The EMS Loophole

I knew there was one (a loophole in the new EMS stroke protocols for Alameda Hospital). And sure enough, there it is: every stroke victim in the City of Alameda that is seen in the field by the ambulance at and after 4 hours after the onset of the stroke, goes to Alameda Hospital.  Sounds sensible, right? Wrong.  I’ll make this simple:

1. Alameda Hospital can only administer IV tPA (intravenous thrombylotics).

2. IV tPAs are only administered from the time of onset of a CVA (stroke) until 3 hours afterwards, i.e., it is not considered effective to be administered 3+ hours after the onset of a stroke (FDA Approval standard, however, the ASA [American Stroke Assoc.] recommends through 4.5 hours).

3. Certified Stroke centers provide effective (save brain cells!) interventions that are effective up to EIGHT HOURS after a CVA Onset.

So it’s medically best to go to a stroke center during the first four hours after a stroke begins AND it’s medically best to go to a stroke center if you’re taken 4+ hours after the stroke begins.

But in the City of Alameda, if you don’t get found by the paramedic within the first 4 hours, you get substandard medical options….

The paramedics have a choice: at/after 4 hours, they can choose to call a base physician at a stroke center or not.  They can choose to take a CVA victim to a regular Emergency Department (ED) (like Alameda Hospital provides and which can only administer IV tPA) or they can choose to call the base physician and take the CVA victim to a stroke center.  The only way that they always deliver a 4-hour-plus stroke victim to Alameda Hospital is if they have instructions to do so.

Given items 1, 2, and 3 above, why would those in charge of our emergency medicine write protocols that deliver 4-hour-plus stroke victims into a regular ED? Another backroom deal perhaps to protect some of the acute cases for Alameda Hospital, for revenue.  That’s the only explanation because there is no sound medical one. Honest.  Here’s the current interventions that only stroke centers can provide for CVA victims, and they are effective during the first EIGHT HOURS AFTER CVA ONSET:

-intra-arterial tPA administration ( a catheter is threaded up to the site of the clot in the brain using fluoroscopy to visualize the path.)  IA tPA can be administered up to 6 hours after Onset and be effective.

– surgical/mechanical blood clot removal from the brain by an interventional radiologist (a catheter is threaded up to the site of the clot, the clot is grabbed and slid back down the artery and removed); this intervention can effectively take place up to 8 hours after Onset. This is very cool; see this video: http://www.youtube.com/watch?v=P2TNz-TniIA&feature=player_embedded

So again—and not to belabor the point—but it’s medically best to go to a stroke center during the first four hours after a stroke begins AND it’s medically best to go to a stroke center if you’re taken 4+ hours after the stroke begins.

WHY is the County EMS continuing to discriminate against Alamedans with the new stroke protocols?  Man! I thought we could rest for a bit when they announced the rescinding of the stroke transport protocol variance for Alameda city, but apparently not!

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About Denise Lai

Alive. Swim (fly is the best). Walking with my dog (weims are the best). Life is good. Would prefer people understood negative externalities and prevented themselves from creating them. Feeling the love anyway. View all posts by Denise Lai

2 responses to “The EMS Loophole

  • Denise Lai

    In Michele Ellson’s 11/30/2010 UPDATED article. she reports that Hospital CEO Stebbins says: “the hospital will still get other stroke patients…who are outside the four-hour window in which drugs that reduce the symptoms of stroke may be administered.” This is the opposite of stroke emergency medicine standards: IV drugs no longer work at/after 4.5 hours. And IV drug therapy is the only therapy Alameda Hospital can provide at this time. I find this to be an appalling misuse of her office, to mislead residents into thinking that going to Alameda Hospital after 4 hours is appropriate when it’s 100% medically contradicted! Ellson article is here: http://www.theislandofalameda.com/2010/11/emergency-stroke-patients-to-be-sent-off-island/

  • Denise Lai

    I spoke with AFD Chief Fisher; he said that in the last four months, the ambulances in Alameda city have taken every stroke victim to a Certified Stroke Center. So now I’m totally confused. Is this a new thing? Or have the paramedics been doing the right thing despite the county protocols? But I’ve heard anecdotal stories that people do get taken to Alameda Hospital for strokes, from neighbors etc. And what the heck is Stebbins talking about? Bottom of this is not near apparently.

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