Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston and a mother of eight, knew her
blood pressure
readings had been dangerously high for five years. But she convinced
herself that those measurements, about 200 over 120, did not reflect
her actual blood pressure. Anyway, she was too young to take
medication. She would worry about her blood pressure when she got
older.
Six Killers
Stroke
This series examines the leading causes of illness
and death in the United States: heart disease, cancer, stroke, chronic
obstructive pulmonary disease, diabetes and Alzheimer's.
Graphic
Dr. Diana Fite, an emergency medicine specialist in Houston, has completely recovered since suffering a stroke while driving.
Then, at 9:30 the morning of
June 7, Dr. Fite was driving, steering with her right hand, holding her
cellphone in her left, when, for a split second, the right side of her
body felt weak. "I said: 'This is silly, it's my imagination. I've been
working too hard.' "
Suddenly, her car began to swerve.
"I
realized I had no strength whatsoever in my right hand that was holding
the wheel," Dr. Fite said. "And my right foot was dead. I could not get
it off the gas pedal."
She dropped the cellphone, grabbed the
steering wheel with her left hand, and steered the car into a parking
lot. Then she used her left foot to pry her right foot off the
accelerator. She pulled down the visor to look in the mirror. The right
side of her face was paralyzed.
With great difficulty, Dr. Fite twisted her body and grasped her cellphone.
"I
called 911, but nothing would come out of my mouth," she said. Then she
found that if she spoke very slowly, she could get out words. So, she
recalled, "I said 'stroke' in this long, horrible voice."
Dr.
Fite is one of an estimated 700,000 Americans who had a stroke last
year, but one of the very few who ended up at a hospital with the
equipment and expertise to accurately diagnose and treat it.
Stroke is the third-leading cause of death in this country, behind
heart disease and
cancer,
killing 150,000 Americans a year, leaving many more permanently
disabled, and costing the nation $62.7 billion in direct and indirect
costs, according to the American Stroke Association.
But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.
Many
patients with stroke symptoms are examined by emergency room doctors
who are uncomfortable deciding whether the patient really is having a
stroke or suffering from another condition and are therefore reluctant
to give the only drug shown to make a real difference, tPA, or tissue
plasminogen activator. Many hospitals say they cannot afford to have
neurologists on call to diagnose strokes, and cannot afford to have
M.R.I. scanners, the most accurate way to diagnose strokes, for the
emergency room.
Although tPA was shown in 1996 to save lives and prevent brain damage, and although the drug could help half of all
stroke patients,
only 3 percent to 4 percent receive it. Most patients, denying or
failing to appreciate their symptoms, wait too long to seek help — tPA
must be given within three hours. And even when patients call 911
promptly, most hospitals, often uncertain about stroke diagnoses, do
not provide the drug.
"I label this a national tragedy or a
national embarrassment," said Dr. Mark J. Alberts, a neurology
professor at the Feinberg School of Medicine at
Northwestern University.
"I know of no disease that is as common or as serious as stroke and
where you basically have one therapy and it's only used in 3 to 4
percent of patients. That's like saying you only treat 3 to 4 percent
of patients with bacterial pneumonia with
antibiotics."
And
the strokes in the statistics are only the beginning. For every stroke
that doctors know about, there are 5 to 10 tiny, silent strokes, said
Dr. Vladimir Hachinski, the editor of the journal Stroke and a
neurologist at the London Health Sciences Centre in Ontario.
"They
are only silent because we don't ask questions," Dr. Hachinski said.
"They do not involve memory, but they involve judgment, planning ahead,
shifting your attention from one thing to another. And they also may
involve late-life depression."
They are also warning signs that a much larger stroke may be on the way.
Most strokes would never happen if people took simple measures like
controlling their blood pressure. Few do. Many say they forget to take
medication; others, like Dr. Fite, decide not to. Some have no idea
they need the drugs.
Still, there is much more hope now, said Dr.
Ralph L. Sacco, professor and chairman of neurology at the Miller
School of Medicine at the
University of Miami
.
Like most stroke neurologists, Dr. Sacco entered the field more than a
decade ago, when little could be done for such patients.
Now, Dr.
Sacco said, there is a device, an M.R.I. scanner, that greatly improves
diagnosis, there is a treatment that works and there are others being
tested. "Medical systems have to catch up to the research," he said.
In medicine, Dr. Sacco said, "stroke is a new frontier."
Promise Unfulfilled
One Tuesday morning in March, Dr. Steven Warach, chief of the stroke
program at the National Institute of Neurological Disorders and Stroke,
met with a team from Washington Hospital Center, the largest private
hospital in Washington, to review M.R.I. scans of recently admitted
patients. They were joined in a teleconference by neurologists at
Suburban Hospital in Bethesda, Md., the only other stroke center in the
Washington and suburban Maryland area.
