The Pelham Podcast

Stroke Awareness & Intervention with Dr. Pilch

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The Pelham Podcast | May 29, 2024 | Episode 1
Stroke Awareness, Intervention and B.E. F.A.S.T.
with Dr. John Pilch and Kellie Geater, RN 

Episode Summary: 
In this inaugural episode, neurologist Dr. John Pilch and Stroke Accreditation Coordinator Kellie Geater talk about their experience treating stroke patients at Pelham Medical Center.  

We’ll discuss how Pelham Medical Center became the first hospital of its size to earn DNV certification as a Primary Stroke Center in the Greenville-Spartanburg area back in 2016. Through collaborative efforts within the hospital, emergency services and in the Upstate community, Pelham Medical Center has been able to maintain this primary stroke certification each year since.  

We’re also teaching you about B.E. F.A.S.T., an important acronym to help anyone spot early signs of a stroke. Early recognition and quick action can help shorten the time to stroke treatment and improve the outcome for stroke patients. 

00:00 – Introductions
00:48 – Primary stroke certification
08:03 – Patient stories
11:12 – Collaboration & teamwork
13:41 – Measuring standards of stroke care
15:05 – The importance of time
17:04 – B.E. F.A.S.T. 
20:07 – Neurology & Dr. Pilch’s career
26:21 – The future of stroke care
29:37 – Conclusion & thanks
 
Learn more: 

  • Stroke care and neurology at Pelham Medical Center and throughout the healthcare system. 
  • Primary Stroke Center and other stroke-related certifications through Det Norske Veritas (DNV) Healthcare, one of the longest-lived and most robust hospital accreditation companies in the U.S. 

 Additional Links

Tony K: Thanks everybody for tuning in to the Pelham podcast. Today, I’m joined by a couple of special guests—Dr. John Pilch, who is a neurologist on our Medical Group of the Carolinas team, and Kellie Geater, who is a nurse by trade and has led our primary stroke certification efforts here at Pelham Medical Center, among many other things. She's been a bit of a special projects guru for us, but took this activity on and has really helped elevate our program greatly. So welcome to both of you. 

Dr. Pilch: Thank you.

Tony K: Why don't we talk a little bit about the fact that at Pelham, we have something called primary stroke certification? It is more than anything a way to validate that we deliver stroke care in an evidence-based quality program. It's not really about getting the designation, but about treatment of the patient. Maybe, Kellie, if you want to talk us through what that certification means for us and what we had to go through to get it?

Geater: So, we originally became a primary stroke center in 2016. There was about a year of prep prior to that. It takes a lot of different people to get together, and you have a lot of policies and procedures and lay the land of everything. Decide on your leaders and that happened in April of 2016. So that was very exciting! We were the first primary stroke center in the area, so that was fantastic for us that we had the leaders to see that vision and be able to do that. It allows us to have that prompt recognition—which is what you want in stroke—time is very crucial.

And so to have that dedicated team who knows exactly what they're supposed to be doing, and that collaboration to be able to do that is what sets us apart from centers that aren't stroke designated. Dr. Pilch and myself—not everybody—not every hospital has that. And that's really a great asset.

Dr. Pilch: Yeah. Kellie, that's so true. As I look back at the beginning, it was probably 2014 or 15 when I was approached about the idea of becoming primary stroke certified. And the first thing I did was bounce that off some of the other physicians that were here at Pelham. Initially, there was a good bit of apprehension about taking on this kind of a project. There was no other small hospital in the upstate that was primary-stroke-certified at the time, so it would have been the sort of first smaller hospital.

And we did have to overcome a little bit of apprehension, just considering the idea that a primary stroke-certified center does a high-level assessment of patients who have stroke symptoms, administers thrombolytics to them, and then actually keeps them on their hospital premises and takes care of them in an intensive care unit setting.

That was a lot to ask of a house staff that really had not seen that in a small hospital setting. To that point, it was being done primarily at the larger hospitals, so it was really quite a bold initiative on the part of the administration to take this on. Really, as we look back, it was really raising the bar for the upstate of South Carolina, and what happened as a result of Pelham Medical Center becoming primary stroke certified. It was really quite fast within the next year or two that all the other hospitals of our size recognized that and also became primary stroke certified or stroke ready, and it raised the bar for stroke care in the upstate of South Carolina—all through the whole Upstate—so it was really quite an amazing thing.

