New stroke protocol requires some patients go straight to RIH


Warwick EMS Coordinator Jason Umbenhauer says a new protocol for treating stroke patients has resulted in two known successful cases since its implementation March 1.

Under the protocol, patients believed to be having a stroke are first assessed under the Los Angeles Motor Scale (LAMS). This scale assesses whether the face, arm, and grip are normal, weak, or flaccid and not moving. The highest possible score is a 5.

Those who are at a 4 or higher are transported to Rhode Island Hospital, which has the only comprehensive stroke center in the state, rather than to a primary stroke center at a hospital closest to the patient. This transportation to RIH, provided the scene is within a 30-minute drive of the hospital, is required by the Rhode Island Department of Health.

At RIH, stroke patients can be treated with the administering of tPA, the “clot buster for stroke,” and with mechanical thrombectomy in which catheters and a stent are used to remove a blood clot. RIH is the only hospital in the state where thrombectomy is available.

Though RIH may be a longer trip, it can save time and lives in the long run, said Mahesh Jayaraman, M.D., who is in neuroradiology at the hospital. Patients who are taken to a primary care center at the nearest hospital are sometimes deemed in need of a transfer to the comprehensive center – those transfers can take an average of 90 minutes, he said, whereas those immediately taken to RIH under the new protocol can receive treatment faster.

“We have this highly effective treatment and we want to get patients to the right place the first time. We’re proud of the fact that our times our phenomenal, that we’re treating patients very quickly,” he said. “But we want to be able to make sure that no one’s left behind.”

In a presentation at the Warwick Fire Department on Tuesday, Jamarayan described a 71-year-old woman who began receiving treatment within half an hour of arriving at RIH. The woman had been at a 5 on the LAMs scale and was brought to the hospital by Warwick EMS, he said.

Jamarayan explained that not every patient should be taken to the comprehensive center, and it isn’t the goal to do so. Sending all patients there can overwhelm the comprehensive stroke center and bypass primary stroke centers for every patient even if they can be treated in primary care, he said.

“Clearly, taking every patient to the comprehensive center is a bad idea because the vast majority don’t have this. Right now, our protocols are build on you either get tPA or nothing, and that’s not the new world we live in,” he said. “So we need to have a treatment that works for patients that need just tPA [and] those that need tPA and thrombectomy.”

Jayaraman said efforts are underway to enact legislation similar to Rhode Island’s protocol in Arizona, Colorado, Tennessee, and Massachusetts. He also noted that the City of Los Angeles is going live with this same protocol this summer.

Michael Dacey, President and COO of Kent Hospital, said Kent is researching and looking into whether gaining the ability to perform the thrombectomy treatment there is in the “best interest of everybody.” He said Kent has had consistent conversations on the subject with the state Department of Health and representatives across the state.

Dacey said that all hospitals in the state are equipped to use drugs intravenously to dissolve clots, an idea on treatment that came about around 10 years ago. He did second the notion that a minority of patients – approximately 15 to 20 percent – who have larger strokes may benefit from a more “interventional approach” like thrombectomy, but doesn’t believe the LAMS scale is the best way to determine whether a patient is a candidate for this type of treatment.

“It’s not a very good test, to be honest… the best test is a CAT scan,” he said.

In addition, Dacey believes Kent could eventually become a comprehensive stroke center if it obtains the ability to perform thrombectomy as the procedure is a qualification necessary to receive such designation.


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