The images were mementos of suffering.
There
was a 66-year-old woman with a stroke so big the scan actually showed
degenerating fibers that carry nerve signals across the brain.
There
was a 75-year-old who had trouble moving her right arm and right side
in the recovery room after heart surgery. At first doctors thought she
was just slow to wake up from the
anesthesia. Now, though, it is clear she had a stroke. She lost the right half of her vision in both eyes and her right side was weak.
There was an 88-year-old who slumped forward at lunch, losing consciousness. When he came to, he had trouble forming words.
There
was a middle-age man whose stroke was unforgettable. When Dr. Warach
saw his initial M.R.I. scan, in his basement office at his home, he
cried out in astonishment so loudly his wife ran downstairs. "I have
never seen anything so severe," Dr. Warach said. None of the three
arteries that supplied the man's right hemisphere were getting any
blood.
Now the man lay in a coma, twitching on his left side,
paralyzed on his right, breathing with the help of a ventilator. If he
survived, he would have severe brain damage.
There was Michael
Collins, a 49-year-old police officer who had had a stroke in his
police car in Takoma Park, Md. Unlike the others, Mr. Collins seemed
mostly recovered. The next few days, though, would determine whether he
was among the lucky 10 percent of stroke patients who escape unscathed
or whether he would always be weaker on his left side. If that
happened, Mr. Collins said, he could never return to his former job.
"You
have to be able to shoot a gun with either hand," he explained. But as
time passed, Mr. Collins continued to be plagued by numbness in his
left hand and on the left side of his face. He wanted to return to work
— "I'm doing great," he said this month — but the Police Department
insisted that he retire, telling him, he said, "it's an officer safety
issue."
The rest of the patients in the stroke units at the two
hospitals that day were less fortunate: almost certain to live, but
also almost certain to end up with brain damage. Some would have to
spend time at a rehabilitation center.
On average, said Dr.
Brendan E. Conroy, medical director of the stroke recovery program at
the National Rehabilitation Hospital, which is attached to the
Washington Hospital Center, a third of the Washington hospital's stroke
patients die, a third go home and a third come to him.
Those
whose balance is affected typically spend 20 days learning to deal with
a walker or a cane; those who are partly blind or paralyzed must learn
to care for themselves. Many functions return, Dr. Conroy said, but
rehabilitation also means learning to live with a disability.
But
what was perhaps saddest to the neurologists viewing the M.R.I. scans
that morning was that tPA, which only recently appeared to be a triumph
of medicine, had made not a whit of difference to these patients. None
had come in time or otherwise been considered medically suitable to
receive it.
Few would have predicted that fate for the drug. In
1995, after 40 years of trying to find something to break up blood
clots in the brain, the cause of most strokes, researchers announced
that tPA worked. A large federal study showed that, without it, about
one patient in five escaped serious injury. With it, one in three
escaped.
The drug had a serious side effect — it could cause
potentially life-threatening bleeding in the brain in about 6 percent
of patients. But the clinical trial demonstrated that the drug's
benefits outweighed its risks.
When the study's results were announced, Dr. James Grotta of the
University of Texas
Medical School at Houston expressed the researchers' elation. "Until
today, stroke was an untreatable disease," Dr. Grotta said.
But the expected sea change did not occur.
One
problem was that patients showed up too late. Many had no choice.
Strokes often occur in the morning when people are sleeping. They awake
with terrifying symptoms, paralyzed on one side or unable to speak.
"That's
the challenge — we have to ask the patient" when the stroke began, said
Dr. A. Gregory Sorensen, a co-director of the Athinoula A. Martinos
Center for Biomedical Imaging at
Massachusetts General Hospital. "If they don't know or can't talk, we're out of luck."
Another
problem is deciding whether a patient is really having a stroke. A
person who has trouble forming words could just be confused. Or what
about someone whose arm or leg is weak?
"A lot of things can cause weakness," Dr. Warach said. "A nerve injury can cause weakness; sometimes brain
tumors can be suddenly symptomatic. Sometimes people have
migraines that can completely mimic a stroke."
In fact, he said, a quarter of emergency room patients with symptoms suggestive of a stroke are not actually having one.
Most
get CT scans, which are useful mostly to rule out hemorrhagic strokes,
the less common type that is caused by bleeding in the brain and should
not be treated with tPA. Stroke specialists can usually then decide
whether the patient is having a stroke caused by a blocked blood vessel
and whether it can be treated with tPA.