Tony K: You guys, you know have really led this very well and made it a reality. Let's talk a little bit about—because I think it can be a misnomer you, Dr. Pilch and Kellie, both brought up—a big undertaking but typically not associated with a small hospital. I think what people don't realize is that small hospitals oftentimes take care of very sick people—and, for example, Pelham Medical Center's always taking care of stroke patients—but at one time, we didn't keep people here who got what you referred to as the thrombolytic or the clot-busting agent.

We would, many times, we might not even administer it, or if we did, we would ship them immediately. So talk a little bit about the impact. Because, again, the benefit of this offering is really about being able to prove or validate high-quality care. So somebody who came in before with stroke symptoms who needed that agent, what happened to them before versus now that we can keep them here in the hospital close to their community and their family network (without having to be transferred to a larger facility)?

Geater: Yeah, you know, as I said before time is just so crucial on stroke treatments, and to be able to come into a hospital in one of probably, you know, the scariest moments of your life—as a family member, as a caregiver, as a patient—to be able to trust strangers, technically, in the scariest time of your life. To keep that continuity of care—in the same facility, in the same building, in the same unit—I think just gives confidence in that patient's level of care. They know that communication is such a huge thing anywhere, but especially in healthcare, and to be able to have that communication between all of the physicians from the emergency room at the time you enter and those nurses to the physicians to get to that ICU room and to have that continuity of care is amazing.

I think, definitely it counts down the timing of it all. That is the most important thing for those patients. We lose, I don't know, there's a certain amount or number of brain cells every minute that goes by how many you lose. So to be able to get them that treatment that fast is amazing.

But just as a patient to feel that level of care and knowing that everybody is on your team, and everybody has been aware of your situation from the moment you walked into the door, until you get that bed in the ICU and that drug is administered. It's just an amazing experience. 

Dr. Pilch: Yes. Kellie, just to add to that, I agree. One of the real benefits of being primary stroke certified is that patients can be treated and hospitalized close to home, and that people don't have to travel and be shipped off to a larger hospital, which was the model prior to this capability. The foundation for primary stroke certification is evidence-based and there are the national bodies that acquire the evidence, vet the evidence and create guidelines, including things like the CMS Conditions of Participation for Hospitals, the Brain Attack Coalition of the National Institute of Neurological Disorders and Stroke, the American Heart Association and the American Stroke Association.

All these are the foundation for the guidelines that lead to high-quality care with a high degree of safety, which are really the two keys to this kind of stroke certification. To Tony's point, the idea that we have a primary stroke certification is founded in high-quality care. Taking care of people who are quite ill, critically ill in many cases, and that we have that capability and that we've proven that capability through quite rigorous guidelines and have met those qualifications.

So it's an amazing, good thing for our community. 

Tony K: Well, you guys are the masterminds behind it, that's for sure. You got any great patient stories you might be able to share with us (without naming names, of course)? We have to respect privacy, but you guys can truly get into the lifesaving business with this kind of work.

Dr. Pilch: Yeah. This work is about, you know, meeting people who are in serious trouble and who need people to help them through that. Early on in our program, there was a nurse here who developed stroke symptoms while on duty and ended up being one of our earliest receivers of thrombolytics. She's a young lady, and she had an amazing event that was quite unexpected at the time. So, we literally ended up fairly newly stroke-certified, and one of our earliest patients was one of our own, who has done exceedingly well and who continues to be one of our own to this day.

That is an amazing story. There are so many stories. I have the great benefit personally of not only taking care of people in the hospital but also seeing them in the office. And that's something that Kellie doesn't necessarily get to do, because she's really primarily hospital-based and really is our leader in terms of the stroke program.

The idea of getting to follow people up and see them recover from what was a pretty devastating event is really a pretty special situation for me. There was a patient that came to the hospital with stroke. He unfortunately did not heed the stroke symptoms and come to the hospital quickly, so he was not a thrombolytics candidate. He's a longtime member of this very local community here, and I get to know these people on a more personal level because I get to follow up with them.

But he had a pretty bad stroke, and he really thought that his life was over—really, that was his mindset in the hospital. He thought, “Man, my career is over. My music is over. I'm not going to be able to do any of these things.” And as he recovered, I got to participate in this, but this story is sweet because he was actually a mandolin player in a local bluegrass band, and he thought he would never play the mandolin again. We encouraged him; he had a great team here—physical therapy, occupational therapy, all the physicians and nurses that took care of him. He worked through it, and he ended up getting back on stage, and it was an amazing thing.

