344 - How ER Teams Respond to Heart Attacks and Strokes (Dr. Ryan Sundermann and Cari Batcheler, PharmD)

St. Luke’s ER Medical Director Dr. Ryan Sundermann and ER Clinical Pharmacy Specialist Cari Batcheler discuss how rapid coordination and lifesaving treatments come together for heart attack and stroke patients when every second counts. 

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Transcript

Dr. Arnold: 00:08
This is LiveWell Talk On...How ER Teams Respond to Heart Attacks and Strokes. I'm Dr. Dustin Arnold, Chief Medical Officer at UnityPoint Health, St. Luke's Hospital. Joining me today is St. Luke's Emergency Room Medical Director, Dr. Ryan Sundermann, and ER Clinical Pharmacy Specialist Cari Batcheler, to discuss how rapid coordination and life-saving treatments come together when every second counts. Dr. Sundermann, Cari, welcome. Thanks.

Cari Batcheler: 00:31
 Thank you for having us.

Dr. Arnold: 00:32
 It's nice to have you here. So when, you know, we hear time is muscle, time is brain. So could you just give an overview when it comes to strokes and heart attacks, why time is so important?

Dr. Sundermann: 00:44
 Yeah. So the reason that's important is because blood carries oxygen. The simplest way to think of it is blood carries oxygen. And if that blood vessel is blocked for any reason, whatever's downstream in that vessel is no longer getting oxygen, and all of your tissues rely on oxygen to perform their functions. So heart attack and stroke are very similar. It's just two different organs, a heart being, you know, heart attack, obviously a heart, and a stroke being a brain. But the mechanism in general, when we talk about ischemic strokes or when a blood vessel is blocked, that blood vessel gets blocked and it doesn't deliver the oxygen downstream. And so in heart attacks, that muscle starts to die, and then in strokes, that brain starts to die. It takes, you know, a certain amount of time, but that process, you know, the longer it's going on, the less oxygen there is, and the worse the damage is.

Dr. Arnold: 01:31
 Well, what do you do in the ER to be more efficient with your time when these patients present? How does that work?

Dr. Sundermann: 01:38
 Yeah, well, we definitely have kind of a swarm approach or a team approach, and so it's kind of an all-hands-on-deck type of situation. That's why we're lucky to have Cari and the rest of our clinical pharmacists there because they have a unique skill set in that they're very adept and their background is in medications. And so one of the key things if somebody is having a stroke or a heart attack is to get a vessel open. And a key piece of that is some of the medications that we give. In the heart attack case, Cari can talk a little bit about that. Ultimately, we want to get them in most cases up to our cardiac cath lab where they can run a special device down and open that vessel up. But in strokes, we don't quite have that luxury, and so we have to use primarily medications only. In strokes, sorry, in strokes we have to use medications only. There are a few scenarios where that's not true, but in the general or in the broadest sense, we've got to get that open with medications.

Dr. Arnold: 02:34
 So, Cari, what are those medications that are used?

Cari Batcheler: 02:37
 So there's a couple different medications that we primarily use for clot-based strokes, excuse me, or ischemic strokes, as we call them. So we here in our hospital use TNK or tenecteplase. Other facilities might use a similar medication called alteplase or TPA. Both of those medications are clot-busting medications that go in and help to break up any clot that may be impeding the blood flow to the brain.

Dr. Arnold: 03:00
 But they're risky medications, correct? What are the risks of using these medications?

Cari Batcheler: 03:04
 Absolutely. So these medications, because they break up clots, they come with a pretty high risk of bleeding. So we choose our patients very carefully. There's a list of contraindications to these medications, and we evaluate those for each patient to make sure that they have no contraindications so that we can decrease that risk of major bleeding.

Dr. Arnold: 03:22
 Now, the window for let's just talk about strokes, used to be four hours, then it was extended to six. Where's that now?