But most stroke
patients are handled by emergency room physicians who often say they
are not sure of the diagnosis and therefore hesitate to give tPA.
Dr.
Richard Burgess, a member of Dr. Warach's stroke team, explained the
situation: There is no particular penalty for not giving tPA. Doctors
are unlikely to be sued if the patient dies or is left with brain
damage that could have been avoided. But there is a penalty for giving
tPA to someone who is not having a stroke. If that patient bleeds into
the brain, the drug not only caused a tragic outcome but the doctor
could also be sued. Few emergency room doctors want to take that chance.
Treatment Barriers
There
is a way to diagnose strokes more accurately — with a diffusion M.R.I.,
a type of scan that shows water moving in the brain. During a stroke,
the flow of water slows to a crawl as dead and dying cells swell. In
one recent study, diffusion M.R.I. scans found five times as many
strokes as CT scans, with twice the accuracy.
A diffusion M.R.I. "answers the question 95 percent of the time," Dr. Sorensen said.
It seemed the perfect solution, but it was not.
Most
hospitals say they just cannot provide such scans to stroke patients.
They would need both an M.R.I. technician and an expert to interpret
the scans around the clock. They would need an M.R.I. machine near the
emergency room. Most hospitals have the huge machines elsewhere,
steadily booked far in advance for other patients.
It just is
not practical to demand the scans at every hospital or even every
stroke center, said Dr. Edward C. Jauch, an emergency medicine doctor
at the
University of Cincinnati
and a member of the Greater Cincinnati/Northern Kentucky Stroke Team.
"If you made M.R.I. the standard of care before giving tPA, most
centers would not be able to comply," Dr. Jauch said. And if it takes
more time to get a scan — as it often does — it might be better to
forgo it and give tPA immediately if the patient's symptoms seem
unambiguous.
Doctors do not need an M.R.I. to diagnose and treat
stroke, said Dr. Lee H. Schwamm, vice chairman of the department of
neurology at Massachusetts General Hospital. But, Dr. Schwamm added, if
the question is, Does it help? there is one reply: "By all means."
It
has still not been shown, though, that M.R.I. scans actually improve
outcomes. It might depend on the circumstances and the hospital, said
Dr. Walter J. Koroshetz, deputy director of National Institute of
Neurological Disorders and Stroke.
But some who use M.R.I.
scans, and who have studied them in research, say the system has to
change. Enough is known to advocate the scans at every major medical
center that will treat stroke patients, they say.
"All these
problems could be solved if there was a will to do it," Dr. Sorensen
said. In his opinion, it comes down to old and outdated assumptions
that there is not much to be done for a stroke, to financial
considerations and to a medical system that resists change. But the
most significant barriers, he said, are financial.
Another
approach, stroke specialists say, is to direct all patients with stroke
symptoms to designated stroke centers. There, stroke patients would be
treated by experienced neurologists and admitted to stroke units for
additional care. For the first time, in its newly published guidelines,
the American Stroke Association recommended the routing of patients to
stroke centers.
But even with such a system in place, many
patients end up at hospitals that are not prepared to treat them, as
Dr. Grotta discovered in Houston.
He thought he could change
stroke care in Houston with the stroke center idea. The first step went
well — the city's ambulance services agreed to take all patients with
stroke symptoms to designated stroke centers.
Then, Dr. David
E. Persse, the city's director of emergency medical services, asked
every one of Houston's 25 hospitals if it wanted to be a stroke center.
While seven said yes, others have declined.
Stroke patients,
unlike heart attack patients, are not moneymakers. Because of the way
medical care is reimbursed, most hospitals either lose money or do
little more than break even with stroke care but can often make several
thousand dollars opening the arteries of a heart attack patient. And
being a stroke center means finding and paying stroke specialists to be
available around the clock.
Soon another problem emerged. As
many as a third of the patients refused to let the ambulance take them
to a stroke center, demanding to go to their local hospital.
"By
law in Texas, we cannot take that man to another hospital against his
will," Dr. Persse said. "We could be charged with assault and battery
and kidnapping and unlawful imprisonment."
The Joint Commission,
which accredits hospitals, recently started certifying stroke centers,
requiring that the hospitals be willing to treat stroke patients
aggressively. But only 322 of the 4,280 accredited hospitals in the
nation qualify, and most patients and doctors have no idea whether a
hospital nearby is among them. (The list is available on the
commission's Web site, http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCOrgs/
under "primary stroke centers.") Some states, like New York,
Massachusetts and Florida, do their own certifying of stroke centers.
