neither the el paso medical society its members nor pbs el paso shall be responsible for the views opinions or facts expressed by the panelists on this television program please consult your doctor hello may is stroke month and i literally just told the docs hey we're just here to have a good time and give information because maybe in stroke month it's not a purpose to celebrate but it absolutely is a reason for us to get together and talk about some of the things that we may not know about strokes and specifically about caring for our brain and that's why we're here this evening during this hour we have experts talking about strokes and all kinds of people not just those who are at high risk because if you're not at high risk of a stroke and you're having a stroke do you think you're having a stroke we don't know that's what we're going to talk about this evening there are strategies there are treatments and there are all kinds of ways to save lives the biggest thing we're going to talk about tonight is time as you know this is a live show so think of some questions that you want to ask about this evening you can call us at 881.0013 we are also streaming live on youtube so if you have to disappear from your tv or if you want to call somebody and say hey there's a show about strokes i want you to watch this have them go to youtube.com and then just search el paso physician live and they can get to this show right now we're streaming it live and they can also ask their questions again that number to call is 915-881-0013 this program is underwritten by tenet the hospitals of providence and we also want to thank the texas tech palo foster school of medicine for providing our very own syed's id tonight and he is going to be sending questions my way of you my telephone so i just told the docs on the air that when i'm looking at my phone i'm not ignoring you i'm just looking at questions from the audience and i also want to do a big high-five to the el paso county medical society who's been doing this show now for 25 years this is the 25th anniversary and good for them thank you for joining us i'm catherine berg and you're watching the el paso physician it's interesting cause i'll have some of these doctors on the show and yeah they're doctors but i've known them for 20 years we've been doing this show for 20 years you know he talks about farts and he talks about diarrhea and he talks about all kinds of things that nobody wants to talk about and that's what's great about the show because you get to hear those things on the show and go i'm not the only one it's great see you pass the physician [Music] so this is kind of a unique show we usually have doctors on the show and every now and again we have another specialist we have a firefighter here with us this evening and his uh last name is peebles and i was joking with him right when we got on the air before we got on the air that i've only known one other person that has your last name and the spelling of your name but we have with us this evening dr alvarez who is directly to my right and she is eternal medicine internal medicine um then we have dr excuse me captain peebles who is with the el paso fire department and then we have dr eze who is a neurologist so all three really fantastic disciplines to talk about stroke and brain health in general and it's nice to have a first responder here because we're going to ask you all kinds of questions of what people ask you because sometimes that's how we're educated it's like what are people asking you and what is it that we're trying to figure out so dr alvarez i'm going to start with you and if you don't mind telling the audience at home you're a hospitalist you're an internist general studies but not so much all day every day what it is that you do is important to the audience at home like what is it that you can say to them it's like this is what i do and this is why i am speaking about stroke this evening so basically um you know i'm in the hospital the whole day seven to seven and i attend to two patients that come obviously sick um and you know i do the full assessment and there's a special protocol for two other things stroke one and the other one is hard because we are a center for both and so we focus on protocols that if we have a patient with stroke we know that we're getting it and um and then we follow a protocol so it comes from treating the patient um and then the education afterwards um so and that makes perfect sense and i know that i kind of put you on the spot because we were all talking right before we were on the air and usually i let people know hey i'm going to ask what you do all day every day and i didn't ask you that so now both of you get to have a little jump on this uh so captain peebles and again not being a medical doctor but being in this field um and what you do all day every day i'd imagine is very different every single day but just to give the audience a brief description of what you do do all day every day fire department people think oh you put out fires but there's a lot more to it absolutely katherine thank you for that question so the el paso fire department we respond to numerous stroke calls probably at least three to four on a day-to-day basis so we have protocols that allow us to to rapidly try to assess and triage these individuals again time is the essence when it comes to stroke that's probably going to hear as a common theme throughout the panel here so time is of essence and we have protocols that are in place that allow from that first 9-1-1 call out from the public from the community for our communications staff to automatically start triaging and identifying whether or not they're going to need that rapid response simultaneously by doing that as these crews are dispatched to those crews the technology that we have from the communication systems are already starting to transmit that information to our first responding units our first responding units typically come equipped with als interventions paramedics we also have first responder pumpers that are equipped with paramedics who can provide als intervention and get that critical assessment don first we used los angeles pre-hospital stroke scale system the instant our teams get on scene and that is a positive lab score we're automatically calling for the mobile stroke unit which the fire department has a collaboration with uh university medical center so once that is activated uh you know we were able to get that care quicker because that dispatch is very precise so we've been able to to triage that out parse out those uh those questions that will require that rapid intervention so that assessment can get done and the patient transported and i'd imagine during this evening there's gonna be a lot of questions on what what first do we see what are we looking for and what is it that people are telling you that have had a stroke because there is