The Columbus Division of Fire (CFD), in partnership with OhioHealth, Mount Carmel Health System and The Ohio State University Wexner Medical Center, launched the Mobile Stroke Treatment Unit (MSTU) at the division’s Fire Station 3 on May 29, 2019.
The MSTU, which is a first in Columbus, is a specialized vehicle that’s designed to diagnose and provide definitive care to victims of stroke in the field. The $1.2 million ambulance was funded by OhioHealth, which is a not-for-profit healthcare network of 12 hospitals. The MSTU operates seven days a week from 7 a.m. to 7 p.m. (The hours of operation derive from EMS data that indicate the hours of likely incidents of stroke.)
The MSTU is one of only 15 such vehicles that are in operation in the United States. It operates as a shared resource for the city’s three comprehensive stroke centers: Mount Carmel East, OhioHealth Riverside Methodist Hospital and The Ohio State University Wexner Medical Center.
The clock is ticking
A stroke (also called a cerebrovascular accident) is a medical emergency that affects the blood vessels and blood supply to the brain. If a blockage, malformation or hemorrhage prevents brain cells from getting oxygen, brain damage might result. When a patient is experiencing a stroke, every second counts.
The most important process measure for stroke care is the time that elapses from stroke onset to treatment, which includes: the rate of a patient receiving the clot-busting drug, tPA (tissue plasminogen activator); identifying the candidate for neurological interventional procedures; and timely blood pressure management. Quick intervention makes a difference; one minute of brain saved equals one week of functional life and a faster recovery.
“We know that when a patient is having a stroke, seconds count,” Dr. Richard Streck of Mount Carmel Health System, says. “Time loss is brain loss. In fact, during a typical stroke, the brain loses two million brain cells for each minute without proper oxygen supply.”
When a call is placed to 9-1-1 with a description that fits the symptoms of a stroke, the CFD dispatches EMS response to the scene (including an engine, a medic and an EMS supervisor) while simultaneously dispatching the MSTU.
Upon arrival on scene, CFD medics follow routine medical care protocol, including initial assessment of the patient, and stroke protocol, if appropriate. If the arrival of the MSTU team is estimated to be 10 minutes or more, the EMS/first responders will transport the patient to the nearest appropriate stroke-treatment center. If the MSTU estimated arrival is fewer than 10 minutes, the responding medics transfer care to the MSTU personnel on arrival. First-arriving EMS personnel also may request the MSTU team if it wasn’t initially dispatched.
The MSTU vehicle is staffed with stroke-specific-trained team members: an advanced practicing provider, a CT technician and paramedics. They have access to an onboard CT scan (computed tomography scanner), point-of-care laboratory testing equipment and stroke neurology expertise via a telemedicine connection.
The unit’s onboard CT scanner is a critical tool for initiating the proper treatment on scene. Strokes that are caused by blood clots that cut off circulation to the brain are treated with tPA. The CT scan allows the medics and remote physicians who assist in treatment to distinguish between a blood clot and a ruptured blood vessel.
The system can provide a complete neurological examination that’s accessible via a video-conferencing system. A stroke-trained vascular neurologist virtually supports the MSTU team via a health monitor screen that’s inside of the medic unit. This includes speaking to the patient, monitoring the patient’s assessment and directing patient care.
If the patient is ischemic—meaning the flow of blood is reduced or blocked—the team will begin to administer tPA on the spot.
The patient also will be evaluated for neuro-intervention procedures and blood pressure management.
The MSTU paramedics utilize a traditional EMS protocol, supporting closest and/or the most appropriate stroke-treatment destination to transport the patient. The patient hospital destination requests will be honored, with the exception of critical care that necessitates transport to a different location.
“This vehicle is unique in the sense that we can start the life-saving, stroke-specific care right there, not waiting until they arrive at the hospital,” Dr. B.J. Hicks, who is the co-director of the compressive stroke program at OhioHealth Riverside Methodist Hospital, says. “As the patient is being cared for in this specially equipped vehicle, a neurologist will determine if the patient is having a stroke and what type through a CT scan.”
Everyone to the table
Getting three regional hospital systems to collaborate on a shared mobile unit and agree on a common protocol for stroke care was one of the initial challenges that was faced by the CFD when they were invited to participate in planning the service in 2017.
The division is the primary EMS provider and regional 9-1-1 dispatcher for a metropolitan area of more than 1 million residents. CFD firefighters respond to more than 400 daily calls for service, with about 80 percent of those responses requiring emergency medical services.
Former CFD Assistant Fire Chief James Davis was invited to participate in the mobile stroke unit’s early planning stage by OhioHealth Riverside Methodist Hospital. The hospital’s intention was to provide mobile stroke care to an area that’s adjacent to its northwest-side hospital complex.
