When Everything Goes Right

Debbie Thomas

While attending the bi-monthly EMS Collaborative meeting at Sentara Williamsburg Regional Medical Center recently, attendees were notified about a Stroke case in which everything came together perfectly and produced optimal outcome for the patient.

Great things often happen at every hospital and for every agency in the PEMS region. Sometimes we hear about it, sometimes we don’t. As the Clinical Programs Coordinator for PEMS, I facilitate meetings for our Stroke Task Force and I know first-hand the great stuff we are doing region-wide. I am sharing this report because it demonstrates best practices in Stroke care across the spectrum.

In this particular area of the PEMS region, direct transport to a Comprehensive Stroke Center for patients with RACE scores of 5 or greater would extend transport time by more than 15 minutes, so agencies routinely transport to the closest Primary Certified Stroke Center.

Even though an agency here isn’t going to bypass based on the RACE score, SWRMC stresses it is still important for them to perform the RACE evaluation, issue a Stroke pre-alert and report the score enroute to the hospital. Doing so enables the hospital to prepare and initiate their plan for management of the patient which may include transfer to a Comprehensive center.

Here’s the story:

  • 82 year old male traveling from PA to Florida with family
  • Family states the patient had no complaints and seemed normal.  He got up from the table, took a few steps and collapsed to the floor; awake but unresponsive at approximately 1515 hours.  Family immediately suspected a stroke and called 911.
  • James City County Fire Department dispatched a medic unit at 15:21 hours.
  • Patient had a RACE score 7 with right-side paralysis and aphasia (inability to speak).
  • Blood glucose checked - 107
  • Blood drawn and IV established.
  • JCCFD medic marked enroute to SWRMC at 15:41 and called in the "stroke alert" to SWRMC at 15:42.
  • JCCFD marked arriving at SWRMC 15:48 (33 minutes after stroke onset)
  • SWRMC documents an EMS door time of 15:53.
  • Patient is seen briefly by Dr. Boesler and taken directly to CT by EMS (Having EMS transport directly to CT eliminates time otherwise spent transferring the patient to an ED bed only to transfer again in CT.)  Every minute counts!
  • Patient's weight was recorded at 16:00.  Accurate patient weight is essential for correct dosage of tPA.
  • CT started at 16:02 – 9 minutes after arrival.  (The CT scan is required to diagnose a hemorrhage, which would be a contraindication for tPA.)
  • Neurology evaluation in CT 16:07 – Patient had an NIHSS (National Institute of Health Stroke Score) of 21, which is quite high.  Nuerology orded alteplase and a CT-Angiogram.  (The CT-Angiogram uses an injection of iodine contrast medium along with the CT to evaluate the condition of blood vessels.  In this case, within the brain. 
  • Alteplase (a medication used to dissolve blood clots) was started in CT 16:15

22 minutes from Door to Needle - Excellent!

1 hour from Stroke Onset - Amazing!

  • Patient exhibits marked improvement in movement to right upper and lower extremities within 30 minutes of alteplase administration.
  • NIHSS changed from 21 to 6 within 24 hours
  • Discharged to Inpatient Physical Rehabilitation on day 4.
  • Discharged to home on day 15.
    • Able to ambulate with walker
    • Able to do most Activities of Daily Living with little assistance
  • The patient has shared his story here:



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Protocol Changes (1)

Two Protocol Changes will go into effect today (2 April 2018) at 1000. Both are administrative changes which by policy do not require approval by the Medical Advisory Committee.

Change 1 is located in the Administrative Policies: STEMI Field Triage.

  • The "Acute Coronary Syndrome" protocol referenced in the Administrative Policies: STEMI Field Triage is incorrectly titled.  The correct title is "Medical: Chest Pain-Cardiac Suspected."

Change 2 is to the "Medical: Chest Pain- Cardiac Suspected" Protocol.

  • The correct oxygen saturation value is <94%. This corrects a typographical error and does not represent a change in  clinical guidance.

PEMS website links to protocol files have been updated.

Agencies with printed protocols be sure to download, print, and insert change pages.

All users of the protocol app will update automatically when connected to Wi-Fi.

Request for EMS Assistance: Airpower over Hampton Roads 2018

18-20 May 2018, Langley Air Force Base, Hampton, VA

Coordinators for the Airpower over Hampton Roads 2018 air show are looking for EMS support for this event.  We are looking for ALS or BLS ambulances staffed with qualified crews for the following shifts:

Friday 18 May, 5:00 pm to 11:00 pm
Saturday 19 May, 9:00 am to 5:00 pm
Sunday 20 May, 9:00 am to 5:00 pm

This is a great opportunity to show off your people and your apparatus.  Please contact us at 804-693-6234 or email This email address is being protected from spambots. You need JavaScript enabled to view it. for further information or to volunteer to support this event.

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