a such a myriad of of things that people are describing to you so i'm going to ask you some of those very specifically there i have a feeling that from the audience all of that is going to come in as well dr eze as the neurologist um this is like bare bones research brain lady right at this point um what you do all day every day we're talking about strokes this evening yes but neurology encompasses so many different things what is it that you focus on during the day so during the day i see patients both in the hospitals and in my clinic patients with very neurologic diseases so we have patients with dementia stroke is a very common neurologic disease so i spend a good amount of time put in the hospital and in the clinic taking care of patients who have stroke in the hospital it's the job of the neurologist in conjunction with the hospitalists and other specialists like the cardiologists and of course the emergency medicine physician first of all to determine if a patient who comes in with an acute condition has a stroke do they have a stroke if they have a stroke it's also our job to say to kind of make a hypothesis where is the stroke would this patient be amenable to the acute treatment protocols that we have for stroke now if the patient is amenable to that we we would give the directions to give them what we call ivtpe at that point we're also assessing to see if it's a big vessel that is involved or a small vessel that is involved because the protocols are different for both we also institute evaluation protocols we order tests that would help us determine how bad the patient is where the patient should go to should the patient go to the cat lab immediately should the patient be taken to the icu what kind of stroke it is is it a hemorrhagic stroke is it an ischemic stroke we make all those determinations there and then and then while the patient is in the hospital we determine how about the patient is what interventions we can we can put in place to help them we also try to figure out what are the risk factors what made this patient have the stroke in the first place because you'd find out that a quarter of people who have strokes have had strokes in the past so we want to reduce that number now occasionally i follow a patient through all the way through their hospital stay into the rehabilitation state so in some hospitals for instance at the sierra hospital you also have a a rehab a neural rehab where the patients go to get stronger and better so that they can get home so i follow them there too and make suggestions sometimes you would see a patient who has had a stroke who is depressed or who has other problems that we take care of there and then then i also see stroke patients after they've been discharged from the hospital kind of addressing the problems are there leftover problems or left over interventions that we haven't addressed while they were in the hospital yeah i need to stop you from talking you know why because the whole show's over now how many pieces of paper [Laughter] seriously i i am so excited to have your area of expertise here and to have your knowledge um and because i like i like trying to going from ischemic so we're going to talk about hemorrhagic and ischemic but what i would like to do is quickly ask you dr essay before we go back to the hospital list because this is where everything kind of comes in you're having a stroke you need to get in immediately it's fast when you're talking about an acute neurological condition if it's not a stroke what would that be or are you talking basically about strokes i know that's a loaded question no okay oftentimes a patient comes into the hospital with their face drooped right it could be bell's palsy it's not a stroke the patient could come into the into the emergency room and they have a bad headache on one side this week we know this patient from multiple hospitalizations the patient is a migraine that may be a hemiplegic migraine a patient could come into the um hospital in the emergency room and has the arm jerking okay is that a seizure is the patient's side weak or the family says oh before the side was weak they had some twitching of their arm that lasted 10 minutes is the weakness due to a stroke or is it due to what we call thoughts policy that happens post seizure the patient could have passed out okay is this um a fencing spell or syncope or could it be due to so those are the things we think about as we're trying to assess the patient in the emergency room and i would love to have just a separate show and i say this a lot just on seizures and syncope because i think those are so common and misinterpreted so i'm glad that we're bringing those up during this program tonight uh what i'd like to do is dr alvarez as the internist as the hospitalist and captain people's kind of listen to this because i might just throw you into some of these questions at the same time when ems is coming to you when captain peebles and his team is bringing someone to the hospitalist and there is you know what these are some of the symptoms and you are trying to assess is this an ischemic stroke let's first define those two actually that's probably the big thing let's define what an ischemic stroke is and what a hemorrhagic stroke is because those are the two biggies and i know there's other kind of little ones that we talk about but let's define those two first so that as we're going through people in the audience know what we're talking about so for the ischemic stroke um we have two types we all hear embolic which is coming a thrombus coming from elsewhere and also like the blood clot is coming from elsewhere okay in a thrombotic stroke that it's coming um it's forming a plaque let's say cholesterol and so that's ischemic and then hemorrhagic you can have an aneurysm that ruptured and so that causes a hemorrhagic stroke uh so that's basically a brain bleed just for those who are not familiar with the wording so it's when the bleeding happens the brain versus the blocking happening in the brain correct okay yes and we also have um i have to include the the tia the transient transient ischemic attack just because it's now included in in the the definition of stroke um and that up it's same as the ischemic stroke but the blood flow resumes so you know it's not really complete so pardon my ignorance and correct me if i'm wrong so a tia is that what if we were to say the old days uh would be a mini stroke and the reason i want to bring that up because i think so many people are familiar with the term oh that's a mini stroke what in the world does that mean so we just described tia right now um but when the blood flow resumes and we're looking at not as much stoppage or damage let's talk about that and then uh captain peoples i'm going to talk to you about time right after we're finished with this so tiaa what is happening during a mini stroke or what really is a tia so the