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This ER Doctor Has a Plan to Stop A Killer

By radically rethinking the way her San Francisco hospital treats victims of strokes, Debbie Yi Madhok is saving both time and minds.

Madhok, center, and colleagues at Zuckerberg San Francisco General Hospital view a CT scan of a stroke victim’s brain.

 

About six months ago, on a Sunday afternoon in July, a paramedic unit notified the emergency department at Zuckerberg San Francisco General Hospital (ZSFG) that it was bringing in a 70-year-old patient who was unable to speak and immobile on one side of her body. The woman’s husband had told the EMTs that his wife had been fine when he’d left for church that morning. When he’d gotten back, he’d found her stricken in the bathtub.

The patient happened to arrive one day before the hospital was to roll out a new, rapid-response protocol for ischemic strokes (i.e., strokes caused by blood clots in the brain). The protocol was designed by Dr. Debbie Yi Madhok, an attending physician of emergency medicine and neurocritical care at ZSFG. In stroke treatment, Madhok knew, time is a patient’s most precious commodity. Every minute that a major blood vessel in the brain is blocked, an estimated two million neurons are deprived of oxygen and can die. Brain damage from an ischemic stroke happens so quickly that a 20-minute delay in care can cost a patient 1.2 years of functional brain life. “As trite as it sounds,” Madhok says, “time is brain.”

On that day last July, Madhok had been working for nearly a year to implement the new intake procedure, which she dubbed the Mission Protocol after ZSFG’s surrounding neighborhood. Her goal was to cut out every minute of delay from the moment stroke patients arrive at the General’s door to the moment they receive medicine or are rolled into surgery. (While designed for ischemic strokes, which account for 75 percent of stroke incidences, the protocol was also expected to streamline diagnoses for patients suffering from hemorrhagic strokes.) The hospital, Madhok believed, was ready to institute her new plan. So instead of going through the previous paces—transferring the patient from the EMT gurney to a bed, evaluating her, calling for a neurological consultation, waiting for a neurologist’s assessment, rolling the patient to a CT scanner, taking her back to bed for medication, weighing surgical options—Madhok launched the Mission Protocol a day early.

With the debilitated woman en route to the hospital, Madhok watched as emergency department doctor Remy Bizimungu and stroke neurologist Sharon Wietstock waited at the door closest to the CT scanner. When the woman arrived, they evaluated her as she was still lying on the EMT gurney— no reason to wait for a bed—and confirmed that she did indeed have paralysis on one side: a clear sign of a stroke. They took her to be scanned, which revealed an ischemic stroke. Wietstock and a nurse prepared and administered a medication called tPA to break up any blood clots that might be causing it. Then, when a second CT scan revealed that a clot was cutting off blood flow in a major blood vessel in her brain, they wheeled her to surgery to remove it.

Doctors can use interventions like these to reverse the devastating effects of strokes, resulting in seemingly miraculous recoveries in which the paralyzed walk and the speechless talk—but only if they can perform them in time. National guidelines recommend that stroke patients receive tPA within 60 minutes of the time of arrival (though the American Heart Association would prefer 45) and that surgery be performed to remove a clot (a procedure called an endovascular thrombectomy) within 120 minutes. Those windows, though, can be meaningless if a patient doesn’t get to the hospital in time.

On that Sunday morning, Madhok and the team in the ED had no idea how long their patient had been stuck in that bathtub—her husband couldn’t say. It was not clear yet that their interventions, no matter how speedily applied, could save her.

 

Madhok began thinking hard about the logistics of stroke care in 2010, when she was working overnight in the neurological intensive care unit at New York–Presbyterian Hospital. One of her patients had been seriously impaired by a massive left internal carotid artery stroke—a blockage in the vessel that delivers blood to one half of the brain—and there wasn’t much Madhok could do to help her. “If you had to pick the worst stroke to have, this would be up there,” Madhok says. “Not only does this artery feed half of your brain, it feeds the half of your brain that is responsible for your understanding language and being able to speak. It manages the whole movement of the right side of your body.”

The patient was given tPA in hopes of breaking up the clot and restoring blood flow, but the blockage was too severe. Endovascular thrombectomy—a procedure in which doctors insert a catheter into an artery in the groin, guide it through the vascular system to the blood clot in the brain, corkscrew into the clot, then pull it out the way they came—was still considered too experimental. “It was devastating to watch the decline of this woman,” Madhok says. “She passed that week, and she was 50 years old.”

The experience stuck with Madhok. Then, five years later, “something really incredible happened.” In 2015, the New England Journal of Medicine published five separate articles from hospitals around the world establishing endovascular thrombectomy as the new standard of care for patients with clots in major arteries in the brain. “This is what I had been waiting for since I saw that patient in 2010,” she says.