Tony K: That's really cool. I mean of the work that goes on here, and I know for you, Dr. Pilch, is probably very gratifying. For me as an administrator, and Kellie, who doesn't really practice nursing directly that much anymore, one of the more gratifying things that our team's accomplished here is that particularly when one of your own family members has an opportunity to get care in a place that she previously wouldn't have been. It really makes the job we do very worthwhile, and it's really about serving the community.

And the things you just talked about, it might be underappreciated by the listening audience, the sheer amount of collaboration that goes on into something like this. People probably don't appreciate how many people besides the two of you are involved in our stroke care efforts. I mean, it's really about putting processes in place and sort of, for lack of a better term, forcing ourselves to be the best we can be and having the right tools and equipment and processes, so that we can respond accordingly to deliver the best outcome possible. 

Dr. Pilch: It is a really monumental, collaborative effort to make a primary stroke certified hospital—from EMS to emergency department staff at every level, transportation, imaging, intensive care unit, hospital, general floor, physical therapy, occupational therapy, speech and language pathology (better known as speech therapy to most of us)—all of those things have to come together. Our hospital also collaborates with a telestroke service and so in this way, we have a hybrid system, in which we have lots of boots on the ground that must be collaborating in order for this to happen, in addition to specialty teleservice that can – must – come and assist in the emergency department evaluation of patients with stroke symptoms.

So it's an amazing collaboration. And honestly, I think it has been good for everyone to sort of work together, and it has created more of a community atmosphere here at Pelham. Really, it requires it in order for that to work, and really just by its very nature of the amount of people involved in a stroke program, it has drawn those people together in a sort of unified goal of creating high-quality, safe stroke care and has created a stroke community, so to speak, that really spills over into the hospital care.

Tony K: That's great. And you know, healthcare really is a collaborative business. Physicians and nurses oftentimes get the most sort of publicity, if you will, because they're the most hands-on. But we have so many other disciplines in the hospital that make the whole process work to effectively take care of people, and this is a program that really underscores that.

Geater: We really try to acknowledge those folks as well because it does take every single person to take care of these patients.

Tony K: Let's talk about that a little bit. Because the listening audience might not appreciate the list of metrics that we track that come along with this certification to validate our quality. One of those involves how quickly, from the time someone gets into the door of the ER, does it take us to administer this clot-busting medication? At a high level, there's some standards around trying to achieve a certain percentage under 45 minutes, a different percentage under 60 minutes. Kellie, we had an episode here where one of our patients was administered the medication in just 22 minutes. Talk a little bit about that episode broadly and how everything had to come together—from the imaging team, EMS, and then for the ER provider and that neurologist online to make the decision—to be able to achieve that kind of a quick administration of medication.

Geater: Our biggest goal is to get that CAT scan as quickly as we can, because that rules out whether or not that patient can have a thrombolytic. We were able to get that imaging—we work with the telestroke folks and really try to get them on as quickly as possible and alert them that we have a sick patient. So just all of that collaboration that everybody has, to get the imaging and to get the labs and to get that physician all of the information that they can. We want to deliver the best care that we can.

Dr. Pilch: Yes, Kellie, and we keep talking about time being so important, and we want people to know that the reason that there is time pressure to treat stroke is that, as you mentioned earlier, every minute that goes by that the brain is not receiving enough oxygen, there is loss of brain cells. We are in a situation where “time is brain,” and the quicker we're able to administer medicine that is clot-busting, the sooner we can restore blood flow and oxygenation to the brain and save the brain. And so time is critical, but to your point, time is not the only thing—we have to do it safely and effectively. And here at Pelham, we have a good track record, and it's quite amazing what the stroke team has been able to achieve. And we've watched it evolve over the last few years to really quite an efficient machine. 

Geater: And we do, we break down that process. There are time measures that we have to meet to keep our primary stroke certification. If we are falling out in one of those areas or maybe something didn't work, that's where my brain kicks in and we try to figure out, “okay, what is going to work; what did happen?” to be the best that we can be.

Tony K: Yeah, I mean, what you're describing to me is a lot like what I envision firefighters go through, you know. We don't have stroke numbers that come in that every fifth patient, for example, coming into a hospital ER as a stroke patient to where it happens all the time, but it shows you how well-trained and prepared our team is with y'all's leadership and that those processes and that muscle memory kicks in because of how you've drilled and trained and created expectations. I think the listening audience might not fully appreciate that, even at a large facility, it's not like stroke patients are coming in one right after the other, but you have to be prepared. You both mentioned how important time is, and there's a saying—I think Dr. Pilch, you even said—"time is brain.” But healthcare is world-famous for acronyms, so talk to us a little bit about the B.E. F.A.S.T. acronym, which is—for the listening audience—some intelligence or information we can provide you to be on the lookout for stroke-like symptoms. 

