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Specialized ensemble orchestrates stroke care at Upstate

Strokes among younger Americans are on the rise, by 51 percent for men and by 29 percent for women between ages 35 and 44. Obesity, diabetes and high blood pressure are largely to blame, according to the Centers for Disease Control and Prevention.

Survival often depends on quickly recognizing the symptoms of stroke and seeking appropriate medical care. Maximum recovery depends, also, on rapid and skillful treatment and quality rehabilitation.

Upstate is uniquely qualified to care for stroke patients. The first designated stroke center in New York, Upstate University Hospital features the region‘s only specialized neuroscience and rehabilitation floors. That means people who are wheeled into the emergency room suffering from stroke receive acute treatment and rehabilitative care under the same roof and followed by the same ensemble of providers.

Here‘s a look at the orchestration of stroke care at Upstate:

1. Recognition


The public performs a crucial role in recognizing the symptoms of stroke. Remember to act FAST:

faceF – Does one side of the face droop? Ask the person to smile.

Is one arm weak or numb? Have the person raise both arms, does one drift downward?A – Is one arm weak or numb? Have the person raise both arms; does one drift downward?

speechS – Is speech slurred? Ask the person to repeat a simple sentence.

Phone dialing 911T – Time is critical; if the person shows any of these symptoms, call 911 immediately.

2. Diagnosis


watchwithin 10 minutes – emergency physician evaluates the patient

within 15 minutes – neurologist consults on patient

within 25 minutes – patient in computerized tomography scanner

within 45 minutes – CT scan is interpreted by radiologist

within 60 minutes – intervention

Paramedics alert the hospital if they believe their patient has had a stroke, and the “stroke team” is summoned to the emergency room. This includes an emergency physician, neurologist, stroke coordinator and emergency department nurses. In addition, the nursing supervisor is alerted, along with the pharmacy, laboratory and radiology departments. The goal is to save a life, and also to save brain cells.

The patient who arrives by ambulance often already has one IV in place, but nurses will insert a second. Blood for testing can be taken through one, and medication and fluids administered through the other.

One of the first tests measures blood sugar, since the symptoms of hypoglycemia can mimic those for stroke. A doctor will conduct a neurological exam that tests different areas of the brain – consciousness, speech and language, memory, eye movement, reflexes and sensation and walking and balance. A magnetic resonance imaging scan can reveal narrowing or blockages of blood vessels in the brain. Other tests or procedures may be used to measure blood flow and detect clots.

The staff will also work to assemble a medical history – whether the patient has had surgery recently, if he or she takes blood thinners, has an elevated blood pressure or bleeding in the gastrointestinal tract. Such information is crucial before developing a treatment plan.

3. Treatment




Walking in hospital

Neurologist J. Gene Latorre MD on rounds with the stroke team.


About 87 percent of strokes are “ischemic,” meaning a clot is blocking a blood vessel. They are not painful. Instead, patients may feel numbness or a weakness or heaviness.

Interventions may include a clot-busting drug called tPA, tissue Plasminogen Activator, which must be administered within three hours of the onset of a stroke. In some cases, concentrated doses of the drug can be placed at the site of the stroke within the brain.

Upstate also offers a clot-retrieval procedure in which a stent device is threaded through a catheter in a blood vessel to the clot. An interventional radiologist captures the clot, restoring blood flow and removing the clot from the body through the catheter.

Both of these treatments are time-sensitive and may not be options for patients who have been slow to seek care. In Syracuse, the clot-retrieval procedure is only performed at Upstate.

About 13 percent of strokes are “hemorrhagic,” meaning a vessel in the brain has burst or an aneurysm has formed and is about to burst. However, because Upstate receives patients with complicated medical emergencies sent from hospitals throughout the region, more like 30 percent of stroke patients at Upstate have had this type of injury,

Depending on the location and severity of the aneurysm, surgeons may be able to place a clip at the base of the aneurysm so blood cannot enter. Or, they may elect to treat the aneurysm from inside the blood vessel, by placing platinum micro-coils that act as a mechanical barrier to blood flow.

Some patients undergo a cooling process during the treatment of their brain injury. In some patients, staff monitor the oxygen level of brain tissue.

4. Recovery




Healthcare workers looking at paper

Neurologist Ashok Devasenapathy MD and neurosurgeon Eric Deshaies MD.


Stroke patients are likely to recover in one of the 11 beds in Upstate‘s neurological intensive care unit. Staff in the ICU, mindful of circadian rhythms, dim the lights from 1 to 3 a.m. and from 1 to 3 p.m. and avoid scheduling treatments during those times. A harpist plays on Tuesday afternoons.

Patients may be transferred to other units as their condition improves, as 35 additional beds are devoted to patients with neurological problems. Nurses and therapists who specialize in stroke care are stationed on these floors.

Depending on the severity of the stroke, patients may remain hospitalized for a few days, a few weeks or longer.

5. Rehabilitation




Margaret Turk MD of physical medicine and rehabilitation with physical therapist Vicki Kalina.

Margaret Turk MD of physical medicine and rehabilitation with physical therapist Vicki Kalina.


Within 24 hours of a stroke patient‘s admission to the hospital, physical, occupational and speech therapists and a psychiatrist evaluate to determine the needs of the patient. Rehabilitative therapy begins almost immediately, depending on the severity of the stroke.

The location of the stroke determines which body functions are affected. Physical therapist Lori Holmes says patients may be able to recover many functions, by retraining healthy parts of the brain through therapy.

Upstate has an inpatient rehabilitation unit, where patients may be moved when they are able to handle three hours per day of therapy. People who have had ischemic strokes stay an average of seven days, while those who have had hemorrhagic strokes stay an average of 20 days.

6. Support




lumbrazo

Stroke coordinator Maria Lumbrazo is a family nurse practitioner.


Rehabilitation counselors at Upstate provide help for patients in returning to work or school.

In addition, a stroke support group meets monthly at the hospital, and Stroke Program Coordinator Maria Lumbrazo says an education group for families of stroke patients is in development.

It's not really magic, but that's how some patients describe their treatment:


Tina Fietta says stents, care her mom received "almost magical"


Ronald Eckert praised his doctor's "magical hands"


Doctor believes he survived his stroke because he came to Upstate

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