same as the ischemic stroke there's a thrombus coming into the blood um vessel and it stops and then somehow it resumes um maybe the the thrombus is not as big and then you know all the symptoms start resolving okay and so so i love that as a transition uh captain peoples and we're looking at you got the call uh your crew gets the call you don't know what the call maybe you do know what the call is but you have someone now you're in their home you're looking at them and i know this sounds so simple for me to say you're looking at them but what are you looking at and what are usually it's somebody else that calls in a stroke usually correct that's that's correct so what is it that someone is describing to you and what questions are they asking you and i know this is also so big what do you start doing immediately so great question again catherine when we first arrive on scene one of the main things we want to do is to do a quick assessment and we're looking for facial droop we're looking for arm drift we're looking for slurred speech a lot of times when we get on scene our initial reaction is to take a quick look at everything that we see around us so once we enter that that set because the family member will approach you and they'll say uh terms that are crude and rudimentary but they'll say such thing as hey it looks like mom is having a bad day her face is twisted or uh dad looks like his face is melting uh they'll also say things like you know what they're just looking funny or they sound funny or they're whistling funny so once we start taking in our our surroundings and our ambiance then we start to focus on the the patient himself because remember we're getting quite a bit of information from our dispatchers and so we're already knowing that time is of essence time is essential and we know already we're starting to see what is the most appropriate facility for this is it going to be a comprehensive stroke center which can handle the most complex cases or is it going to be a progressive stroke center so we're also making the determination again as to get that lapse done that assessment that pre-hospital in the home at that time figuring out where do i take them what is the best place to take them to right now absolutely and these things go very fast they go very fast but we have like i said pre-established protocols and procedures in place that allows that quick assessment to take place once we come in and we find out that they have a positive lapse we're already on the phone calling in the appropriate hospital for a possible cold brain cold brain is our policies and process policies and procedures that alert hospitals er physicians the team here that we could be coming in for a possible cold break because we know even though we're still with the patient we're loading and go getting the vital signs getting the glucose ruling out all of those other possibilities that you've heard some of my colleagues speak about but in the back of our mind we know that there's a time limit for the strep the kinase or to connect the place we know that there's a ct that needs to be done so all of these things are happening in a very rapid sequence so our team is very efficient at doing these assessments and then we get ready to take it to the specialist to to call in what we see so it happens very fast like i said some of the some of the more archaic terms uh are not suitable for the show but sometimes you'll get on saying they'll just say mom really looks bad yeah just messed up messed up right but we've also seen it where you know they're just so slight and subtle to where the medical terminology would be ptosis with to the eyelid droop but they'll just stop very minimum you know very minimal so there's a lot of conditions that we should be looking at but los angeles pre-hospital stroke screen is is what we do to to recognize and parse those kind of patients out so this is where i would like to say to the audience and i'm looking at you specifically and also that you're a fine young man but it matters the 9-1-1 phone call matters this is not a time because we were talking about be fast and we'll talk about that specifically in a moment but 9-1-1 means that you guys are on the spot absolutely that time that you're talking about is crucial and when we say time we're talking between 20 minutes and an hour could mean all the difference time is of the essence absolutely i'd love for you to to hammer that home because 9-1-1 people are like oh should i call 9-1-1 she just looks a little droopy what do i do don't hesitate okay don't hesitate and you have the program in the right direction you should never hesitate if there's any doubt call 9-1-1 let us get there and do our job let us get there do the quick assessment again we're gathering information from the time that phone call comes in when dispatch calls that in they're already relaying that to the crews by the time it's relayed to the cruise we're already in route by the time you are on route you're still on the phone with the dispatcher our crews are there usually within about five to seven minutes that's so impressive it's very impressive and it's gotten even more impressive now that we have a partnership with university medical center with their mobile stroke unit because that stroke unit is also staffed by highly trained fire department members who can recognize specifically these types of strokes that range from you know tia's ischemic you know hemorrhagic and so and when we do our assessment we report not only the lapse but we also will report to the receiving facility the lamb score which they will use to rule out maybe a possible large vessel occlusion but i'll let my colleagues dolly that's a perfect segue to dr essay and and let's let's say that we kind of are looking at now with what information's been giving that it's an ischemic stroke which means there is a blockage and there are several ways to treat that there is you go in you do imaging right away there are some medications you can do try to get the blood flow going and then there are some procedures to do so i'd like to kind of take it from ischemic right now because then we're going to do hemorrhagic in just a little bit so let's just say an ischemic stroke is coming in to the hospital what is it that now the hospital starts doing i know that you're the hospitalist but we're just gonna we're just gonna bounce us back a little bit back and forth so this patient shows up in the hospital in the ear one of the first things that the er daughter asks is the time so we need to know the time time is of essence there are medications that are available for patients who come into the er in a timely manner okay so if patient iv tpa i just want to repeat that because i think that's super important so iv tpp so through iv okay clock busting medication within three hours you also have the extended window four and a half hours but you don't want