TPA to Go: Working on the Barrow Mobile Stroke Unit
Shortly after their pagers sound, three women in gray polo shirts labeled “stroke team” hustle toward the 11-ton, blue and white vehicle parked outside the Emergency Department at Barrow Neurological Institute.
They hop into the cab and consult the computer in the center console, which displays an incident history and location from the Phoenix Fire Department. There’s a sense of excitement as the Barrow Emergency Stroke Treatment Unit turns onto Third Avenue, heading to its latest stroke call.
CT technician Wendy Faseler is at the wheel. Everyone who drives the stroke unit undergoes training with the fire department on a skills course to ensure they can maneuver the 26-foot-long, 10-foot-wide vehicle.
One of the registered nurses, Christa Cobos, starts the navigation on her phone and texts the on-call neurologist. The other, Nicolette Owens, prepares the paperwork and communicates with Phoenix Fire over radio. The trio works seamlessly, each person knowing her role.
Just before the stroke unit arrives on scene, the women let out a collective “ugh.” They’re stuck in a line of cars waiting to turn left, and the light has just changed to red. Faseler says dealing with traffic is one of the biggest challenges of the job.
Because the stroke unit is the first of its kind in Arizona—and only the 10th to hit the roads in the United States—current legislation doesn’t allow it to use lights and sirens like an ambulance. Barrow is working to change that so that the unit can reach patients faster.
The stroke team arrives and loads the patient into the unit. It’s a warm day in April but nowhere near the triple-digit temperatures that Phoenix will see in the summer. Faseler says working in the desert heat is the other biggest challenge, and Owens agrees.
The mobile stroke unit is equipped with telemedicine capabilities, allowing the on-call neurologist to evaluate the patient over video. After a brief physical and neurological examination, the neurologist asks Faseler to take images with the on-board computed tomography (CT) scanner.
The scan shows no signs of a clot or bleed, but the neurologist requests that the patient be taken to the hospital for magnetic resonance imaging (MRI)—which will provide a more detailed picture—to be sure. Several conditions, such as complex migraine and hypoglycemia, can mimic a stroke.
Owens accompanies the patient in the Phoenix Fire ambulance. Cobos and Faseler take the stroke unit back to Barrow, where they will assist in the Emergency Department—always remaining close to the truck to take the next call. They may not get another before their 12-hour shift ends, or they may get several more.
“The most calls I’ve had in a day is seven,” Owens said. “Those days are fun because we are doing what we are trained to do.”
Time is Brain
The Phoenix Fire Department dispatches the mobile stroke unit when it receives a call of a possible stroke. The unit operates around the clock and has a 20-minute response radius from wherever it is located at the time of the call.
The unit is not yet able to transport patients but instead serves as a mobile emergency room specifically designed for stroke care. Barrow launched the unit in partnership with the fire department to speed diagnosis and treatment times for stroke patients, which can dramatically reduce death and disability.
“I applied to work on the unit because I enjoyed the community outreach aspect of the job,” said Owens, who has been working on the unit since it launched in 2017. “I think it’s important to educate the community as well as our first responders on how important giving tPA to an acute stroke patient really is.”
When it comes to stroke, “time is brain.” According to a study published in Stroke, the average human forebrain has about 22 billion nerve cells. For every minute a stroke is left untreated, an estimated 1.9 million nerve cells are lost. Every hour results in the death of 120 million nerve cells and accelerates brain aging by 3.6 years.
In 2018, the mobile stroke unit reported 192 patient contacts. The stroke team administered the clot-busting drug tPA (tissue plasminogen activator) in the field 38 times.
Strokes caused by a clot, known as ischemic strokes, account for about 87 percent of all strokes. The remaining 13 percent are hemorrhagic strokes, which occur when a weakened blood vessel in the brain ruptures and bleeds into surrounding brain tissue. These patients are not treated with tPA.
Despite traffic, the stroke unit had a median time from dispatch to tPA administration of 41 minutes and a best time of 30 minutes in 2018. Its best “door to tPA” time, or the time between loading the patient into the truck and tPA administration, was six minutes.
“When we are out here in the general public working side by side with the Phoenix Fire Department and helping patients who have the ability to regain motor function, speech, and cognitive ability, there’s nothing like it,” Owens said.
The Big Picture
Owens said she’s had many great saves on the unit, but the one that stands out in her memory is a call from a man with numbness in his tongue. Although his symptoms were mild, his wife insisted he call 911.
“He, in fact, was having an acute stroke,” she said. “It made me realize that as a new wife personally, I need to take everything seriously and be an advocate for my own family if something doesn’t feel right. This woman saved her husband, and he made a full recovery.”
Owens also joined the stroke unit to challenge her knowledge and skillset and to build upon her foundation in emergency medicine. She holds certifications in Emergency Neurological Life Support (ENLS) and the National Institutes of Health Stroke Scale (NIHSS) assessment. Owens said the nurses on the stroke unit are the only nurses in the Emergency Department who hold these specialty certifications, allowing them to serve as a resource when not on a call.
The quality of life that this truck brings to the community is priceless.
-Wendy Faseler, Barrow CT Technician
“The BESTU has been a special project and challenged all of us in ways that our practice hasn’t been challenged,” she said. “I learn something new every day from our neurologists.”
Faseler, who has also worked on the unit since its launch, has been in the CT arena since 1996. She, too, was ready for a new challenge.
“I applied to be part of the team because I have always enjoyed being part of new technology and new aspects of doing things,” she said.
But Faseler said the big picture is seeing a change in a patient who receives tPA in the field.
“The quality of life that this truck brings to the community is priceless,” she said.