MD Roundtable – Neuro Exams

Neurological Exams

I’d like to introduce you to Dr. Matthew Eshelbach. Dr. Eshelbach has been with us for several years. He’s up on the northwest coast and he is not just an emergency physician, 9-1-1 doc, teaches on the 9-1-1 circuit, but he also is the chair for the medical school up there.

So he has a lot of background in EMS operations and EMS paramedical level experience as well as EMTs and AMTs. And so far it looks like most of you guys on your paramedic, but I see at least one P1 or AMT student and one EMT student. And as you know, even with paramedical level type discussions, there’s a lot of the EMT nuggets and lower level that comes into that because you have to have those basics in place.

So don’t let the fact that sometimes we start discussing paramedic level stuff fool you or make you think this is not applicable to you, because you can pick out what you need for your level out of each of these roundtables. We do expect you to participate and to participate, you can either type in the chat room or better yet, just unmute your microphone and ask your question and then re-mute your mic. But we do need you to either answer a question, ask a good question, give some good nugget of feedback, something so that we can give you a grade for either your EMT roundtable or if you need it for your chat room.

So that having been said, Dr. Escherbock, I’m going to mute my microphone and turn this over to you. Very good. Well, welcome everybody.

Sorry for the little slow down. I’m going to turn my camera off because it helped me with the broadband. Sometimes it comes in and out and I’d rather have you hear what I’m saying and see me.

So we’re going to talk today about the 10 second neuro exam and the 10 minute neuro exam and the 10 hour neuro exam. You’re going to be around for one and two. You won’t be around for the third, but we’ll explain that as it goes.

So what is a stroke? Got lots of names. It’s changed over the year. Apoplexy is a real old term.

Stroke, CVA, which stood for cerebrovascular accident, and brain attack is what they call it when they try and get you to move fast and have it sound like a heart attack. So time flies, tempus fugit. Over the course of the last 30 years, the treatment of stroke has moved from a very passive observation, trying to see passively what goes on with the person, see if they get better in a couple of days versus aggressive action and diagnostic treatment, which we’ll talk about tonight.

Wait and see is given away to a two hour window, and the two hour window is given away to the 12 hour window, the six hour window, 24 hour window. It seems that stroke, there’s never a time that’s too long for stroke treatment. Initially, I was asked in 2005 at the EMS conference on the coast to give an update on stroke in 2005.

Why 2005? Well, that was the first year that the American Heart Association included stroke in getting people to emergency rooms quickly and a triage and a chain of events. And the name of my talk at that time was stroke, where are we today? Hurry up and wait. The public was poorly informed.

Response time was too slow. Very often, people presented too late and the hospitals were not prepared. It was our fault for not being prepared.

You guys would rush people there and we would just sit and wait. And it was a fatalistic view, as opposed to where we were in 2021 and 2024, where people are much more responsive. Presentation is never too late and hospitals and systems are much better prepared.

There might be two hospitals within 10 miles of each other, but one might be a stroke center and EMS knows which one to go to. And we now have clearly defined protocols. Sorry.

So here is that chain of survival that you will find in your basic cardiac life support books, rapid treatment and getting these people into a stroke unit for rapid admission. What we do in that algorithm is we get things ready very quickly. Notice this check glucose right away, because the worst thing to do is spend $10,000 on a CAT scan when your blood work comes back and it says that your patient’s blood sugar is 26 and you probably should have checked that to begin with.

You give them some glucose and their stroke symptoms go away. That can happen and I’ve seen it happen. People, you see these on billboards all the time.

They talk about fast with face drooping, arm weakness, speech difficulties, and that’s time to call 911. There’s even an app that you can download from the American Heart Association in English and Spanish that help you determine whether or not someone is having a stroke. So it is now part of the mainstream.

No sound, sir. Oh, very dramatic in Hollywood, but very true. So our objectives are to identify and understand strokes, differentiate the different types of them and the causes of them, learn rapid evaluation so that we can actually do something, suggest that differential diagnosis is what else could it be, and develop secondary and tertiary exams, which we’ll talk about as we go along.

So what is a stroke? Brain ischemia is what it is and it’s lasting seconds to minutes and it can sometimes last for longer periods of time. Neurologic symptoms don’t always reflect the presence or absence of infarction in the brain. I’ll talk about that in a little bit and treatment depends on identifying the cause of the symptoms.

So time is brain and brain attack and heart attack are now likened to each other. So what does EMS have to do with this? Well, here is a typical protocol like we have and you’ll see that we make sure we ask right away to do a 12 lead with universal precautions and then try and get a blood glucose and if it’s low, immediately treat it to see if the symptoms go away. As I said, there’s nothing worse than getting to the hospital and alerting the stroke team and getting the CAT scan ready or giving a CAT scan and finding out that the blood sugar was 26.

And then transporting, here we have in Bend is our major hospital, Redmond is one of our minor hospitals and we have two other minor hospitals and we try and get these people right away into a place where they can be quickly CAT scanned and we can activate the chain. So you’ll follow our protocols are designed to get the person to the right hospital as soon as possible. So what is a stroke? Is the stroke a block or a bleed? And there’s two times a stroke.