By that time, Madhok was finishing up a neurocritical care fellowship at the University of Pennsylvania, where she helped implement a stroke care protocol similar to one created in Helsinki. Both models prioritized getting patients to treatment as quickly as possible. Madhok liked Helsinki, but thought it had a few problems. One, it cut ER doctors out of the process. When EMTs called in a stroke, only the neurologist would meet the patient. But what looks like a stroke can be a symptom of another problem, like nonstop seizures, or a major traumatic injury to the aorta, the largest artery in the human body—problems a neurologist might not catch. Two, it was created before endovascular thrombectomy became recommended for clots in major vessels in the brain. And three, it was created in Finland—a country with a wealthier, healthier, and more homogeneous population than you’ll find in most metropolitan areas of the United States.

Now that endovascular thrombectomy was an option for so many patients, Madhok wanted to create an improved version of Helsinki at her next hospital, a protocol that would serve a diverse and often underprivileged population. She even mentioned it to Dr. Claude Hemphill, the chief of neurology at ZSFG, during her interview process there in 2015. Doctors at the General had been working to cut down on what Hemphill calls “door-to-needle” time for about 15 years, but making change in any big system isn’t easy, much less in a hospital that acts as safety net for an entire city.

When Madhok arrived at the General in September 2015, she spent a year learning its systems and hierarchies—not just in the emergency department but in neurology, too—and getting to know her fellow doctors and nurses. (The ED alone has 400 nurses.) There was also a slew of meetings to convince all the stakeholders that a modified Helsinki approach was the right one. Then it was another 10 months of training and practice on mannequins with everyone, including EMTs, nurses, nurse’s assistants, residents, CT scan techs, and all the doctors from both departments. The process required a level of coordination “that has not happened before and does not happen in many places,” Hemphill says. A year in the making, the Mission Protocol was ready to launch in July 2017, when the EMTs called to say they were bringing in a 70-year-old woman who couldn’t speak and could barely move.

 

Debbie Yi Madhok was born in Mount Vernon, New York, in 1979, one of three sisters. Though she grew up with her mother in Rye, a wealthy suburb of New York City, her father stayed in working-class Mount Vernon, where he served as the police department physician and chief of the local hospital. Madhok’s father’s career left a mark on her; she may not have planned to be a doctor, but she did want to somehow save lives.

As an undergrad at Brown University, she read an Economist article on microloan financing and bartering systems that gave her an idea for financing healthcare clinics in developing countries. Double-majoring in economics and international relations, she set in motion a plan to complete an analyst program at an investment bank, earn an MBA, and then land a job at a place like the World Bank. In June 2001, Madhok graduated from Brown and joined Goldman Sachs in New York. “I figured I was on my way to saving the world,” she says. But not long after she started her job, terrorists attacked Lower Manhattan.

Madhok had thought it would take her years to get into development work, but because of the attacks, there was a sudden surge of it in New York. Madhok left her job and went to work for a firm whose big client was the Lower Manhattan Development Corporation. Now free of investment banking hours, she decided to take a community college class at night for fun. Ignoring the fact that she hadn’t taken the prerequisites, Madhok settled on microbiology. One night, her teacher pulled her aside and told her that she should go to med school.

Around the same time, Madhok decided to take a week off work and headed to Puerto Vallarta with a friend during her college’s spring break. While there, she got a midnight call informing her that her sister, Christine Yi, had fallen onto the subway tracks in New York and been run over. Emergency responders had to lift the train off Yi to get her off the tracks, and she was in critical condition. It took Madhok almost 24 hours to get to the hospital, where she stayed for a week before she was sent home to shower. Her sister spent more than three months in the hospital, endured more than 15 surgeries, and lost her leg.

“I got to witness something very beautiful in the hospital—nurses, doctors, techs, everybody working together as an orchestra to save my sister’s life,” Madhok says. “It made me realize I had to find a way to become a doctor.” Madhok adjusted her life plan. She would still make sure that forgotten populations got the medical care they needed— she would just do it as a physician on U.S. soil, rather than by funding medical clinics abroad.

After more community college classes, a one-year postbaccalaureate degree from Bryn Mawr, med school at Albert Einstein College of Medicine, an emergency medicine residency at New York–Presbyterian, and the neurocritical care fellowship at the University of Pennsylvania, she landed at the General. “When your mission in life is to take care of the forgotten,” she says, “there is only one choice in the Bay Area.”

 

Zuckerberg San Francisco General Hospital is the city’s only trauma center. And thanks in large part to Priscilla Chan and Mark Zuckerberg’s record-breaking $75 million donation, it now has what Madhok calls the most sophisticated neurointerventional suite on the West Coast. For a physician whose goal is to improve stroke care outcomes for everyone, a need-blind hospital with a racially and ethnically diverse set of patients was the ideal place to create a new protocol.

