We focus a lot on acute stroke patients. Rapid response. Rapid assessment. Rapid transport. Dispatch, Delivery, Door, and Drug. But what about the other D’s associated with stroke such as Discharge? And Disability? And Depression?
Stroke is the chief culprit of serious long term disability in the US. Below is the Modified Rankin Scale (MRS), a scoring system used to rank the severity of a stroke survivor’s disability (This is also heavily used to define endpoints and outcomes in clinical research).
MRS scores of 0-1 are generally considered to be good outcomes following a stroke, while 2 or higher are poor outcomes. (For example of clinical research use, in the 1995 NINDS TPA trial, an MRS of 0-1 was a measurement of a good outcome. This endpoint is still consistently utilized)
Stroke generally cause 5 types of disabilities: 1) paralysis & movement, 2) Sensory & pain issues 3) language & speech issues 4) cognition & memory issues, and 5) emotional disturbances.
1) Paralysis & movement: here you’ll find the well-known hemiplegia (one-sided weakness) & hemiparesis (one-sided paralysis). Also, ataxias (gait and coordination disorders) and dysphagia (difficulty swallowing) are common. Typically in the hospital and rehab units ‘sip’ or ‘swallow’ tests are performed to assess a patient’s ability to swallow water and food and patient’s are kept on NPO status until cleared. After discharge, it’s good to be aware that a stroke survivor may have difficulty eating and drinking, which may lead to choking or aspiration emergencies.
2) Sensory & pain: Paresthesias (tingling) in the extremities are common, as is neuropathic pain. Patients with a paralyzed or weakened arm commonly experience moderate-to-severe pain. Think about that for a moment, and then read it again. Nowhere in EMS education do we teach on the constant pain these patients may be suffering from. This pain can be caused by the immobilized joint being “frozen” in place and the ligaments and tendons weakening. It may also be caused by damaged pathways in the brain sending false pain signals.
3) Language and speech: Here lies the aphasias (global, expressive, and receptive). A patient may not be able to understand and speak (global), or just be impaired in the ability to speak (expressive) or receive (receptive). Dysarthria (slurred speech) falls under this category as well.
4) Thinking and memory: Obviously, areas of the brain which housed memory and aided cognition can be directly damaged and destroyed. In addition, anosognosia is the inability to acknowledge the reality of the physical impairments being suffered. Sometimes, a patient’s consciousness simply rejects their impairment. Think something similar to the phantom limb syndrome.  Neglect is the loss of awareness of one area of the body, often the side effected by the stroke. Apraxia occurs when patients become unable to follow a set of instructions, thought to be due to damage done to the neural connections linking thought to action.
5) Emotional disturbances. And it’s in this category that we do the worst job. We’re trained to be impersonal, detached, professional, & precise. In an emergency, this mechanistic approach works excellently, however as EMS moves further into community care, chronic care, and as the population ages, we will need a new model for addressing the emotional and psychological needs of our patients. Depression, anxiety, fear, self-loathing, anger, hopelessness, social withdrawal, irritability, fatigue, depression, suicidal thoughts….all of these are common, natural, and expected reactions following a stroke. How would you cope with suddenly being bed bound with parts of your body permanently immobilized, your dreams of the future crushed, and potentially losing the ability to even use the bathroom on your own? Our patients are more than amalgamations of bone, tissues, cells, and neurons. Severe depression is rampant in stroke survivors.
Falls are the number one injury suffered by a post-stroke patient. EMS transports a number of these, and we could probably do an excellent job intervening in patients homes to prevent these from occurring. As “community paramedicine” emerges, perhaps we will play as great a role in the chronic, disabled stroke patient as we do in the acute stroke patient.
