“There’s not the same one correct answer for all patients,” said Dr. Raul Nogueira, an interventional neurologist at Grady Memorial Hospital in Atlanta. Where a patient should be taken for care “really depends on travel time,” he said. “It’s all about time.”
For years, the advice for stroke patients has been to get to the nearest hospital as soon as possible. A stroke cuts off blood flow to part of the brain, and the sooner that blood flow can be restored the better. So, the idea has been to get patients to a doctor — any doctor — quickly.
But that advice is now evolving. Research shows some stroke patients benefit more from advanced procedures typically done by specialists at large medical centers. The new goal is to get patients to the right doctor at the right hospital as soon as possible.
In some cases, that means skipping the closest facility. For patients with severe strokes, in which a clot is blocking one of the brain’s major arteries, the American Heart and Stroke associations recommend traveling up to an additional 30 minutes in urban areas and 60 minutes in rural areas to reach a hospital with more advanced stroke capabilities.
While that’s easy enough in a city where multiple hospitals are clustered together, in rural areas like Fentress County the question of where to take a patient has become increasingly fraught.
Big decisions, little time
When Lottie Crouch had her stroke, what would have been the nearest hospital, less than 20 minutes away, had closed two months earlier. It’s one of 136 rural hospitals nationwide that have shuttered since 2010, including nearly three dozen across Appalachia and the Delta. That meant the closest in-state hospital for Crouch was nearly 45 minutes away by car, and medical centers with the most advanced care were more than an hour’s drive. That left EMS services stretched thin trying to transport patients farther away.
Each step in the process to get someone who’d had a stroke to the right care within the right amount of time had become more complex.
The decisions along the way are rarely clear-cut, Nogueira said. If a patient has a severe stroke, they might benefit from getting to a large medical center where they can undergo surgery right away, he said. Stopping at a smaller hospital that can’t perform that procedure might unnecessarily delay care.
But if the stroke is less severe, the person might benefit more from first going to a closer facility that can offer medications to break up the clot sooner, Nogueira said. Then the patient could avoid unnecessary medical bills from a long trip, anything from $500 for a ride in the back of a regular ambulance to $50,000 for a helicopter. And their family could save the time and money needed to visit them in a faraway hospital.