At the time of printing, we will just have had World Stroke Day on Thursday 29 October 2015. World Stroke Day was established by the World Stroke Organization in 2006 to underscore the serious nature and high rates of stroke, raise awareness of the prevention and treatment of the condition, and ensure better care and support for survivors (American Heart Association, 2015). This event is part of the continuing efforts to raise awareness and knowledge of stroke among the general public and healthcare professionals.
The focus of World Stroke Day this year is on how stroke affects women, as one in five women will experience a stroke during their lifetime as opposed to one in six men. Not only do women have a higher lifetime risk but they also account for the majority of stroke deaths (Seshadri et al, 2006; Seshadri and Wolf, 2007; Bushnell, 2008). Stroke is the third leading cause of death for women in the UK and kills three times as many women as breast cancer (The Stroke Association, 2015). Women may be at higher risk but stroke is a condition that can affect men and women at any time in their life. An information leaflet describing the stroke risk factors for women and listing support sources is available at: http://bit.ly/1XJrruO.
Stroke makes up around 2% of all calls that paramedics attend (Seymour et al, 2012), and yet stroke as a condition does not receive a lot of attention in pre-hospital care, especially compared to the advances in areas such as trauma care and the coverage given to hot topics such as sepsis. Perhaps this is due to the perception that paramedics can do very little for stroke patients apart from identify the more common presentations and transport them to appropriate care. I think this view is wrong. We as paramedics need to be aware of what is happening in the wider field of stroke care as there are opportunities to change, and hopefully improve, the way we treat stroke patients.
Pre-hospital stroke care
Paramedics are an important link in a stroke patient's journey as we provide the first direct healthcare contact for 80% of stroke patients admitted to hospital (Royal College of Physicians (RCP), 2015) and we have the ability to influence the long-term outcomes of these patients by our actions, such as rapid recognition of potential stroke patients, rapid transport with pre-alert and providing direct access to a Hyper-Acute Stroke Unit (HASU).
UK paramedics work to national guidelines which recommend pre-hospital stroke identification using a standardised assessment process. The assessment most often used in the NHS is the Face Arm Speech Test (FAST) (Harbison et al, 2003), which identifies approximately 75% of stroke patients. However, due to the possibility of missed (false negative) cases, paramedics are also encouraged to make a provisional diagnosis based upon their own clinical judgement (RCP, 2012). In order to be sensitive to different possible combinations of symptoms across a broad range of patients FAST, along with all stroke identification instruments, overestimates incidence, which results in 25–50% of emergency admissions to HASU being patients with a stroke mimic condition (false positive) such as seizures, infections and migraine (Whiteley et al, 2011; Alonge et al, 2013; Siddiqui et al, 2013).
Pre-hospital stroke research
The Stroke Association is the leading UK charity dedicated to improving the care of people who have experienced a stroke. The Stroke Association supports healthcare professionals interested in stroke research through a range of fellowship schemes. These schemes have historically been accessed mainly by nurses and therapists but this year the Stroke Association funded me, a paramedic, through their Postgraduate Fellowship Programme. The Stroke Association is supporting my studies with the Stroke Research Group at the Newcastle University Institute of Neuroscience, where I will be investigating whether paramedics can identify the previously mentioned stroke mimics, and if we can, what are appropriate and acceptable treatment pathways for these patients? More information on the opportunities available through the Stroke Association, along with the research they support, can be found at https://www.stroke.org.uk/research.
On a national scale, UK ambulance Trusts are in the early stages of two large multicentre stroke trials that are being conducted in the pre-hospital setting. The Paramedic Acute Stroke Treatment and Assessment (PASTA) trial and the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial 2 (RIGHT-2).
PASTA is part of the larger Promoting Effective and Rapid Stroke Care (PEARS) programme and will investigate whether an expanded paramedic assessment involving collection of specific pieces of patient data relevant to treatment (thrombolysis) decisions, allied with extending paramedics' interaction with the patient into the hospital, can improve stroke patient outcomes. More details can be found at: http://www.ncl.ac.uk/nctu/research/project/5192.
RIGHT-2 is a clinical trial funded by the British Heart Foundation assessing the safety and efficacy of transdermal glyceryl trinitrate (GTN) patches versus sham patch for patients suffering acute stroke when administered ultra-acutely by paramedics in the pre-hospital setting. More details can be found at: http://right-2.ac.uk/.
These trials have both been developed with the input of numerous stakeholders, including paramedics, and offer paramedics the chance to support, and be directly involved in, research which may influence the way we treat stroke patients in the future.
Treatment for stroke
There are also developments in hospital-based stroke treatments that will potentially impact on paramedic practice. In simple terms, Intra-Arterial Thrombectomy (IAT) does for the brain what primary Percutaneous Coronary Intervention (PPCI) does for the heart, it mechanically removes the blockage causing the stroke (Mordasini et al, 2012). This is a relatively new treatment and is only performed at a small number of centres in the UK at present. If IAT is adopted as a mainstay of stroke treatment then it may require a similar model to PPCI as it is unlikely that all HASUs will offer IAT. Paramedics may need to bypass local hospitals, who may or may not have a HASU, with appropriate stroke patients in order to access regional neurosurgical centres who can provide IAT. The evidence at present suggests IAT is time dependent, in a similar fashion to the current standard treatment of thrombolysis, so accurate assessment of potential stroke patients by paramedics followed by rapid transport will remain key interventions.
Summary
‘Every 2 seconds, someone in the world suffers a stroke. Every 6 seconds, someone dies of a stroke. Every 6 seconds, someone's quality of life will forever be changed—they will permanently be physically disabled due to stroke’
In the time it has taken you to read this brief article someone, somewhere in the UK will have had a stroke. Options for paramedics to treat this population and deliver pre-hospital stroke care have changed very little in recent years. Difficulties in accurately diagnosing stroke and limited options for treatment mean paramedics have been largely limited to providing supportive care to stroke patients. Rapid advances in other areas of pre-hospital care have perhaps led to stroke being out of the limelight recently, but the coming years should see a growing interest in pre-hospital stroke care. This will lead to more pre-hospital stroke research and ultimately better outcomes for the women, and men, who experience a stroke.