It’s easy to get caught up in the technology inside the new UCHealth Mobile Stroke Treatment Unit (MSTU): the mobile CT scanner; the InTouch Health telemedicine robot; the “pram” – a bumblebee-yellow patient-carrier that would look at home in the new Star Wars movie; the telescoping outriggers capable of leveling the vehicle on a 10 percent grade.
But when the MSTU rolls into service on Jan. 13, the success of the region’s first (and just the nation’s third) mobile stroke unit will depend at least as heavily on how well the UCHealth team and partners apply those technologies. That team spans Fort Collins, Denver, and Colorado Springs and includes, among others, mechanics, MDs, dispatchers, and data specialists. They are leaving nothing to chance.
Starting December 21, the Mobile Stroke Team launched weeks of simulations – “sims” – to tie together integration and planning work underway since before the MSTU pulled into Colorado from Texas in early July. The simulations put the many parties involved in a mobile stroke deployment to the test under realistic conditions. The ultimate goal, run after run, was to get simulated, clot-busting tissue plasminogen activator, or tPA, into simulated patients as quickly and safely as possible. That way, come Jan. 13, real patients having real strokes can benefit from the precious minutes saved by bringing stroke diagnosis and treatment straight to patients rather than bringing patients to the treatment.
The mobile stroke units in Cleveland, Ohio and Houston, Texas have been running since 2014. While there are lessons to be learned from them, the Colorado version is integrated into UCHealth’s Epic electronic health record, among other key differences.
“The hard part is there’s no textbook,” said Brandi Schimpf, RN, UCHealth’s Mobile Stroke Unit program manager.
So Schimpf and many colleagues have written their own, starting with scheduling. During a go-live period from Jan. 13 to March 4, the MSTU will run Monday through Friday, 8 a.m. to 8 p.m., serving patients in Aurora. Then the vehicle will spend half its time based at UCHealth Colorado Springs. It will run Thursday through Tuesday in one city, then the other, transitioning between them each Wednesday.
In addition to serving different geographies, the unit’s alternating presence and absence will lend itself to understanding the unit’s true impact on stroke outcomes in either city. That will be key data for a mobile stroke clinical trial whose local arm is being led by University of Colorado School of Medicine neurologist William Jones, MD, MS, medical director of the University of Colorado Hospital Telestroke Program and the Mobile Stroke Unit.
What little data there is on mobile stroke looks promising. The world’s first mobile stroke unit, in Homburg, Germany, cut the time from the emergency call to tPA treatment from 73 minutes to 38 minutes. That 35-minute advantage over hospital-based treatment translated into tens of millions of preserved neurons per patient and, by extension, improved prospects for recovery.
On the ground
The promise of using a revolutionary new tool to improve stroke care is what attracted Martha Creazzo, a UCH emergency medical technician, to join the mobile stroke team.
“It’s a change of pace, and just an exciting opportunity to be part of such a cutting-edge thing,” she said.
On a cold late-December morning, Creazzo stood near the MSTU in the UCH loading dock, listening as Schimpf briefed her, paramedic Desmond McNeal, neuro ICU nurse Christopher Smith, RN, and CT technologist John Violette on the day ahead. Violette will be a constant present with the unit, to be spelled only occasionally by a half-time CT tech. Rotating in will be seven EMTs, five paramedics, and six nurses – including Schimpf, who intends to take mobile stroke shifts in addition to managing the operation. That doesn’t count Jones and a half-dozen neurologist colleagues on the UCHealth Telestroke team, who will beam in to diagnose patients in both Aurora and Colorado Springs.
It was, for McNeal, Smith, and Creazzo, their first day on the rolling unit. They were scheduled for three runs, destination unknown.
“Today, it’s a safe environment,” Schimpf tells them. “Take your time.”
Schimpf then walked through a long, memorized checklist. Ask when the symptoms started (if more than 4.5 hours ago, tPA can’t be administered on the MSTU). Ask about blood thinners (also a problem with tPA, except for warfarin, which is okay). Ask or visually inspect with respect to age and pregnancy and weight. Blood sugar testing should have already been done by Aurora Fire Department first responders; if not, check it in the rig. Note the time of dispatch, of arrival, of decision to treat, of CT start and image-file send. Check vital signs every five to 15 minutes; if the patient ends up on tPA, it’s vitals plus NIH stroke scale every 15 minutes.
There was much more. Schimpf read a list of phone numbers, which all but the simulation-veteran Violette entered into their phones: Telestroke DocLine, Aurora dispatch, University Biophone and charge nurse, Aurora South Biophone and charge nurse.
“Any other questions? Issues? Anxieties?” Schimpf asked. The assembled shook their heads.
On the move
Creazzo, the EMT, drove; McNeal, the paramedic, sat up front. Violette and Smith were in back. Along for the ride were Schimpf and David Severenuk, UCHealth’s telehealth system architect. He and Schimpf have been working together so much that they joke about calling themselves “Crazy Dave & D.J. B.-Dazzle, droppin’ hot beats.” The past two mornings, there had been wireless connectivity problems at Aurora Fire stations; Verizon engineers would check it out this afternoon; Severenuk suspected some sort of strong Wi-Fi interference.
“We’re very dependent on the data service,” Severenuk said, keeping an eye out the MSTU’s side window to keep motion sickness at bay. To no small degree, he and his colleagues were riding in an elaborate, lifesaving mobile app.
When the rear doors opened at nearby Aurora Fire Station 2 at 12600 Hoffman Blvd., the LiquidSpring suspension system sank the vehicle’s bed about a foot like a kneeling steed. Smith led the way inside a solid metal door to a tile-floored community room. In its center sat Capt. Jim Moon, who was having his seventh simulated stroke that week. He runs operations for Aurora Fire Department EMS. Smith, the nurse, quickly determined facts, ranging from left-sided weakness to a patient weight of 81.5 kilograms, making the decision to treat.
Moon’s colleagues helped McNeal lift Moon to the pram and into the MSTU. Several firefighters came outside to check out the unit and talk with Schimpf, who answered questions and took advice. Bring along a few traffic cones to route traffic around you, one recommended, because “obvious doesn’t work anymore.”
Lt. Tom McKay, Aurora Fire’s medical support officer, was among them.
“It’s new and innovative,” McKay said. “We’re certainly looking forward to being part of this research project to provide faster care for stroke patients.”
Back to base
The 4G connection had started spotty, but now showed a speedy 9 megabits per second.
Violette started the CT scan at 9:37 a.m.; by 9:40, Jones, connected in though a laptop computer, had received the scans. Rather than Moon’s head, the images were digital slices of honeydew melon upon which a face had been drawn in blue marker.
“Honeydews hold up better than pumpkins,” Violette explained.
En route back to UCH, Moon reclined in the pram, phantom tPA in his bloodstream. Through the monitor, Jones described an issue of the sort that takes a realistic simulation to catch. In Epic, he couldn’t enter the patient’s weight, and without that, he couldn’t enter the tPA dose they had administered. They’ll look into it, Schimpf told his flat-screen image.
At the UCH Emergency Department, the mobile stroke team disembarked together, rolling Moon into Resuscitation 2. He hopped up from the pram and was gone, headed back to the office until the next stroke. Schimpf explained the details of the ED’s role in mobile stroke to a group of UCH staff.
Back outside, Violette prepared for the next run.
“It’s an amazing setup,” he said. “Rather than door-to-needle, it’s symptom-to-needle. To be able to bring the ER to the patient is amazing, to say the least.”