A stroke of luck saves New London patient

A new telemedicine initiative brought a potentially lifesaving drug to a patient 50 miles away.

When Jeanne Munnelly went for a swim at a high school in East Lyme one August morning, she could not have known she was about to have a stroke—and make medical history in Connecticut.

At about 8:15, as she swam in the school’s pool, Munnelly became weak on her right side and unable to speak. Lifeguards pulled her out and emergency personnel based at the fire station across the street arrived within five minutes. She reached New London’s Lawrence and Memorial Hospital in just 15 minutes.

That’s when Munnelly, 67, became the first patient to benefit from the Yale-New Haven TeleStroke Network, a program modeled on a similar initiative at Massachusetts General Hospital. The TeleStroke Network allows area hospitals to call upon Yale neurologists’ expertise in assessing stroke victims. Using high-speed network videoconferencing and image-sharing technology, neurologist Joseph Schindler, M.D., evaluated Munnelly via computer from Yale-New Haven Hospital (YNHH), then gave the “green light” to physicians in New London to use the clot-busting drug tissue plasminogen activator (tPA). Munnelly received the drug only 37 minutes after reaching the hospital—much more quickly than if she had been transported to YNHH first.

Schindler said the process of evaluating a stroke patient via TeleStroke is the same as when he sees a patient in YNHH’s emergency department. “It’s no different; it’s just the use of technology to do it remotely,” he said.

Speed and decisiveness are critically important in treating stroke victims. Most blood clots that cause ischemic strokes can be dissolved by tPA, a thrombolytic agent. But this medication can also cause bleeding in the brain, and that risk increases beyond three hours after the onset of symptoms. To meet that three-hour deadline and try to prevent this complication, doctors must ensure that a patient is an appropriate candidate for tPA. Yet in most hospitals, neurologists are not always available to assist emergency physicians with the evaluation and treatment decision. As a result, many patients who might benefit from tPA do not receive it.

With telemedical technology, a neurologist need not be physically present. While seated at a computer 50 miles away from the patient, Schindler, the clinical director of the Yale-New Haven Stroke Center, used a high-speed Internet connection to speak with the patient, family and clinical staff and review Munnelly’s medical history, blood tests and CT scan. He also examined her using a camera with a zoom feature. She was, he determined, a good candidate to receive tPA. Shortly after receiving the drug, Munnelly regained the use of her right leg as well as some ability to speak.

Schindler, who is optimistic that Munnelly’s condition will continue to improve, was pleased not only that the technology worked but also that he and the team in New London could act so quickly. “We’ve done it at Yale when the entire team was already in the ED; we [assessed and treated the patient] in a similar time. But to have that done remotely, it’s wonderful.” (See related story, “A viper’s venom and stroke.”)

—Jenny Blair

With virtual lives on the line, simulations help responders assess triage systems

Imagine being the first paramedic on the scene after a tanker truck has plowed into a city bus. Traffic is snarled, cars are honking and people are screaming. Who needs your attention most—the man on the concrete holding his bloodied knee or the woman on her back with closed eyes? What about the people inside the overturned bus? And what is that white vapor drifting from the truck’s tank?

In emergencies, prioritizing care for victims is called triage. The word comes from the French trier, “to select” or “to sift,” a usage that goes back to Dominique Larrey, the chief surgeon of Napoleon’s armies. A victim might be color-coded as red, meaning he needs help immediately; yellow, meaning he will need help soon; green, meaning he has minor injuries; or black, meaning he cannot be helped with available resources. But sorting human lives in this way is still more art than science.

This uncertainty persists because, although many rules exist to help rescuers, it is hard to evaluate whether those rules actually save lives. The decades-old Simple Triage and Rapid Treatment (START) system color-codes patients as described above. But like other such systems, said David C. Cone, M.D., associate professor of surgery (emergency medicine) and of epidemiology, “we have no idea if it works.”

Cone has spent his career thinking about disasters and mass-casualty triage. He studies emergency medical services and plans for chemical, biological and nuclear terrorist incidents. He has run disaster simulations at Tweed-New Haven Airport complete with volunteers smeared with fake blood. But triage research is inherently difficult. For one thing, said Cone, “we don’t even know what we want a mass-casualty triage system to do.” Is the best system the one that’s easiest to teach? Quickest to apply? Is the most important goal to get patients into ambulances as quickly as possible? Or to save the greatest number of lives? The complexities mount when one considers that every disaster is unique—it is almost impossible to compare triage systems in the real world. Now, though, Cone has begun working with a new tool to study start and other triage systems: a virtual-reality (VR) simulator.

While studying in Italy for a master’s degree in disaster management in 2004, Cone saw a VR simulator used to train Dutch firefighters and realized that the software could be adapted for triage research. Developed by the Dutch company E-Semble, the simulator looks like the highly realistic video game Grand Theft Auto. Learners at a laptop “walk around” a vivid scene, assessing and triaging victims. Dangers and distractions, like toxic spills or television reporters, can be added to the scenario. The learners are timed and their actions exported into a database that can then be analyzed.

Working with emergency medicine resident John Serra, M.D., and supported by the Centers for Disease Control and Prevention and the Laerdal Foundation, Cone plans to teach paramedic students two different triage systems several months apart, then compare how they did with each system in identical VR scenarios. “Once we get the software tuned, then we can design the larger studies,” said Cone. He plans eventually to use the tool to explore whether rules for triage are even necessary, or whether victims are better off being triaged by experienced rescuers who rely on clinical gestalt.

VR may one day allow researchers around the world to collaborate, exchange scenarios and compile “libraries” of standardized victims. Cone hopes the controlled VR environment will allow for real progress in triage research and ultimately save more lives during real disasters.

—J.B.

et cetera

Chocolate and pre-eclampsia

Eating chocolate may lower the risk of pre-eclampsia, a dangerous condition in pregnancy characterized by increased blood pressure and proteinuria, according to a Yale study published in the journal Epidemiology in May. But the study is not a free pass for chocoholics. Eating too many sweets can cause health problems, said Elizabeth W. Triche, Ph.D., of the Yale Center for Perinatal, Pediatric and Environmental Epidemiology, who led the study.

Triche’s team wanted to find out whether chocolate—especially dark chocolate with antioxidants that confer cardiovascular benefits—would protect pregnant women against pre-eclampsia. The study found that women who had more than five servings a week had a lower risk of pre-eclampsia; those who had high levels of theobromine, a byproduct of chocolate consumption, were nearly 70 percent less likely to develop pre-eclampsia than women who had low levels.

“This looks promising, but we need to do more research into how much and what type of chocolate is the most beneficial,” Triche said.

—John Curtis

A viper’s venom and stroke

What does snake venom have to do with stroke? Depending on the results of a study in which Yale-New Haven Hospital (YNHH) is participating, possibly a lot.

Doctors at YNHH are administering ancrod, a drug derived from the venom of the Malayan pit viper, to eligible patients who enter the hospital with symptoms of acute ischemic stroke.

In such cases doctors may administer a clot-breaking agent—tissue plasminogen activator, or tPA—but it must be given no more than three hours after symptoms appear. Ancrod has an anticoagulant effect and can be administered up to six hours later. “If ancrod is safe and effective,” said Joseph Schindler, M.D., assistant professor of neurology and neurosurgery and clinical director of the Stroke Center at YNHH, “it will double the time frame during which stroke patients can be treated.”

YNHH is the only Connecticut hospital in the trial, which is expected to last one to two years.

—Charles Gershman


			Originally published in Yale Medicine, Autumn 2008. Copyright © 2008 Yale University School of Medicine. All rights reserved.