Dr. Sundermann: 03:29
 Well, it can be all the way out to 24, even, and sometimes even longer in some experimental things. We coordinate with the University of Iowa for some special procedures where they can actually use a similar device to what they use in heart attacks, where they can use a catheter. What that means is essentially a catheter is just a tube that you can administer something through. So it's like a straw essentially, and they run that through a blood vessel and then it travels up into your brain, and they can identify a vessel that is there. And so the problem is that because of the risk of bleeding from the TNK and medications like that, as the tissue gets less and less oxygen and gets more and more damaged, it's more and more fragile, and so it can bleed easier. So the longer you go without having good blood flow to that brain, the more fragile that tissue gets. And so when you give that TNK, it's at risk of bleeding even more than if you—so at 30 minutes, you have a lot less risk than if you're at six hours. And the other thing is that that medication is given systemically, meaning it's given through an IV, so it's all over your body, not just in your brain. And so you can have risks of bleeding not just in your brain, but like your gums, and we often see patients bleed into their bladders and through their IVs. So we coordinate with the university very tightly so that for the right patient, and it's a smaller subset of these stroke patients, we can send them down and they can run a catheter up and administer some of that medication just in the blocked vessel and they can free it up. So it takes away some of that additional bleeding risk. That's because they've been able to do that and we've been able to share those protocols. We can get them down there if it's appropriate, you know, and that's why we have a helicopter and these rapid transport mechanisms to get there ASAP.

Dr. Arnold: 05:18
 Because although there's a risk of bleeding, there's also a risk of disability if the stroke continues to evolve, yeah, and perhaps even death.

Dr. Sundermann: 05:26
 So yeah, it's definitely risk versus benefit. And, you know, we have to have that discussion with the patients and their families about that. We have to say, you know, there is a real risk, as high as like five or six percent, I think, is a bleeding risk. And again, the further you get into the stroke, it's 100% if you're the patient that it happens to.

Dr. Arnold: 05:40
 Yeah, right, right, yeah, right.

Dr. Sundermann: 05:42
 Yeah, so there's a fairly high risk, but the thing is that you're facing, you know—and so if somebody comes in with milder symptoms, a lot of times we don't give it. Like maybe they had just a little subtle facial droop and then it's resolving. A lot of times we might hold off. It's case by case, obviously. But if somebody comes in with pretty profound deficits, meaning that they have like a severe facial droop, can't speak, can't see, the whole arm doesn't work, you know, that's something that they would have to live with for the rest of their life. And so that is a discussion that we have to have with the family about what their wishes would be and whether or not they are comfortable with that small risk of bleeding. But the thing is that your best chance of returning to your baseline function is if you get that medication. Yeah.

Dr. Arnold: 06:21
 And my years of practice, I found that patients—the thought of disability is worse to them than death. You know, people just don't want to be dependent on others and for understandable reasons.

Dr. Sundermann: 06:37
 I'd say just to put the population at ease, I would say most people decide to receive the medication if it's appropriate, and a much smaller subset choose not to have it. And so sometimes they're having a hard time making maybe knowing what would most people do helps make a decision, and most people would choose to have the medication, assuming that we've gone over all the risks and made sure that you haven't had any procedures or anything that would add any additional risks.

Dr. Arnold: 07:03
 So I would say of clinicians, 100% would recommend the medication for themselves or their family members just because we've seen the long-term effects of stroke. Absolutely. Yeah, devastating. Well, we've talked about heart attacks of the brain. Let's talk about heart attacks. What happens? Take me through like a cath lab alert.

Cari Batcheler: 07:25
 Sure.

Dr. Arnold: 07:25
 You want to go ahead? Can you go? I can start.

Cari Batcheler: 07:28
 So the patient arrives to the emergency department. They typically present with chest pain, but they can have some other symptoms that we can talk about a little bit later. So they present with chest pain. The first thing that we prioritize in those patients is getting an EKG. So our nursing staff is phenomenal at recognizing when a patient might be having a heart attack. They get those EKGs done very quickly, ideally within the first 10 minutes of patient arrival to the emergency department. They bring that EKG to a physician who activates the cath lab if they feel that it's appropriate, if they meet the criteria for a heart attack based on that EKG. And then we do a whole bunch of things, as Dr. Sundermann mentioned, it's kind of a swarm effect at that point. Once the cath lab alert is activated, we all kind of swarm the patient. Nurses are getting an IV started, they're hooking the patient up to the monitor. We're administering certain medications that we like to get in prior to cath lab, like aspirin, sometimes ticagrelor, clopidogrel, heparin, and then we're coordinating with our cardiology team to get that patient up to the cath lab as soon as possible.

Dr. Arnold: 08:28
 So one of the things I know we talk about and we pride ourselves on is our door arrival to balloon time in the cath lab. What are our times at and how does that compare to the national standards?

