Every minute stroke victims go without treatment, the further the lives they used to lead recede into the distance. As neurologist Andrew Southerland, MD, explains, “When a major artery is blocked during an ischemic stroke, the brain loses 2 million neurons and 7 miles of nerve fibers every 60 seconds, which can lead to paralysis, speech or vision problems and permanent disability.”
The treatment of choice for ischemic stroke — the clot-busting drug tissue plasminogen activator, ortPA — is effective only if given within the first few hours in most cases and is generally more effective the sooner it is given. The same urgency applies to hemorrhagic strokes.
Before physicians can administer therapy, however, they must first conduct a neurological assessment and get a CT scan of the patient’s brain. When patients are transported via ambulance, these initial steps don’t happen until patients arrive at the hospital, so treatment is delayed even further, especially if they are coming from distant rural areas.
Southerland and his team were determined to find a way to close this gap and get patients into treatment more quickly. They realized that by using standard, off-the-shelf wireless technology, they could move the neurological assessment from the emergency room to the ambulance, reducing the time to treatment after hospital arrival. “It’s a commonsense insight,” he says, “but one that rests on UVA’s expertise in delivering telemedicine and emergency telestroke care.”
With funding from UVA Neurosciences Center, federal funds from the Health Resources and Services Administration and the Virginia Alliance for Emergency Medicine Research, Southerland and his team launched the iTREAT study to test the feasibility of mobile neurological assessments during ambulance transport. The acronym stands for Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine.
With Clinical Research Coordinator and professional EMT Jack Cote, Southerland’s team is developing an iTREAT toolkit for emergency medical technicians capable of creating a live video link between the ambulance and specialists in the UVA emergency room. The toolkit consists of a tablet computer (Apple iPad), a high-speed modem and a portable magnetic mount antenna. After extensive feasibility and simulation testing, the goal is to place the first toolkits with the Greene County and Western Albemarle Rescue Squads by the beginning of 2015. With the additional leadership of UVA Prehospital Care Director, Debra Perina, MD, and local EMS partners, the iTREAT team hopes to further expand mobile telestroke capability for other rural ambulance agencies in central Virginia.
Creating Ambulance-Ready Technology
In order to facilitate a mobile neurological assessment, iTREAT requires a continuous, two-way, high-speed connection. To overcome technical challenges, Southerland and team members in the UVA Center for Telehealth turned to Verizon Wireless, Cisco Systems and Access Wireless Data Solutions. The companies helped the researchers select components that maximize connectivity, optimize live video streaming, and in some cases, when ambulance-run simulations revealed gaps in service, Verizon was able to boost the signal at its cell towers.
But Southerland and Cote understood that efforts to resolve technical issues would be in vain if they couldn’t deliver technology that EMTs would adopt. Here, Cote’s extensive background in emergency medical services proved invaluable. In a crowded ambulance, space is at a premium, so compact design is essential. After several iterations, Cote has reduced the size of the kit to a 20-inch by 14-inch by 8-inch package. Because EMTs must be able to use both hands for their other duties, Cote also had to find a way to attach the tablet to the foot of the stretcher or the ambulance’s grab rail. “We needed to find a clamp that could accommodate a variety of rail shapes yet was also strong enough to provide a stable image for the physicians at the hospital,” he says. Finally, Cote addressed cost, finding ways to slash the toolkit’s original projected cost of $5,000 by half, which is important for application in rural areas.
Putting EMTs and Physicians in the Same Virtual Space
As Southerland notes, the successful implementation of iTREAT will require a subtle realignment in the relationship of physicians to EMTs. Currently, EMTs conduct a broad-based stroke exam and call in their results before arriving at the emergency room. With an iTREAT system, physicians, with assistance from the EMTs, will administer the NIH Stroke Scale exam over the video link during ambulance transport and allow stroke specialists to begin the doctor-patient interaction well before hospital arrival.“There’s going to be a cultural shift,” he says.
With this in mind, Southerland and Cote have met extensively with members of the Thomas Jefferson EMS Council, which covers six counties surrounding UVA Medical Center, to introduce iTREAT. “The reception has been great,” Southerland says. “Virtually every agency and director we’ve talked to is enthusiastic about adopting it.” By building these new relationships through technology, the future is bright for innovation in prehospital stroke care and better outcomes for stroke patients.
Watch the video below about iTreat.