to wait because the more time you wait at home the more brain cells are dying you don't want you don't tell yourself or four and a half hours let me check it out a little bit right you want to get there because if the blood vessel is open on time then you you're likely going to be left with as little deficit as possible so the patient comes into the ear unit we do the nih stroke scale that tells us in a nutshell what's affected how big of a stroke it is what blood vessel are we looking to that may be affected basically is it a small blood vessel sometimes a big we may not know we may have a fair idea by looking at the antihistal scale as we're getting that we're drawing some labs because we're thinking of because it's often very difficult for you to tell an ischemic from a hemorrhage right exactly and if it's a hemorrhagic stroke the patient would not benefit from being given ibtp so we want to we most ers are trying to reduce the time it takes to get to the city scanner to get the uh ct scan the ct scan is done is read almost instantaneously we get the word it's a hemorrhagic stroke no ibtp or it's not a hemorrhagic throat go ahead oh it's an ischemic stroke but we're already seeing the stroke on the ct scan so the brain is probably it may translate it might not be a good candidate for ibtpa but let's say the brain looks good then the neurologist says okay gives the world to give ibtp ibtp is given while all this is going on we're also taking another scan called the cta this looks at the blood vessels remember the it might be a small blood vessel or it might be a big blood pressure now if it's a big blood vessel which we call the large vessel occlusion then you more rooms for more therapy is open in most comprehensive in all comprehensive stroke centers you have a neural interventional person on call the neuro interventional specialist is a neurologist who is also trained to go in and pull out a clot in a big blood vessel there also by training either stroke specialists or intensivists so i'm going to stop you there because i'm going to ask when a uh we've got a neural intervention assist there how are they going in to take that blood clot out and i think that's super important too because if you're looking at a large artery um versus a small blood vessel this is where you're trying to depend small blood vessels you're trying to depend on the anti-blood clotting medication so we're looking at now that's not working we're finding we're now in the hospital for a good half hour let's say that's 30 whole minutes and the medication's not working so now we have interventional neurologists so what do they go in to do physiologically if you can explain what it is that they're doing how they're getting that clot if it's a large vessel stroke okay from the nih stroke scale or the c and the city angiogram they see the blood vessel the stroke the um interventional team is already on the standby because they got that um from the calls from the mr captain people exactly they got that call so they're already waiting they take the patient to the interventional unit and they go through the big blood vessels that can be assessed peripherally they could either go through the radial artery the artery in the on the wrist or they could go through the big groin femoral artery go up there with their dye look for the clot and oftentimes they have different techniques for trying to get out those clots sometimes they try to aspirate they aspirate and they aspirate and they get out the clot or sometimes they go so explain what aspiration is so let's just these the so let's just think the people at home don't understand what aspiration is or ischemic so when you say aspirate we're trying to little by little break the clot up if you can describe it you're trying to use some little vacuum accents to pull the cloth out there we go okay pressure pulling the cloth out with that's aspirating okay cooling with some pressure then you have they could also use retrievers kind of like hooks to go in they go up they go in and pull the cloths down and out down and out and then they um push their die and look at the blood vessel and oftentimes you would see the blood vessels open up again and you have a lot of clapping in the right right everybody's all happy we got the aspirations out part of the clots going out now beautiful so that's what they do okay so dr alvarez so almost actually just the opposite situation now we're going to look at a hemorrhagic stroke so if we think hemorrhagic just think of hemorrhaging when someone hemorrhages they're bleeding bleeding bleeding so now we've got to blame a brain bleed going on so now it's this type of stroke and as a hospitalist again captain peoples and all of his guys have been communicating with you you kind of know it's a hemorrhagic stroke you're going to do all the imaging how does one treat that so ischemic i can see that because you're looking at trying to get the clot you're loosening the clot but now we've got a bleed going on how does one stop a bleed do you number one try to do medications first then is there a procedure and so i know it's almost the exact opposite of the previous question but have at it have a good time so it will depend on the the size of the bleeding and thank god we don't need an mri sometimes like we do with ischemic stroke with the ct will be enough and that will depend how big is the hemorrhage if it's going to the other um half of the brain or it's you know small so we depending on that we have you know diverse actions that we we go from so if it's too big and it's compressing really the brain the other half or the same half then you call the neurosurgeon because we need to open that up to release the pressure because then yeah so that concern is more about now we've got so much fluid on the brain or by the brain that we're looking at damaging the brain because there's so much fluid in there meaning blood in there correct okay um and the reason i'm asking this too is there a certain point where you have to go into the skull and relieve the pressure from opening up the school so talk about that because i know it's gross and disgusting but it's real and it matters yes um so talk about how that pressure can be relieved in all of the easy ways but also going into the dramatic ways of having that happen so it will depend on other comorbidities that the patient may have where the neurosurgeon may say it's too risky and i don't think you know you know we should do it just because of the multiple medical problems even a bleeding problem that the patient may have so in that case we may use some medications to try and minimize the bleeding especially his profuse but then our job as a hospital is stopped there and then the neurosurgeon takes over and you know we open that up we call that craniotomy um and the the the other thing here that we haven't mentioned is blood pressure like patients with ischemic