Nonetheless,
most ambulances do not consider stroke center designations when they
transport patients. And, said John Becknell, a spokesman for the
National Association of Emergency Medical Technicians, national
programs can be difficult because every community has its own rules for
which ambulances pick up patients and where they take them.
As a
result, most stroke patients have no access to the recommended care and
even fewer get M.R.I.'s, a situation Dr. Warach said he found appalling.
"How can it ever be in the patient's best interest to have an inferior diagnosis?" he asked. "It borders on
malpractice
that given a choice between two noninvasive tests, one of which is
clearly superior, the worse test is the one that is preferred."
Averting Catastrophe
In
those awful moments when she realized she had had a stroke, Dr. Fite,
unlike most patients, knew what to do. She told the ambulance crew to
take her to Memorial Hermann Hospital, even though it was about an hour
away. She knew that it was one of the Houston stroke centers, that Dr.
Grotta worked there, and that its doctors had experience diagnosing
strokes and giving tPA.
When she arrived, Dr. Grotta asked if
she was sure she wanted the drug. Did she want to risk bleeding in the
brain? Dr. Fite did not hesitate. The stroke, she said, "was just so
devastating that I would rather die of a hemorrhage in the brain than
be left completely paralyzed in my right side."
"In my horrible voice, I said, 'Yes, I want the tPA,' " Dr. Fite said.
Within 10 to 15 minutes, the drug started to dissolve the clot.
"I
had weird spasms as nerves started to work again," Dr. Fite said. "An
arm would draw up real quick, a leg would tighten up. It hurt so bad I
was crying because of the pain. But it was movement, and I knew
something was going on."
Now, she looks back with dismay on her
cavalier attitude toward high blood pressure. She knew very well how to
prevent a stroke but, like many patients and despite her medical
training , she found it all too easy to deny her own risk.
Researchers have known for years the conditions that predispose a person to stroke —
smoking,
diabetes, high
cholesterol and an irregular heartbeat known as atrial fibrillation. But the major one is high blood pressure.
"Of
all the modifiable risk factors, high blood pressure leads the list,"
Dr. Sacco said. "With heart disease, you think more of cholesterol;
with stroke you think of high blood pressure."
The reason, Dr.
Sacco said, is that with high blood pressure, the tiny blood vessels in
the brain clamp down so much and so hard to protect the brain that they
can become rigid. Then they get blocked. The result is a stroke.
Often,
people decide they do not need their blood pressure medication or
simply forget to take it because they feel well. But, Dr. Sacco said,
patients are not solely to blame. Doctors may not have time to work
with patients, monitoring blood pressure, telling them about changes in
their
diet and exercise that might help, or trying different drugs and combining them if necessary.
And
it is not so simple for people to keep track of their blood pressure.
Machines in drugstores and supermarkets are not always accurate.
Doctors may require appointments to check blood pressure.
Even when people do try to control their pressure, doctors may not prescribe enough drugs or high enough doses.
"They're
on a couple of drugs, and the doctor doesn't want to push it," said Dr.
Jeffrey A. Cutler, a consultant to the National Heart, Lung and Blood
Institute and its retired director of the clinical applications and
prevention program.
The result is that no more than half the
people with high blood pressure have it under control, Dr. Cutler said.
He estimated that half of all strokes could be prevented if people got
their blood pressure within the recommended range.
Another lost
opportunity to prevent strokes is the undertreatment of atrial
fibrillation, in which the two upper chambers of the heart quiver.
Blood can pool in the heart and clot, and those clots can be swept into
the brain, lodge in a small blood vessel and cause a stroke.
Strokes
from atrial fibrillation can largely be prevented with anticlotting
drugs like warfarin. Yet many who have the condition do not know it and
many who know they have it were never given or do not take an
anticlotting drug.
Some strokes can also be prevented by procedures to open obstructed arteries in the neck that supply blood to the brain.
As for Dr. Fite, she completely recovered. And she has changed her ways.
She
was sobered by the cost of her treatment and brief hospital stay —
$96,000, most of which was paid by her insurance company. But she was
even more sobered by how close she came to catastrophe.
Now, Dr.
Fite takes three blood pressure pills, a drug to prevent blood clots
and a cholesterol-lowering drug. She plans to take those drugs every
day for the rest of her life.
"I was so stupid," she said. "Boy, when you go through this, you never want to go through it again."
"I have been given that precious second chance," she said. "I was so blessed."
how *far* i have come in just a year. its def been a long time in coming...
also good time to reorient myself and do some self-rediscovery, which is something u definitely cannot accomplish when around other people all the time. i almost lost myself a few times doing the regular thing...but am grateful for the times where I can refocus...
and WAI i think u look good in pics =P
>
boo
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