Dr. Sundermann: 08:38
 So we're doing—we do well. We're, I think—gosh, good question. I don't know if I looked up our most recent, but we're always top in the state for sure. And obviously time—and it used to be when I started 20 years ago here, we were happy if we were getting there even close to an hour. It was about 90 minutes is what our target was. And then probably 10 years ago, we started shooting for under 60 minutes, and now we're shooting for 45 minutes or under 45 minutes, and that's door to getting the vessel open. And so that's when they run a wire, typically now in your wrist. When Dustin and I were doing this a while ago, they'd typically go in through a big vessel in your groin, but these catheters are so well made and so small now they can typically go in your wrist in a vessel right down by your hand, and they run that wire up. And so the door-to-dilation time is when they actually achieve blood flow back through that vessel. And so those times—I think well above 50% of our patients are getting door-to-dilation under 45 minutes now. But it's a hustle, that's for sure.

Dr. Arnold: 09:41
 How often, you know, there's a time where we'd use prior to the DANAMI study, we'd use TPA for heart attacks. Does that happen anymore?

Dr. Sundermann: 09:49
 Yeah, I mean rarely. It kind of depends. Not so much here, in certain situations, but some of our smaller hospitals will use it. And I don't know if you've had experience with that.

Cari Batcheler: 09:57
 A few years ago, I think we had incidents where there was a patient at one of our critical access hospitals that was there during a snowstorm and there was no transport available. So I think we did do alteplase for a heart attack patient a couple years ago. But ideally we get the patient up to the cath lab and we use the clot-busting medications in heart attacks less often.

Dr. Sundermann: 10:14
 And that's not a bad option. I mean, if you do have a loved one that's 90 minutes, two hours away. And then during COVID, we had a lot of delays in patients getting because the hospitals were so full. But yeah, if there's a snowstorm or something, it's definitely an option. It's not a bad option. And the risk of bleeding elsewhere, as opposed to a stroke, when you have a stroke that tissue is so damaged that it's just so much more likely to bleed into that damaged brain area. It's less so in the heart. You still get some bleeding that you can see through IVs and things like that that is a little bit expected. But there's still a risk in it, but it's definitely worth it. Like if you have a family member and you're faced with that decision, I'd definitely recommend it if there's going to be any delay in care. And they can still do the cardiac cath. We used to call it a drip and ship. And so we used to do that pretty routinely. We'd start that TPA or TNK, and then if it was a long transport time by ground or whatever, by ambulance, if a helicopter wasn't available, they would start that medication just to get that vessel open as soon as possible, and then they could still do the cath. There's obviously more bleeding when the cardiologist does the cardiac catheterization, but it's worth it because you've got to get that vessel open.

Dr. Arnold: 11:23
 You talked about the EKG determining the next clinical decision to be made. For strokes, how's that clinical decision made?

Dr. Sundermann: 11:33
 So there's a couple of different ways. We use a couple of standardized scores. The most widely used stroke evaluation is called an NIH scale. And there's a very long list of things that includes everything from facial droop, vision, hand and arm movement, coordination, speech, things like that. And we run through that on all patients. But when they come through the front door, we are really just doing—there's a couple of them. There's a BEFAST one that we recommend that the public use, but we use something very similar to that called a VAN score, and that's really just like you're doing a very basic evaluation of that patient. You're checking to see whether they can talk, whether they can see, and whether they can move their arms essentially. There's another portion of it where you're evaluating them for something called neglect, which is just kind of a very subtle thing, but it can suggest that a larger vessel is blocked. It's basically simply saying if you were to stand in front of a patient, they could see you and recognize you're there. If you're on one side, they know somebody's there. But if you go to this side, even though they can see you, they don't recognize it. That's called neglect. And we don't expect the public to be able to screen for that. But when they come in and we screen them—and that's the other thing is when we get an alert, if they come in through the front door by a private vehicle, our nurses are doing a lot of that initial screening and they'll call a stroke alert and then we announce it overhead, and everybody goes to that room, and everybody's in that room instantly. We often, if they're coming in by ambulance, and that's why we recommend to the public that they call the ambulance, because these paramedics know what to call and what to do. They actually, when they come in through the ambulance, they don't even go to a room. We meet them at the ambulance bay, and because if they tell us that they're confident it's a stroke, even if it's not a stroke, we want them calling us so that we can meet them at the door. And in almost all cases, and the paramedics are fantastic in all of our surrounding communities, especially with Area Ambulance, Hiawatha, Marion, they all do a phenomenal job. And they come through the door and we evaluate them right there outside of the ambulance bay, and then we take them right to our elevator up to the CT scanners. So we pop them right in, we go there, we often accompany them there, and I'm calling the neurologist on the phone as the patient's getting loaded up onto the CT scanner. So this is a lot of stuff happening simultaneously, just to really expedite that.