strokes will help will you know come in with high blood pressure so we have some allowance in there with the hemorrhagic one we we have to be more aggressive on controlling the the blood pressure because it's the one probably causing more bleeding um and so we have to see those things too either we're gonna treat uh or not in that case with the hemorrhagic we were more aggressive um so we have some parameters there um to see if we're gonna stop a drip uh with a medication that will lower the blood pressure or not okay and so in terms of like really having a medication um for that it's not the same as with ischemic stroke so right that's more like getting in there and getting the pressure released and and then like dr s has said we have this new um well it's not new but um the interventional neurologist will come and also coil if this is an aneurysm and same procedure as the ischemic stroke we'll take the patient in the cath lab and we'll probably coil the the aneurysm so or um also you know so i'm gonna so coil the aneurysm so in my head i'm thinking okay so you're taking whatever that vessel is that's had the the bust the bleed so to speak and you're coiling it are you cauterizing it like what are you physiologically doing when you coil that and maybe i'm reading it wrong with how you're saying it no well it does the the way the procedure is called because of the name um but yeah i'm not sure what they exactly do i don't know if that tracy will have a better idea but um well yeah it makes sense somehow you're just trying to cut off the the the extra bleeding from there um captain people is what i like to do and i haven't i haven't queued you in on this but we all saw on my paperwork from past shows be fast and so i'm thinking to myself right now that let's say that i've been noticing that my mother's been having a problem for like the last two or now three hours so we're going in the time now so when we were talking about be fast um we're going in time like okay i'm finally going to call 9-1-1 because things just aren't right is there a certain time and i think uh dr eze you were talking about there's three hours four hours but let's not wait that long when is it that this really is danger point that we've waited too long and now we're really going to have an issue later with rehab or you know the brain's been cut off from blood too long if there is a way to give me a scope of time like three hours to six hours one hour to four hours and the reason i'm saying this too is we want people to be on it right when something's off is there an approximate time frame you can give to that so so that's a good question and and let me let me try to address it best i cannot i'd have to go back uh to my colleague here to the right so our main objective is to identify that stroke victim uh and get them transported as quickly as possible so like i said we're usually there on scene within about five to eight minutes from the phone call and that's that's the um and the reason i'm the reason i'm asking this is that i just know myself too i'm like ah they're gonna be fine so let's just say three hours have passed right so we that's a good question when they say a time has passed there's things like wake up stroke you know but no matter what type of stroke when we first assess we know that there's a time window for our other colleagues four and a half or three okay our goal and objective from the pre-hospital standpoint is to identify that that patient or that individual in a very rapid uh concise manner so that we can meet the benchmarks and the metrics for the hospitals for those comprehensive stroke centers again when we look at the question that you posed we have paired with a mobile stroke unit in which we will respond on scene once we have a positive lapse we have a partnership again with umc the mobile stroke unit where we will bring those resources and these types of colleagues that surround me at the table straight to the patient so once we get on scene and we recognize that there's a positive lapse we automatically call for the mobile stroke unit so as the mobile stroke unit is arriving and they usually get there their times are very very fascinating actually but usually they're within eight to ten minutes also okay so we have already began to to work the patient up such as uh i've started the iv we've done the assessment so we're starting to do that that initial pre-hospital stroke scale we start documenting it this helps with the continuity of care so by the time the mobile stroke unit is on scene they're going to arrive with the ct scan right they're going to have the neurologist or the tele neuro interventionist they don't know how far into it absolutely okay and and so they'll get there and then that transfer of care will happen uh the tele neurologists will either repeat the uh the los angeles pre-hospital stroke scale or they'll automatically go straight for ct scan but they are immediately transferred over to our colleagues who are present with me now but we bring the care to them right so i do want to open a tad bit on those wake up strokes because a lot of the things that we talked about are very sentinel such as the drooping eyelid uh slurs you say wake up strokes literally they wake up in their feelings exactly so your your original um scenario post it was like they you wait about three hours you weren't sure you were kind of wondering and that that reminds me of of training and teaching that they talk and wake up stroke because much like our colleague elite alluded to you can have a migraine there's different causes that was palsy but the flip side of it is you have to be in tune with what's normal for mom or dad so again time is of the essence if you have any doubt you should be calling so from the first onset that they're saying well you know what mom's mom's kind of slouched to the left today and normally she's not like that or you know what dad is really he's really got that limp shoulder going on and that's not normal the other thing is is what's very important that i know my colleagues here will definitely ask when i get to the er is when was the last scene normal when's the last that's the big question so when you pose a question on the time frame it's very hard to truly box that questioning because things are so dynamic but what we do know is that we are gathering that information making that assessment notifying early on cold brain in route rather we transport it to our colleagues or whether we activate the mobile stroke unit so we we want to identify that stroke in a rapid manner and the public can help us by again being very alert and attentive to what's normal for mom and dad what's new don't be afraid to call 9-1-1 i think that's a thing too it's like well it's going to cost money you know it matters tremendously time is of the essence time is absolutely of the essence um dr eze i'd like to go back to what we talked