Joseph Madaras, 74, couldn’t get out of bed.
The retired community college professor, 74, couldn’t feel his legs that December 2022 morning. He had no idea what was happening – but knew it couldn’t be good.
While he was quite familiar with stroke symptoms, “I didn't think of stroke in that moment. I struggled to get out of bed for quite a while and finally called to my wife, Hilda. The minute she came up the stairs and looked at me, she knew what was happening. And thankfully she knew what to do. She called 911. And they, thankfully, responded in an incredibly timely manner, knew what was going on and got me down to the ambulance.”
And what happened next is an example of the teamwork between Forsyth County Emergency Management Services (EMS) and Novant Health Forsyth Medical Center emergency room teams that centers on delivering care that can mean the difference between full recovery and permanent disability or death.
EMS knew from the 911 dispatcher that they would likely be attending to someone who’d experienced a stroke. “Dispatchers are highly trained in what they do,” said Bryan Gallimore, Forsyth County EMS assistant chief. “They are excellent at triaging calls and telling us – quickly – what we’re going to be faced with when we arrive on scene.”
Check-ups are a smart first step in stroke prevention.
If the patient is having chest pains, that tells EMTs one thing. If they’re having trouble breathing, that tells them something else. And if the patient can’t move, it may be a stroke. But they have to remain open to other possibilities.
“We have to be flexible,” Gallimore said. “It may not be what we’ve been told.”
EMTs radio to the hospital's triage nurse to let them know a possible stroke patient is on the way. They provide the details, give the patient’s vitals and an ETA. (See sidebar for a play-by-play of how EMTs handle a stroke call.)
That triage nurse immediately activates the hospital’s rapid-response team. When the ambulance arrives, it’s greeted by a neurointensivist, stroke coordinator, pharmacist, triage/communications nurse and ER physician. From that point on, the action plays out as we illustrate in this video.
On the way to the hospital, the paramedic is assessing and re-assessing the patient. Not every patient who’s transported via ambulance travels with sirens. But stroke patients do. That’s because up to 2 million brain cells die every 60 seconds when oxygen and nutrients are cut off. Fast action can mean all the difference.
Know the signs of stroke – and act FAST
- F: Face: Ask the person to smile. Does one side of the face droop?
- A: Arms: Ask the person to raise both arms. Does one arm drift downward?
- S: Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange?
- T: Time: If you see any of these signs, call 911 right away.
The stroke team is ready
Since the ER has been notified, there’s no need to register the patient upon arrival. The stroke team is typically assembled and starts care instantly.
“Mr. Madaras came in with left-sided weakness, some slurred speech and facial droop,” recalled Dr. Lauren Peruski, a neurologist and the stroke medical director at Novant Health Forsyth Medical Center. He woke up with “a lot of common stroke symptoms. But it's really hard, when it's happening to you, to know that it’s a stroke.”
“What we see often, unfortunately, is people waking up with neurologic symptoms, and trying to wait it out or sleep it off. And then when they come in, we’re not able to do much to help. We see a lot of people who come in with ‘wake-up strokes’ who wait a long time before coming in. And that’s very dangerous.” The takeaway: “Never try to sleep off symptoms or take a wait-and-see approach.” Call 911.
Because Peruski and her team got a pre-hospital notification that EMS was on their way, they leapt into action.
“The examination starts right away – looking, listening for anything off about their speech,” she said. The team then performs a complete stroke scale assessment, sometimes referred to as RACE tests. “Based on our physical exam alone, you can generally tell if someone's having a large stroke, and Mr. Madaras certainly seemed to be. We immediately got him a CAT scan to make sure he didn’t have a brain bleed.”
Strokes can be caused by bleeds in the brain or by insufficient blood flow getting to the brain caused by a blockage, she said. Madaras did not have a brain bleed.
“The next thing we do is a CT angiogram, which is a special CT with dye that looks for blockages in the brain,” Peruski said. “That’s how we detected the clot in Mr. Madaras’ brain and knew it was in a favorable location to remove.”
A neurointerventional radiologist, having been alerted, is standing by. In Madaras’ case, it was Dr. Morry Brown.
“Time is brain” is the phrase stroke doctors often repeat. Peruski and her team try to do their part within an hour or less and get their patient into surgery, if that’s recommended.
Brown performed a thrombectomy on Madaras. The proceduralist uses a catheter to enter the body at the groin, proceed up through arteries in the leg, with a microwire and follows it with CT scanning – or contrast dye – so they’re able to see where the wire is going. They go through the carotid artery into the brain and capture and remove the clot.
“A thrombectomy is probably the greatest advance thus far in stroke medicine,” Peruski said. “It's only utilized in specific cases with specific clots and specific localization. So, it's not one-size-fits-all. But when the patient has the right properties of their stroke, we’re able to do it. Mr. Madaras’ stroke was one the procedure was made for. His wife, calling 911 when she did, saved his life or saved him from severe disability.”