“Specifically, they were trying to replicate a program that had started in Houston and that Cleveland was initiating, which would provide a mobile CT machine to assure that stroke patients were not suffering from a head bleed and then give them the drug tPA, which is a clot-busting thrombolytic,” Davis says.
Davis, who is now the chief of the Fort Worth, TX, Fire Department, was guiding the CFD’s EMS and Training Bureau in 2017.
“The concept was very exciting to me,” Davis says. “As I saw it, it was the modern version of the Heartmobile.”
(A 1966 partnership between The Ohio State University Medical Center and the CFD culminated in one of the nation’s first mobile cardiac care units, which was christened the Heartmobile. The collaboration between cardiac care physicians and firefighters ushered in a new class of medical care provider: the paramedic.)
“However, there were a couple problems with the OhioHealth mobile CT plan,” Davis explains. “One was that their target area of service around Riverside Methodist Hospital is primarily upper-middle-class white residents. The area of Columbus that has the highest rate of death and disability from stroke, however, is the inner-city area and, primarily, minority.” Davis also knew that a mobile unit that was dedicated to a single hospital system couldn’t provide timely stroke treatment citywide.
“We began meeting individually with the other regional hospital systems about the concept and, finally, started having discussions as a group,” Davis says.
“The leverage that we had in Columbus was the 9-1-1 computer aided-dispatch (CAD) system,” he adds. “The MSTU needed to be dispatched through the CAD to make this work. It took an immense amount of relationship development, evidence-based research and assurances that this would be done collaboratively to even get everyone to the table to talk about it.
“When organizations really begin working together in the best interest of community health, it’s amazing what can happen,” Davis says. “This would have never been completed without everyone giving a little and placing some trust in the Columbus Fire Department.”
Scanned on scene
The average time of the MSTU’s arrival on scene to tPA treatment is 25 minutes. The industry time metric for patient arrival at the hospital to tPA is nearly 60 minutes. Many hospitals that are in central Ohio do try to achieve times that are less than 60 minutes. (OhioHealth Riverside Methodist Hospital typically averages about 28 minutes.) The MSTU removes the transport time and transfer of care time from the equation.
For example, in early 2020, the CFD was summoned to a 41-year-old male patient who was reporting sudden weakness in his left arm. The patient had no significant medical history. Upon arrival, the CFD medics quickly assessed the situation and conducted a LAMS (Los Angeles Motor Scale) exam to measure for the possibility of a large vessel occlusion (LVO). (The test measures bilateral arm motor function, facial droop and handgrip strength and produces a number value between zero and five.) The test resulted in a downward drift on the patient’s left arm, which scored a two. Medics also noted that the patient had left-sided vision and awareness neglect.
The MSTU arrived soon after the EMS medic’s assessment, and care officially was transferred to the MSTU team. The MSTU advanced practitioner and the neurologist determined that the patient had an NIH Stroke Scale/Score of 6. The patient immediately was scanned in the field.
The CT scan revealed a dense vessel sign, and there was concern for an LVO. The neurology interventionists were notified of a thrombectomy case, and the patient was transferred rapidly to The Ohio State University Wexner Medical Center.
At the hospital, the patient received another CT scan, this time with contrast to highlight the blockage with occlusion of the proximal middle cerebral artery. The patient was taken to surgery, where he underwent a thrombectomy. The revascularization was achieved, allowing blood circulation to return to that portion of the brain.
The patient spent five days in the hospital and was discharged with no deficits.
In alliance
Initial analysis of response times shows that the MSTU provides faster treatment to patients experiencing a stroke than they receive via transport by a conventional ambulance. However, it still is unknown how much patient overall outcome is directly affected. The research team is gathering data and outcomes, to improve response and procedure and to share the model with cities across the country.
“By decreasing the time to definitive care, we will potentially reduce the debilitating results of a stroke, giving patients the greatest chance of recovery,” CFD Chief Kevin O’Connor says.
“All of our organizations working together with the Mobile Stroke Treatment Unit is special,” Hicks says. “This vehicle and the work being done here will save lives.”
“This vehicle is unique in the sense that we can start the life-saving, stroke-specific care right there, not waiting until [patients] arrive at the hospital,” Dr. Vivien Lee of The Ohio State University Wexner Medical Center adds.
For CFD paramedic Lt. Matt Parrish, getting the three hospital systems together to achieve faster treatments can be a template for EMS providers in large cities across the country. “We are the fire department, so we only want what’s best for the patient,” Parrish says. “This is the silver lining of the Mobile Stroke Treatment Unit.
“Bringing the three hospital systems together in the collaboration, we are bringing the best care to our patients by eliminating the competition to provide comprehensive stroke-care citywide.”
