading cause of disability.

Catheterization is considered a more advanced type of treatment. While intravenous drugs are still the most common treatment used to break up most stroke-related clots, catheters work well on large vessel clots.

The procedure involves a doctor inserting a catheter into an artery in the groin and snaking it through the body. Another device is sent through the catheter to grab the blood clot and pull it out of the body or a drug can be administered through the catheter at the site of the clot to break it up.

Large clinical trials in the last few years have found better rates of survival using this catheter procedure compared to administering drugs that break up the clots. Demand for the procedure has increased as a result, but not many doctors are trained to perform it. Smaller hospitals in particular might not have someone on staff with that expertise.

Transporting doctors to stroke victims could be one viable way of bringing the procedure to more patients, Hui believes. He has been flown to Suburban Hospital to treat three patients this year. Early indications are that it is less expensive and faster than transporting a patient to the doctor.

In a case study of one those incidents printed in the Journal of Neurointerventional Surgery earlier this month, it took Hui 77 minutes to fly to the hospital and complete the procedure. The helicopter took off for the 19-minute flight from Hopkins to Montgomery County at 12:24 p.m. At 1:07 p.m. Hui inserted the catheter into the patient and he completed the surgery by 1:47 p.m.

The full process took about the same amount of time as it would have if Hui had performed the procedure on a patient at Johns Hopkins because doctors at Suburban prepped the patient before Hui arrived to the hospital. It likely would have taken longer to prepare the patient to be transported to Hopkins, let alone travel time and preparation and surgery once there, he said.

Although the study wasn't designed to look at the health outcome of the patient, studies have shown that timing is crucial when treating stroke patients because patients lose brain capacity with each minute they are not treated. Stroke victims do best when they are treated as quickly as possible — ideally in 100 minutes or less.

Studies have shown that patients had a 91 percent chance of survival if blood flow was restored within 150 minutes of having a stroke. For every additional hour a patient went without treatment their chance of a good recovery decreased by 10 percent.

"We want to save as much brain in as many people as possible," Hui said.

Dr. Rafael Llinas, director of neurology at Johns Hopkins Bayview Medical Center, said the helicopter could be a viable option for getting patients the best treatment. Transporting patients compromises their safety, he said.

"You put people in a helicopter and they can become unstable," he said. "You take them out of the safe hospital and put them in an unstable and uncertain environment."

Helistroke is just one of the ways hospitals are trying to make the catheter treatments available to more stroke victims.

"The medical community is really grappling with this," said Dr. William J. Powers, chair of the department of neurology at the University of North Carolina at Chapel Hill. "It really is a formidable challenge. This is a technical skill that takes a lot of training and only a certain number of people can do it. How do we get the people who need it to the people who do it?"

At UNC, Powers and his colleagues have made the process of transporting a patient by helicopter less cumbersome.

"When we get a call from another hospital, we have the ability to dispatch a helicopter or ambulance," Powers said. "We don't have to go through registration and make sure a bed is available — all that stuff that grinds everything to a halt we can avoid. In the background all the registration, patient information and bed assignment gets done, but the helicopter is already on the way out there."

The American Heart Association and the American Stroke Association developed an algorithm to help emergency medical technicians better diagnose the severity of a person's stroke. The hope is that those first responders can more quickly identify larger clots that may require catheterization. Then they can bypass smaller hospitals that don't offer the procedure so the patient doesn't have to be transported later, delaying treatment.

"Sometimes, this could mean bypassing a smaller, closer hospital to get the patient to a larger center providing specialized treatment," said Dr. Peter D. Panagos, co-chair of the associations' committee that helped oversee and develop the algorithm.

"Not only does it help to get stroke patients to the optimal hospital, but the algorithm also requires that smaller centers and larger centers work together in a collaborative fashion to streamline the effective care of stroke patients," said Panagos, also an associate professor of emergency medicine and neurology at Washington University School of Medicine in St. Louis. "We like to consider most care is appropriate locally and reserve transport to larger centers in only the most extreme cases."

Powers said the Hopkins option could be a good one for certain hospitals, but that there could be some limitations. For instance, not all hospitals have the structural resources and equipment to handle a catheter procedure even if a doctor is flown in.

Suburban is part of the Johns Hopkins Medicine health system, which made partnering less complicated. But Hui said he believes the process could work across hospital systems as well. He also said it could work well at rural hospitals where access to specialized treatment is limited.

"We don't have extra time when it comes to strokes," Hui said. "We want to get to people as quickly as we can. Every minute counts."

amcdaniels@baltsun.com

Twitter.com/ankwalker

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