Peruski credits EMS with his excellent outcome, as well. “EMTs have to respond to a call and very quickly figure out what’s going on,” she said. “And of course, they see every kind of problem. So, the fact that they’re able to identify a stroke very quickly, and let us know before the patient arrives at the hospital that it might be a stroke, allows us to get a lot of things in place before the patient arrives. They play a crucial role. We heavily depend on EMS to care for stroke patients.”
Doctors know right away if surgery was successful. “You can see clinically if the patient is improving,” Peruski said. “Sometimes, you remove the clot, but there’s already been some damage done. So, we really want to look for clinical improvement. Within the next day or two, you can get a good sense for how the person is doing. Sometimes you can tell within hours.”
Doctors prescribe medication that may help prevent future strokes. “Then, it’s all about rehab and having them work with physical, occupational and speech therapy in the hospital,” Peruski said. “Oftentimes, they’ll need inpatient rehab before going home.”
‘Lucky to be alive’
When Madaras woke up in the hospital after his thrombectomy, he had all his “faculties and was moving fairly well,” he said. “I heard about the procedure they performed and find it absolutely amazing.
“In the hospital, I went through all kinds of tests and could see the amazement on the faces of my doctors and nurses,” he said.
Madaras, who was chairman of the vocational and correctional education department at South Piedmont Community College in Anson County before he retired, was in the hospital for a week before being discharged on Dec. 21 and transferred to inpatient rehab for another week.
“I think I amazed them in rehab, too, because when they read what had happened, they expected a completely different case,” he said. “I could walk with no problem. They’d have me walk upstairs – which was no problem – and do a lot of manipulating things, which I also had no problem with. In rehab, the staff told me when they saw me walking the halls, they figured I was a visitor – not a patient.”
Madaras tires easily these days, which Peruski said is normal after a stroke. He’s been able to return occasionally to his beloved woodworking shop behind his house in historic Old Salem. He specializes in making Moravian stars – one of the symbols of Old Salem. The fatigue he feels is normal, Peruski said. “Your brain has to compensate for everything that took place,” she said. “It should improve over time, but many people notice a bit of fatigue after a stroke.”
Madaras was so grateful to everyone involved in his care and recovery that he asked to meet the hospital team and EMTs, including paramedic David Harris. “It was a wonderful occasion,” he said. “At least five people from Novant Health, including a couple of doctors and nurses, were there. I could see from the looks on their faces they were quite pleased and surprised about how well I was doing. I try not to dwell on how scary it was – and how bad it could’ve been. But I know I’m lucky to be alive. This was really a perfect storm. Everything worked.”
First on the scene
Stroke care starts with EMTs
A lot has to happen before a stroke patient arrives at the hospital. Emergency Medical Services (EMS) is in charge from the time they reach a patient until the patient is officially in the care of the emergency team at the hospital. The amount of time EMS is with a patient is mere minutes – but every second matters.
Once on the scene, EMTs first determine if it’s safe for them to be on-site. Then, they go about quickly – everything’s happening fast – determining what’s going on. They take vitals. Is the patient breathing? Do they have a pulse?
Sometimes, a first responder crew – generally firefighters – will also arrive on scene to help. Firefighters are trained “as basic-level EMTs,” said Bryan Gallimore, Forsyth County EMS assistant chief, and they can help lift the patient and assist with logistics.
Once EMTs are confident a stroke is likely, they try to find out when the patient’s “last-known normal” was.
They administer some quick speech, cognition and muscle movement tests. They’ll ask the patient to smile to check for facial droop. They’re also looking for weakness on one side and arm or leg motor impairment.
EMS’s goal is to be in the ambulance and headed to the hospital within 15 minutes of arriving on scene.
Once in the ambulance, the paramedic starts an IV. Every step is designed to prepare the patient for the stroke team. EMTs radio ahead to the hospital – to a triage nurse in the ER – to let them know a potential stroke patient is on the way. “We want the patient to go straight to a CAT scan,” Gallimore said.
EMTs rarely have downtime after an adrenaline-filled trip to the hospital. More often than not – because there’s a nationwide shortage, Gallimore said – they’ve got to head straight to the next emergency. “After we drop a patient at the ER, most of us are thinking: Is there anything I could have done better or faster?”
Gallimore’s team is supposed to work 12-hour shifts. But he said if a crew is 11 hours and 45 minutes into their day and gets a call, they stay on the job.
Gallimore has been an EMT since 2004 and a paramedic – the highest level an emergency responder can attain – since 2006. During that time, he said the way EMTs treat stroke hasn’t changed – but hospital protocols and medical interventions have. “It used to be that a stroke call was just a very sad call,” he said. “But stroke medicine has made such strides that there is now great hope for stroke patients.”