about a little bit earlier when you were saying uh that about a fourth of the people that are having strokes have had some kind of a an issue and or stroke in the past that is fascinating to me because that's a large number so um if there is someone that has and knows that they've had a tia and i'm looking at what are some of the symptoms and or risk factors for people having strokes so one of them is you've had a previous stroke but let's expand on that a little bit on uh having a mini stroke and then might that lead to something bigger in the future etc what are some of the questions that you're asked on that oh transcendence transient ischemic attacks or ti is which colloquially are known as mini strokes are very important because that serves as one opportunity that we have to prevent a patient from having a stroke like my colleague dr alvarez said ischemic strokes are caused by blockage so you have blockage in the case of a taa for whatever reason the blood vessel opens up woolla the patient is good they had right um weakness and now they don't now we still want them to come to the hospital because this is our opportunity to find out why they had a stroke and to intervene and prevent find out why they had a tie which is the same reason they're probably going to have a stroke if left on catered for and then to intervene to prevent them from having a stroke now what are the common reasons for having a tia or a stroke there are factors that you have some you can modify modifiable factors and there are factors that are not modifiable so not modifiable factors it's more common to have a stroke the older you are because the blood vessels are more craggly the blood blood vessels don't look as good as they used to be when you were 20 so it's more likely that this blood vessels could get blocked okay you can't do anything about your age what are the things we can do stuff about the risk factors for stroke that are modifiable include high blood pressure dr alvarez talked about high blood pressure as a very common very important risk factor for both ischemic and hemorrhagic strokes so we want to know if some patients come into the hospital with a tia or stroke and that's the first time they're finding out that they have high blood pressure right what other risk factors we talk about diabetes mellitus is a patient diabetic a lot of people don't know they don't know what they haven't been to a doctor yet so they don't know if they're diabetic or not we talk about hypercholesterolemia is the cholesterol high we also while the patient is in the hospital as part of the testing that is done we've talked about looking at the blood vessels in the head and neck could either be done with a quick ultrasound or carotid ultrasound it's also done with a ct angiogram looking at those blood vessels is there a blood vessel that is almost occluded because that would be a chance for us to send the patient to a cardiothoracic surgeon who can open up that blood vessel before it occludes entirely okay so it's also the opportunity also arises while in the hospital to do an echocardiogram which is an ultrasound of the heart is the heart looking good is there a blood clot sitting in the heart because if there is a blood clot sitting in the heart that is throwing off little blood clots that may come through then we should walk on that blood clot and make sure the patient is on a blood thinner and anticoagulant so we also while the patient is in the hospital put the patient on a heart a rhythm monitor one of the most common causes especially in elderly individuals i'm glad you're going to bring this stroke is what we call atrial fibrillation exactly it's it's not something that the patient would know they had right they have a tia they come in we put them on telemetry for twenty describe with uh what afib is just for the an audience heartbeat okay so when the heart is beating very irregularly then the blood doesn't flow so well and because the blood doesn't flow so well you can have blood clots sticking on the sides of the heart and this blood clot when the heart contracts can get off go to the brain and cause a stroke so atrial fibrillation is something we're typically very worried about especially in older individuals who have had a stroke or something that looks like a light vessel occlusion type of stroke so in the hospital we put on we do an ekg we put on a telemetry monitor to see if we see atrial fibrillation okay we don't see the atrial fibrillation while they're in the hospital we're getting the cardiologists involved hey cardiologist can you see this person can you take a look to see if this patient could have atrial fibrillation oftentimes we link the patient up to a cardiologist while in the hospital the patient goes out of the hospital on aspirin and plavix just to keep the blood flowing while they go to the cardiologists and the cardiologists oftentimes would give them a loop recorder something they can carry they can have on them for 30 days looking for that sometimes elusive atrial fibrillation rhythm so all this is geared towards making sure that we prevent what could possibly cause a bigger stroke so tias though they're called many strokes and often overlooked by patients are actually even more important super important to brain right strokes that makes sense that makes perfect sense and i and i know that there is and not that one is more dangerous than the other but if you're looking at a blockage stroke meaning a blood clot stroke which is ischemic versus a hemorrhagic stoke stroke which is again a bleeding stroke is there one that will cause more damage in the future than the other and the reason i'm bringing this up is that we're starting to get into the show now i want to talk a little bit about what brain damage there is and how people can start rehabbing if there has been a prolapsed amount of time and and we're in trouble now and you're the hospitalist um and i don't know if neither one is good and i get it but is there one that can cause more damage than the other it's like doctor say mentioned it depends on the the vessel you know if it was a large or small uh how much of a time we let you know um unattended the stroke and so it comes to various things um also what other comorbidities maybe the patient wasn't walking anymore maybe the patient had dementia and won't remember and won't talk again so um when when we activate also the stroke um in the protocol that we have we have various ancillary services um and speech will come the same day depending on the the time that the patient arrived but speech occupational physical therapy like doctor as i said a cardiologist obviously the neurologist too so it will depend on how fast we move it will depend the size it will depend on what other medical problems the patient has um so the age right the age that makes a big difference too um i'm going to throw this question out to whoever would like to