Dr. Pilch: It's true that one of the most important steps in stroke care happens in the community to the person or the family where stroke symptoms first occur. The stroke team here at Pelham cannot do anything if people stay home with stroke symptoms. and it is one of our greatest rate-limiting steps, if you will, that prevents the stroke team from acting—the rate-limiting step being that people often don't realize the danger of stroke and stay home with stroke symptoms.

And so the medical community has worked on different algorithms to try to train people out in the community to recognize the stroke symptoms. And there are various ones, but B.E. F.A.S.T. really focuses on the stroke symptoms. And if people have difficulty that suddenly comes up that can be recognized out there, they will seek help.

B.E. F.A.S.T.
 - B stands for balance trouble—someone who suddenly has trouble with balance.
 - E is for trouble with eyes.
 - F is for facial weakness
 - A is for arm weakness. Some people have drifting of their arm.
 - S is for trouble with speech, 
 - T just means “time to call 9-1-1.”
 So if people have trouble suddenly with balance, vision, facial weakness, weakness in an arm, speech, then the answer is they should call 9-1-1.

The reason we say call 911, is that as soon as the EMS reaches your home, you are suddenly in the midst of professionals who know about stroke, and they can actually call ahead to the emergency department and already be coordinating your care. If you decide to get in your car at home with stroke symptoms and drive to the hospital (because many people think it's just more efficient to do it), the answer is it isn't more efficient. Because as you're driving to the hospital, things could get worse, and you are not in the presence of trained professionals to help administer oxygen and check blood pressure and start to give life-saving treatment. But also because when you show up at the emergency department door, you will be triaged, but the answer is there are lots of other people there at the emergency department door. If you show up in the ambulance, you immediately get the care that you need. So we highly recommend calling 9-1-1 as that final step in the B.E. F.A.S.T.—time to call 9-1-1. 

Tony K: Absolutely. Dr. Pilch, earlier you mentioned the fact that we're supported by teleneurologists. Talk to us a little bit about the discipline of neurology, and also the fact that there's unfortunately not many of you out there. So technology has been a great win for healthcare in many ways, and being able to access neurologists who might be either local or in another location altogether to help support the emergency provider—you can't be everywhere all at once—but talk to us a little bit about your discipline.

Dr. Pilch: Yes. So neurology is the study of the nervous system, and the nervous system is something that, most people are somewhat familiar with in the form of the brain and say “the spinal cord,” but really the nervous system throughout the entire body from the tips of your toes to the top of your head. And it is really the central processing unit at the level of the brain and the signaling that takes place throughout the entire body, and so really the neurologist is someone who is a student of and an expert in how the body works really in general. The nervous system is running the human body.

But, you know, my colleagues in cardiology would also say, “yes, but without the heart, I can't have an operating nervous system.” And the answer is that's absolutely true, which brings us a little bit around to stroke because, the heart is the pump that sends oxygen to all of the tissues, which is really the most important thing that allows energy production and for cells to work. And so the heart is really just a modified blood vessel, honestly. And the blood vessels course throughout your entire body as well, from the tips of your toes to the top of your head. Of course, stroke is an interruption of blood flow to an area of the brain, spinal cord, or to the retina—all of those classify as stroke.

And so blood flow interruption really is at the heart of stroke, but blood flow interruption is a part of the vasculature, of course, so all of those things are important. The neurologist really needs to understand on a detailed level how stroke can present in a lot of those unusual ways that Kellie mentioned. There are some things that really almost anyone could recognize as stroke, but the neurologist is someone who's trained in the details of the nervous system and can recognize, the more subtle signs of stroke. There is an old adage in neurology training that you learn neurology “stroke by stroke.” And the reason for that being that there can be interruption of blood flow anywhere in the nervous system, and that does happen everywhere in the nervous system. As that occurs, you learn as a training neurologist how things work and how things can go wrong within the entire nervous system.

Tony K: And while we're talking primarily about stroke, talk to the listening audience a little bit about other situations and patient diseases you might help take care of for patients. 