Dr. Arnold: 13:50
 So the CT scan is the EKG of the brain, basically.

Dr. Sundermann: 13:54
 Yeah, so initially the EKG initially really is our screening and is just kind of going through that checklist, and then the CT scan is kind of confirming, but more than anything—and in fact, the CT scan often doesn't even identify the stroke. And that's what some patients—sometimes they assume that we tell them that the CT scan looks okay, but what we're really looking for there, because if we can see the stroke on that CT scan, then generally it's a pretty big one. What we're really looking for is are they bleeding? Because if I evaluate that patient and they're clearly having a stroke to me based on my clinical findings, then what I want to know is is there any bleeding? Because there are bleeding strokes that can present just like a blockage stroke or these ischemic strokes. And so we just need to make sure that that's not bleeding because we cannot give TNK to those bleeding patients, because clearly that would make it much worse. So as long as we can confirm they're not bleeding, then they come down and they get the medication. And ultimately, our final diagnosis is usually made on the MRI that they do kind of the following day. And that just kind of confirms where it is and how big it is and things like that.

Dr. Arnold: 14:54
 So someone could have a brain tumor, right?

Dr. Sundermann: 14:57
 I mean present similar, seizures, low blood sugars. So that's a nice thing about the paramedics. Somebody comes in with a stroke, they've already done the blood sugar, they've already done—you know, so we know these guys have already screened them for kind of some of the other things, so it's nice to have it. It wasn't always like that.

Dr. Arnold: 15:12
 I mean, yeah, yeah. So if we try to get the EKG done for a heart attack in 10 minutes, how soon do we try to get them in the scanner, Ryan?

Dr. Sundermann: 15:23
 Fast. We want that head CT ran and read within less than 30 minutes. But even 30 minutes—we even have a special phrase that we put on our head CT. We use a stroke order set, which means it's a whole bunch of stuff that I can kind of one-click, one-button, and it orders all that simultaneously. And so it shows up as a stroke head CT, which prioritizes it. But then we even put on the note in there, we say this patient is a TNK candidate. Because sometimes they come in and they might be, you know, we're like, ah, this might be a stroke, but it's small, it's subtle. We're like, I don't know that TNK is the right answer for this guy. But if the clock's ticking and we want to give that TNK, we put that so the radiologist can see TNK candidate, and so then they call us with that read, but we're all hovering around waiting for that thing to come back anyway. Everybody's looking. It's pretty redundant because we don't want to have any delays or misses and things like that.

Dr. Arnold: 16:17
 I think it's good to mention for the public and listeners that in a utopian world, we could just get an MRI on everyone, right? But they take time. They're long, 20 minutes, you know. You don't want to wait.

Dr. Sundermann: 16:31
 Yeah, and then if the patient has a potential to get worse, it's a better study ultimately. But yeah, you gotta be careful when you're putting patients in there. Yeah, definitely.

Dr. Arnold: 16:41
 You know, you mentioned calling 911 if you have that. Patients ask me, well, when should I go to the emergency room? So you should go anytime. Let us determine whether or not it's significant, not you. But really time is muscle, time is brain. And so the takeaway to the public is initiate that emergency rescue system to get here quickly, correct?

Dr. Sundermann: 17:10
 I mean yeah. So 911 is there for a reason. And that's the thing is let us—if you think it's potentially an emergency, assume it's an emergency. Your emergency is our emergency, essentially, and we'd rather have you kind of go way over the top and then we can de-escalate, as opposed to delay. So I tell people when they come in, especially as an emergency physician, my job is to think of the five or six worst things. One of my old mentors used to tell me that. He said, I want you to start at the very top and work your way back down. You don't have to tell them because you might scare the patient, but your job is to think of those worst things and work your way back from there. Whereas your primary care doctor, it's a completely different environment. You're like, hey, I've had this little back pain for the last three days. He's like, oh, it's probably muscle strain, all the common things. But if somebody comes into me and they're like, I have this horrible back pain that started one hour ago, I'm going over kidney stone and aortic dissection. And I got to think that out. Doesn't mean I have to go after it. So that's the thing is if you think it's an emergency, let us help you make that decision and we'll start at the top and work our way backwards from there. Never feel silly for coming in. Patients say to me all the time, oh, I'm sorry if I wasted your time. That is never the case. I don't care what the complaint is, right? Because it's not a problem. What you don't want to do is not go in and then regret not coming in.