take it because i know that they're you know a comprehensive stroke center and you were talking about that uh captain peoples earlier i'm going to keep calling you doctor because it just comes out of my mouth sorry um um but there's also the idea of what's on the horizon as far as treatments go um we we've talked about this and maybe there's not something specifically that that's coming up but i feel i think to myself as emergency response vehicles and i think man there's a there's a new piece of equipment in there every six months or every year and maybe we can kind of start with that because if you i've luck been lucky to go inside one of these units and i'm thinking this is a hospital on wheels and you've got almost everything in there so if you can describe what is in an emergency response vehicle and what may be you as captain peebles who's been doing this for quite some time are excited about you know what next year we might be getting an a b and c that maybe chicago has or new york city has etc if you can take that question and expand it any way you'd like sure i'd be delighted one of the things i think is the the most cutting edge and the most uh one of the greatest accomplishments that the city of el paso along with a university medical center and the apostle fire department is that we have been able to implement a mobile stroke unit and there's a 21 mobile stroke units throughout the country texas 21 throughout the country 21 throughout the country we have one here you have one here as a matter of fact houston was the first okay uh so there's two in texas and uh houston is one and el paso is the second so we that that's been one of the greatest uh accomplishments i i think from from the pre-hospital emergency setting again with with my colleagues here at the panel we were actually able to bring the ct the tele neurologist uh this team of interdisciplinary professionals acute care nurses uh ct techs we bring that straight to the patient so when we talk about time it is very crucial that we you're going to always need comprehensive stroke centers there's no doubt about it um but as time moves on and we continue to advance the care for stroke and recognition of stroke i really do think that pre-hospital is where it's going to to be where we really make that difference because we're able to bring those resources there so typically even as fast as we are by the time we alert the cold brain there's still some time you know my colleagues alluded to that you still got to go through the ed you got to do that assessment you got to get the labs everything is going but in the pre-hospital setting we're able to make that assessment bring those resources to the patient so that window that time of opportunity you know that is so crucial so prudent we're able to intervene right then and there so we they go from their living room to the ct scan in the field and we're able to start to connect the plays we're able to initiate many of the therapies and treatments are there we've got a we're usually fortunate either with a resident uh on board or a specialist here who can actually tell us hey you know what we're going to have you titrate the blood pressure or you have the tele neurologist who is going to say you know what uh this may be an opportunity for a coiling which you refer to and so if you if you look at that we don't have to go code three now because there's there's there's things that have already been done right there's things that have already been done so so that care is already established uh it's already ongoing and that provides the in-hospital setting to be a little bit more aggressive with the rehabilitation part that my colleagues have alluded to throughout the course and that's again where time is so of the essence and it's very exciting to me every time i learn about what's in these vehicles it's just it's fascinating to me honestly um we're in about yes i'm sorry it's a 16 slice ct scan a 16 slice ct scan in a vehicle pretty much on wheels pretty novel right for an ems outside agency so i it's that's where i see the the future of stroke care going and um it's it's amazing pretty soon we'll be able to have that on our phones absolutely um what i'd like to do is we're about 10 minutes out before the show ending and i know it goes super quickly um dr essay i'd like to start with you if there is something that we have not yet discussed this evening but on your way over here or when they said hey you got to go do this medical show um is there anything that we have not talked about yet that you would like to bring up before we start closing the program there isn't anything we haven't talked about yet but i just want to emphasize that time is brain i i see a lot of patients in clinic who could have made it to the hospital like they knew when the symptoms started and they waited and waited and waited and now they have a deficit okay something stroke is the leading cause of disability you don't want to have and you know you have that disability it's not something that you can heal you can rehab but it's it's probably never going to go back to what it used to be before so at the point you have the symptom go to the pick up your phone call emergency medical services to get you to the hospital there are some we talked about three hours we talked about four and a half hours but there are also eight hour and twelve hour windows for some of the large vessel occlusions or some of the wake up strokes so okay you could say okay mom has been out for four and a half hours i don't know get them to the hospital the neuro-interventional this if it's a large vessel stroke and still go in and pull out the clot for what it's what you know it's interesting to say wake up strokes because that could mean anywhere they went to bed at midnight now it's 8 in the morning it could be anywhere in that time frame so i love that you brought that up and i also like that you said not like that you said it but stroke is the leading cause of disability not that it's preventable but if you're on it and your timing is better and if you're not like well should i call 9-1-1 or not it could be lesser of a cause of disability so i'm super happy that you talked about that um captain peebles is there anything that we haven't spoken about yet that you'd like to get across this is like the the hour that you're like oh let's go let's go let's go what do you want to say and it's hard but at the same time sometimes you're like oh i didn't bring up the snack and the other so is there anything that you'd like to bring up that we haven't yet i really want to just echo the same sentiments that has been a common theme throughout the show is time is of essence okay uh recognizing when was the last scene normal is essential it's critical um and normal i think that's such a big word and if you can describe that again if someone's just looking and i know you said crude words you said