Treating patients with the same conditions in the same way seems like a no-brainer, but statistically, not everyone gets the same level of care. Studies have found that black patients receive clot-busting therapy less frequently than white patients. Women get less endovascular therapy than men. And patients who don’t speak English and don’t have insurance typically get less of everything. In 2016, ZSFG treated 345 stroke patients, 30 percent of whom were Asian, 22 percent Latino, 23 percent African American, and 19 percent white. By creating a rigid process to assess every emergency room patient—almost a living flowchart—Madhok is hoping to ensure that there will be no difference in treatment among her extraordinarily diverse patients.

But eliminating differences in treatment can’t happen only at the hospital, she realized. In the spring, the team at the General will start the next two phases of the protocol: free training for EMTs and ER doctors in San Francisco and community education. On EMT education day, the team will make sure that paramedics know the signs of stroke (confusion, facial drooping, weakness in one side, difficulty with speech), which hospitals offer endovascular thrombectomy (in San Francisco, only ZSFG, UCSF, and California Pacific Medical Center), and to notify hospitals that they’re on their way as soon as possible. With  community members, the team will work to drive home the signs of stroke, when to call 911, and, perhaps most important, the need to minimize delays in getting to the hospital. Part of that education, points out Dr. Christopher Colwell, the head of emergency medicine at ZSFG, is explaining how much has changed in stroke care over the last couple of decades. Even if people see symptoms of stroke, they may not realize that doctors can potentially fix what used to cause lifelong disabilities—if, that is, patients get to the hospital in time. Madhok, her team of med students who are helping to track the Mission Protocol’s data, and other volunteer doctors and nurses will be going to churches, community centers, and parks to talk about the signs of stroke. At events in the Mission, they’ll have Spanish speakers; in SoMa, Cantonese speakers.

In the six months the Protocol has been in place, Madhok, Hemphill, and Colwell say, they’ve already seen serious improvement. Door-to-needle time has dropped from around 45 minutes to under 20. “What could 20 minutes mean?” Hemphill asks. “It can mean the fundamental difference between being severely disabled and a near-complete recovery.” Increasingly, doctors at the General say, they are seeing patients come in seriously impaired and be back on their feet the next day. “Now that this protocol requires immediate attention, everyone is more in tune to when stroke victims are coming in, and paying close attention to whether it’s the real thing and whether we need to intervene,” Colwell says. “We’re seeing the impact already.”

And it’s not just on patients. EMTs don’t usually get a chance to see the results of their work; their turnaround time in the hospital is just 15 to 20 minutes. But Colwell says that under the Mission Protocol, he was able to show one paramedic a patient who, having come in unable to speak, was talking again— before the ambulance left for its next run. Another time with another EMT, a partially paralyzed patient was walking. “You could see in the paramedics’ eyes that they’d never seen something like that,” he says. “They go back and tell their colleagues how exciting it is. It generates excitement across the board.”

Some of that excitement has influenced stroke care at other hospitals as well. According to Anthony S. Kim, associate professor of neurology at UCSF, the hospital was considering implementing the Helsinki model but instead decided to wait until Madhok arrived (she’s also a professor of emergency medicine at UCSF) to get her input. “Her efforts at ZSFG definitely greased the wheels here,” he says. Though it’s clear that the new process has cut down on door-to-needle time at the General, Madhok won’t be able to write up the findings until she has a year’s worth of data. It’s too early to say if the Mission Protocol has improved patient outcomes across the board. Anecdotally, though, she has seen much that gives her hope.

With that first Mission Protocol patient, the one who arrived after her husband discovered her in the bathtub, Madhok watched as the team in the emergency room got her to tPA in 16 minutes and into surgery in under an hour. And though they had no idea how much time had elapsed between the onset of the patient’s stroke and her arrival at the hospital, the woman was transferred out of the General the following day, able to speak and walk normally.

And this seeming miracle hasn’t been the only one. On the weekend before Thanksgiving, a particularly vulnerable patient—an 80-year-old Latina woman unable to speak or move the right side of her body—arrived at the hospital at a particularly bad time, a Sunday morning. “At any hospital in America, it’s hard to get the same treatment on Sunday morning that you would on another day,” Madhok says. The patient also didn’t speak English. But with the Mission Protocol now ticking like clockwork and a Spanish translator on hand, the patient made it to tPA in under 20 minutes. Later, an attending anesthesiologist told Madhok that he witnessed something he described as “amazing.” Patients undergoing endovascular thrombectomy are conscious during surgery and free of tubes in their mouths. In the middle of the procedure, as the doctor monitored the patient’s breathing, her lips began to move. Then she started to talk. The next day, the woman left the trauma center for her own hospital, speaking and mobile again.

 

Originally published in the January issue of San Francisco

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