Dr. Arnold: 18:28
 And also, I think it would be appropriate to mention at this time that if you come to the emergency room for a concern that's urgent, perhaps not emergent, needs to be addressed, some of these patients who come in with these other conditions may bump you down a little bit on the list. And so if you're waiting for a period of time, I think it's important for people to understand that. We don't want you to wait, we'd prefer you not wait, but yeah, sometimes emergencies come in that are of higher priority.

Dr. Sundermann: 18:60
 That's the triage process that we do, you know, and that's going to be very frustrating for somebody if they do have some back pain or they sprain their ankle a little bad or something, they're sitting there, but then somebody's coming through. And the thing is, it's not like they're announcing overhead what that person's complaint is, so you really don't know. And you see three people go in front of you after you were there before them, that can be frustrating. That's certainly understandable. And we try to communicate that message. No, you guys do a great job of being transparent about where the patients are at. I think with all the TV shows out there now, they're starting to get the idea, like, oh yeah, crazy stuff comes in when I'm just sitting, you know, watching from the window over there.

Dr. Arnold: 19:32
 So speaking of TV shows, you watch The Pitt.

Dr. Sundermann: 19:35
 I've watched the first series. It's written by emergency doctors, and so the first couple of episodes, I was like, these guys seem to have a lot of inside knowledge compared to all the other shows that came before that. And one of the things that I do in a podcast I listen to is the physicians that actually write it, and they're fantastic. And so watching it, I was like, I gotta quit watching this. It's like watching myself work. They compress a lot into that time. But it's good to watch them include a lot of the other social issues that occur in the emergency department because we really are the safety net for a lot of the population, or in the middle of the night when nobody else is open. I kind of tell people sometimes, we're like Walmart, we never close, even on the holidays, you know, we're always here. And so it's a good show. I think it represents a very much inner-city feel. I did my training in Detroit, I think you worked in Detroit too, and definitely kind of a different environment in an inner-city situation. But all the same problems are the same for all humans, and it's cool that it brings light to—we all suffer and we all get sick in the same ways and we all heal in the same ways.

Dr. Arnold: 20:43
 And so I think they've done a good job of highlighting some of those bed availabilities that we deal with every day. Hospital problems, you know. I think they've hit a lot of stuff that people don't typically think that we have to think about. Uninsured patients, we would give them the same care we give everyone else.

Dr. Sundermann: 21:07
 I have no idea what your insurance is when you're going to come here, and nor do I care. That's why I do the job. Absolutely. Because I'm going to take care of everybody the same no matter what they got going on.

Dr. Arnold: 21:17
 Cari, are you a little upset that The Pitt doesn't feature clinical pharmacists like they do?

Cari Batcheler: 21:21
 Yeah, why don't—you know what, I don't watch the show myself because again, I don't want to feel like I'm at work when I'm not at work. But I think there was a clinical pharmacist featured recently. Actually, I think we got our little moment in the spotlight. So I appreciate them including the interdisciplinary team.

Dr. Arnold: 21:36
 Well, you know, we've had multiple podcasts about heart disease and prevention, one recently with some of our cardiology colleagues. What about stroke prevention, Cari? What would be the recommendation from your clinical training and experience to prevent strokes?

Cari Batcheler: 21:54
 Yeah. So it's actually very similar, preventing strokes is to preventing heart attacks. Some of the same risk factors apply to strokes as do heart attacks. So one big thing is controlling your blood pressure. So if you have elevated blood pressure, make sure you're taking your blood pressure medications, make sure you're watching your diet. Secondly, we want to control your lipids in your blood, your fats in your blood. So if you have hyperlipidemia or high cholesterol, make sure you're taking your statin medication or any other lipid-lowering medications that are prescribed. If you're diabetic, watching your blood glucose is important, making sure your blood sugars are in check. And then getting regular exercise as well is very important in preventing strokes and heart attacks. So some of the similar recommendations. Yeah, some of the risk factors are very similar between the two disease states.

Dr. Arnold: 22:38
 Well, Dr. Sundermann and Cari, I want to thank you so much for joining me. This has been great information. Once again, this was St. Luke's ER physician Ryan Sundermann, Medical Director, and ER Clinical Pharmacy Specialist Cari Batcheler. For more information on emergency care, symptoms of heart attacks and strokes, and more, visit unitypoint.org. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcast. We're available on Apple Podcasts, Spotify, Pandora, or wherever you get your podcast. Until next time, be well.