that earlier people will describe it crudely but if you just don't look right right and that's a good point and this is why like i said the last scene normal is is essential it's crucial but more importantly knowing what is abnormal in other words knowing what's odd what's wrong because on many of the examples that we have provided sometimes it may be as it may not be as overt you know it may not be as startling as a facial droop or a arm drift or slurred speech it could be anything from a flutter you know to just uh block loss of vision on one side you know so it's what i would recommend to the audience is to recognize that time is essential and identifying when something is abnormal right if it doesn't look right call 9-1-1 so here's a difficult question because usually especially in the idea of strokes there usually is a person that sees this happening in the other person right so let's say now you're a person that lives alone has lived alone and you're just i mean what are you feeling like you can see a stroke on someone else easier than you can feel what's happening in yourself because you might you might not see your face drooping you might just think well i'm slurring because i'm tired um is there any advice there because i feel like yeah when we're looking at someone fine all these things but now it's just me i'm at home i'm 61 years old it's 10 in that at night and i'm just feeling odd do i call an ambulance like what do i do so great question and the first thing is to yes call 9-1-1 but more importantly i would have to say focus in on what you could do for those modifiable risk factors the non-modifiables and the modifier risk factors that the doctor here has alluded to early in the program there's very little you can do about age but you can still watch your diet she mentioned hyperlipidemia you can change and have dietary and behavioral modifications you know control your hypertension my colleague alluded to that earlier so if you follow you know preventive practices such as taking the medications that that have been preserved that should kind of educate you and cue you in when you're by yourself so what do i mean by that so if i've been listening to the panel and my colleagues and i'm on hypertensive medication and i was told that i had a history of afib or that i'm susceptible to afib the instant that i even fill a flicker i'm calling 9-1-1 because you kind of know because i know the symptoms so when we focus on prevention preparedness and education we're able to kind of self-assess ourselves so yeah you're right we won't be able to see the facial group i may not even feel it but if i'm focused on prevention preparedness and education and i've been listening to my colleagues then i may be able to know hey these risk factors that are modifiable or non-modifiable those are things i should be watching for anything else that's why people come into this program so seriously thank you for being here for that it makes a difference know yourself in almost every program we do just kind of know what's normal right and what's not absolutely dr alvarez you've been waiting for this moment [Laughter] anything that we haven't discussed yet that you'd like to get across well i have a few minutes there you go oh no i'm just kidding um i would say probably i was just discussing with with juan here that what is one thing that i can advise people to do or not to do at home when they are feeling that they're having a stroke we will say you know take an aspirin and i would say don't until it's better to call ems and get them assessed and maybe they can judge better if you are having an ischemic or a hemorrhagic because you know it may be contraindicated so i would say just call just call just call make make sure that that phone call is made um i know that we're running out of time but i do want to get this out here for anyone who is watching who has had a stroke in the past or just wants to know a little bit more about it the city of el paso is conducting a stroke walk on sunday um and the nice thing is that sunday at scenic drive um it's going to be on the west side entrance scenic drive is closed anyway on sundays because we like to get people out there walking um but this is a special sunday to be able to do that and again it's um it's going to be kind of neat there's going to be information out there there's going to be a lot of your guys out there ems people out there giving out information um and also there's going to be like a stroke survivors walk there so that might be kind of a neat thing to be a part of i wanted to uh i almost want to throw out one more questions we have like three whole minutes which is in eternity and tv all two whole minutes um then i will say this if you have questions about strokes if you have questions about aphid which is atrial fibrillation and we talked a little bit about that but we really didn't go into it but i feel like that's something that we hear a lot about now with different commercials on different platforms television it's when your heartbeat is just off it can race one minute and feel like it's thumping through another minute we didn't talk a lot about that tonight but there's information out there when it comes to that too i know that this program is sponsored by tenant by hospitals of providence you can also go to webmd and look up those questions if you want to see this program again it might be kind of helpful because sometimes you miss something the first the second or third time around so to watch this program again you can go to kcostv.org or pbselpaso.org and just look for watch and look for the el paso physician you can also go to the el paso county medical society and the nice thing on both of these platforms you'll have all of this the different programs from my goodness the last several years and you can search the specific program that you're looking for you can find that there and also youtube.com you can find el paso physician right now if you're looking at it you can find that el paso position live or you can go back and find this program again so that's going to be super helpful and again be fast stands for who am i putting on the spot balance your eyes eyes your face face arms arms speaking speaking empty is tight and t is time so be fast that matters when it comes to when it comes to stroke i mean you want to be super super quick when you can get there again i want to thank you so much for watching this is the el paso physician we've been doing this for 25 years and again uh dr eze dr alvarez and captain peebles thank you so much for being here and may is stroke awareness month and it matters again we weren't talking about celebrating but it's just about getting the information out and if you have nothing going on sunday head up to scenic drive take a walk enjoy the sun we are in el paso after all this is the el paso physician i'm katharine berg good night [Music] [Music] you