Dr. Pilch: So, I like to say I've never had a boring day in my entire career, because it's true. And neurology—I continue to be what we would call a general neurologist, which at this point in history, is now a minority of neurologists. Most neurologists do not consider themselves general neurologists. They have specialized in a certain area, but we still practice in my office general neurology, which means we take on all forms of neurological disease (and that is a wide range of diseases). So we take care of people who have not only stroke, but who have dementia, who have epilepsy, who have movement disorders (such as Parkinson's disease), who have spinal cord disorders, multiple sclerosis, who have peripheral neuropathies, who have myopathies, muscle diseases, who have diseases of the neuromuscular junction.

And so as we think about the nervous system—brain, spinal cord, peripheral, nerve, neuromuscular junction, muscle—we take care of people with diseases at all of those levels, things as well-known as stroke and things as unusual as myasthenia gravis. So the neurologist has a wide range of conditions that they take care of and are knowledgeable about. And it is both challenging and also very gratifying to help with those things. 

Tony K: Yeah, it's a great specialty. I wish more people would go into it. It's just a terrific, needed specialty. 

Dr. Pilch: The truth is, I really fell in love with neurology. I planned on going to medical school, becoming a family practitioner, and moving to the country. That was really my plan. That was my goal. I love wide open spaces and wild places, and that was my goal—to go to a small community and just be a country doctor. But when I was exposed to neurology, I was literally, what I like to say, wowed by it. It is a “wow” experience (at least for me). And so it is true that neurology is an amazing thing to participate in.

We do know that young people can be intimidated by neurology when they look at it. And so one of the things we are trying to overcome is that sort of intimidation factor that happens with the nervous system when you start to study it, and it is true that only about two to three medical students in a hundred choose neurology. And that has been the same number for about the last 30 years. We would love to expand that, because the need for people who are skilled in taking care of people with diseases of the nervous system is expanding. We really need more of those people. 

Tony K: Are there any novel or new techniques in stroke care—that you're aware of—that are out being tested now that could be created in the future?

Geater: I know there are a lot of different medications and different things that they're looking at as far as treatments go.

Dr. Pilch: The technology side is absolutely booming in every facet of our culture. And it's also true in stroke care, and we're excited for that capability. To that point, really one of the things that is up and coming in our stroke care algorithms is mobile stroke units, better known as the MSU. These are things that started some 20 years ago—really, over in Europe, it was really the genesis of mobile stroke units—but mobile stroke units exist in some of the bigger cities, and they really mean that there is a mobile truck, if you will, that actually has an onboard trained professional in stroke. It has a CT scan capability, and it has the capability to administer thrombolytics out in the field. And so, while we do not have a mobile stroke unit (that I know of) in the upstate of South Carolina at this moment (there are very few of them in the U.S.), it is a growing thing.

We are planning on having a new medicine—Tenecteplase—that is a new thrombolytic. We will be administering it here at our primary stroke center within the next year, and it is a medicine that will help our capability. I think it will help the administration. It's a medicine that, compared to what we're using now, which is a medicine called Alteplase, can be administered more quickly. It is less expensive. It is more powerful in terms of its clot-busting capability. It has a longer what we call half-life, meaning it sticks around a little bit longer. And so, because of all the advantages of this medicine, we should be administering it here at our center within the next year. It is already being administered in a high percentage of stroke-certified centers nationally. So that's another change.

One of the most interesting things that I'm coming across these days in stroke care that I just find fascinating—and that you may see and that you could read about—is remote ischemic limb conditioning. And so there are people who've been working on this for really quite a long time, meaning maybe 20 years in its genesis. Remote ischemic limb conditioning means that if you, let's say for example, apply a blood pressure cuff to someone's limb and blow it up to a high enough pressure that it prevents arterial blood flow to the limb, you cause ischemia in that limb, which normally would not be a good thing. As I said earlier, oxygen is very important, but this is a treatment where causing ischemia in a limb, which is safe to do for a brief period of time, actually causes some effects on the entire body—both what we call humorally, a release of chemicals into the vasculature, but also neuronally, changes in the nervous system that feed back to the brain that increase collateral blood flow.

Tony K: It's been a fascinating discussion, and it shows you just how medicine is not a static thing. The medical profession is always trying to do better for patients, with the principle of first do no harm still being at the core and always looking for ways to create better outcomes. So we're very blessed to have you two as leaders on our team here at Pelham Medical Center. Thank you very much for what you do, and you help keep us on the front lines of stroke care and being on the cutting edge for our patients.

Dr. Pilch: I mean, it's an honor to be a part of this team. It's an honor to work with Kellie—and really all the professionals here at Pelham Medical Center—and I am blessed to be a part of it.