And in the most rural parts of both these regions, people are less likely to be near an advanced-care stroke facility.
Rural and largely African American
While reaching appropriate stroke care in time is difficult for many rural Americans, such as Crouch, who is white, the concerns are compounded for places with a large Black population.
Black Americans have strokes more often and at younger ages than their white counterparts. They’re also less likely to receive clot-busting medications because they often arrive at the hospital outside the window of treatment.
In Sumter County, Alabama, several people interviewed — from a business owner to a college professor to the district judge — were able to name someone off the top of their heads who has had a stroke. The county is more than 70% Black, and it is one of the poorest areas of the state.
The only hospital within county lines has no stroke certification. Loretta Wilson, the CEO of Hill Hospital of Sumter County, wishes her facility could do more for stroke patients. But clot-busting medications can cost $8,000 per dose, and the hospital can’t always afford to keep them on hand, she said.
Most stroke patients are taken to larger hospitals at least 30 or 40 minutes away. That can be a long and expensive journey for many residents, Wilson said.
Understanding that, Wilson focuses largely on prevention efforts. She runs a nonprofit that tackles issues like high blood pressure, obesity and diabetes, all of which increase a person’s risk of stroke. Her organization partners with churches to teach people about healthy eating and exercise, and passes around blood pressure monitors so congregants can screen themselves after services.
“We have a high African American population,” said Wilson, who is African American too, “and those are the ones who really need the services.”
Other organizations in the county also work to educate people about heart health and when to call 911. The local college’s nursing program has a scholarship aimed at bringing more medical providers to the area.
Using telestroke to boost rural care
In rural hospitals, even if doctors have access to clot-busting drugs, they may hesitate to administer them for fear of harming the patient. In rare instances — about 2% to 7% of cases — the drugs can cause bleeding in the brain.
But not using the drugs can also have consequences. A national study published in 2020 found stroke patients were less likely to receive those medications in rural hospitals than urban ones, and stroke patients were more likely to die in rural hospitals.
Telestroke programs can help bridge that gap, said Dr. Amelia Adcock, a neurologist at WVU Medicine in West Virginia and head of the system’s telestroke network.
By connecting doctors from smaller, often rural, hospitals with an on-call specialist at a large medical center, the programs allow people “to share the burden of decision-making,” Adcock said. And the liability.
Dr. Michael Gould is an emergency medicine doctor at the 25-bed Potomac Valley Hospital in rural northern West Virginia. His hospital is not stroke-certified and does not have a neurologist on staff. He said giving clot-busting drugs is “one of the decisions in medicine that makes me the most nervous.”
But consulting with neurologists at WVU Medicine’s hub about 80 miles away in Morgantown has given him more confidence, he said. Gould estimated he now administers the drugs once or twice a month.
A study of WVU Medicine’s telestroke network found the number of stroke patients receiving clot-busting medications nearly doubled over the first three years of the program.
Last fall, Christopher Green was picking up groceries when he suddenly developed a severe headache and lost his peripheral vision. Green, a longtime paramedic, immediately recognized what was happening. “Oh, my God, I’m having a stroke,” he remembers thinking. He was brought to Gould’s hospital, and the ER staff immediately fired up the telestroke program.
Within 30 minutes, Green got drugs to break up the blockage in his vessels. "A textbook outcome," said Green, who has responded to many 911 calls for stroke.
Looking back, Green said he probably would have taken a patient in his situation to a farther hospital that was stroke-certified. But experiencing the telestroke program firsthand changed his outlook.
”Now I see that delaying that treatment 20 to 30 minutes makes a difference on whether you have a full resolution or some kind of residual effects,” he said.
‘What could it have been?’
Back in Tennessee, Debbie Cook was grateful her mother was taken to the advanced-care stroke center in Knoxville. It allowed Lottie Crouch to get the treatment she needed so she can still lead a mostly independent life.
But there were trade-offs. The distance took a toll on the family. Cook, her sister and her daughter took turns driving nearly two hours each way to watch over Crouch in the hospital each night.
After 10 days, when Crouch was transferred to a rehab facility closer to home, the family felt a sense of relief. They could bring her meatloaf and wild blackberry dumplings for dinner. And “a lot of peppermint candy,” Crouch recalled — her favorite.
Although Crouch is now healthy and at home, her 27-year-old granddaughter, Haelee Stockton, is still haunted by the possibility of what could have happened that day. If the paramedics hadn’t made it in time or if bad weather had prevented the helicopter from flying, her granny might not be alive.
“What could it have been?” Stockton said. “How lucky was she? And how many people are going to get that lucky in the future?”
(Aneri Pattani led the reporting and writing for this story. Hannah Recht led the data analysis and graphics. InvestigateTV’s Daniela Molina contributed to this report. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.)(c)2021 Kaiser Health News Distributed by Tribune Content Agency, LLC