There’s an ischemic stroke that can come like a heart attack with cholesterol blocking a vein or a bunch of platelets blocking an artery or there could be a bleed hemorrhagic stroke which can cause significant symptoms of stroke. Now ischemic strokes are a blockage and oxygen-rich blood can’t get past the blockage and therefore the brain distal or after the blockage begins to die whereas the artery bursting and bleeding will also lead to the same thing because fresh blood can’t get there and the artery will die. That’s why we don’t have EMS giving clockbusters in the ambulance for stroke symptoms because if it’s a ischemic stroke, great, but if it’s a hemorrhagic stroke, you’re going to cause this person to die very, very soon.

So the types of stroke, again, ischemic. Lacuna is an area down here where the tiny small vessels are or is it a thrombus meaning a clot that broke off from somewhere else and then traveled. That’s a thrombus or an embolism which is one that also traveled from somewhere else as opposed to the hemorrhagic stroke which you can have internally in the small vessels or externally in the large vessels and I’ll go over those in a few minutes.

This, you want to come back to it, look at it again. You can see that there’s different types of strokes, hemorrhage, hemorrhage, ischemic and ischemic and it kind of lines up with just what I showed you. So endocerebral hemorrhage, that’s a bleed when the arterioles and small arteries in the brain begin to bleed and they form this hematoma just like if you sprain your ankle and you get swelling, that’s a hematoma and that accumulation of blood over minutes to hours can be like a snowball rolling down a hill.

It causes increased intracranial pressure, high blood pressure in the brain, some other bleeding can happen and what happens is sometimes tumors bleed or ruptured veins can bleed and over minutes to hours you can develop stroke type symptoms. Subarachnoid hemorrhage are rupture of arterial aneurysms and these are usually caused by high blood pressure, for example, and you get blood into the cerebral spinal fluid and that blood spreads quickly and then you can get deep coma-like symptoms as well. We’ve got two questions in the chat really quick, but is having images, resources, and CT scan really the main differentiation and what makes it a stroke center? The answer is no.

A lot of hospitals have CAT scans. A stroke center is someplace where a hospital, and I’ll go over this as we go forward, differentiates treatment. Is there someone in that hospital who can snake a wire into the brain and remove the clot? That’s the difference between a hospital and a stroke center, not a CAT scan.

Would a blood clot in the brain give the same symptoms as bleeding? The answer is yes. Okay, so here’s intracranial hemorrhage versus a subarachnoid. This person is bleeding into their brain as opposed to someone who has the subarachnoid hemorrhage and the symptoms are going to be very, very similar.

You don’t really have to know the difference. It’s up to a stroke doctor after a patient gets a CAT scan to help me figure that out, so you’re not going to be able to differentiate that right away. The only thing you might get in the history is someone would say they were fine and they had the worst headache of their life and they heard a pop in their head and then they had symptoms.

That is historically something that somebody who has a subarachnoid hemorrhage will tell you. The worst headache of their life and they heard a pop and they can tell you exactly when it happened. We’re going to talk about symptoms a little bit and the symptoms of stroke.

Subarachnoid hemorrhage, sudden severe headache, worst headache of my life. It’s usually lateralized, meaning left or right, 30 percent of the time and it may or may not be associated with a brief loss of consciousness, nausea, vomiting and a very quick neurologic deficit like they can’t talk or can’t move their arm or something like that. Now we’re going to move on to ischemic strokes.

Again in the chat, just a second. No, it’s just a thank you. Okay, you’re welcome.

Three main types of brain ischemia, thrombosis, embolism and hypoperfusion. We’ll talk about those. Brain cells in the affected area of a clot will die.

These dead cells release chemicals that set off a chain reaction called the ischemic cascade. Once the ischemic cascade begins, the chain reaction will lead to more brain cells dying. Here, for example, here is a thrombus, this blood clot here, and you can see that the platelets are contributing to the size of the clot and blood tries to squeeze by in maybe an area where there is what we call collateral flow, where other arteries might serve this area, but here’s the main area and you see this white area just like we did with heart attacks.

That’s the infarction zone and this penumbra is this gray zone and if this gray zone gets bigger and bigger, eventually it looks like this infarcted area and those brain cells die. The blood is compromised but not completely cut off because maybe there’s collateral flow helping, but if this is in an area of your speech or in an area of your movement of your arm, that’s why you get weakness in your arm. This penumbra will come back to when we talk about MRIs.

Without prompt treatment, this penumbra will eventually also die. If the clot is way down here or way up here, this area all becomes infarcted and will die and this penumbra will get larger. Thrombotic strokes are those which happen when a thrombus or a blood clot forms in an artery either by maybe reduced blood flow or some kind of fragment that breaks off and travels from one artery to another and they can either be large or small vessels in the brain.

Again, with the embolus blocking flow, you’re trying to get oxygen to this area of the brain and the brain tissue begins to die. If the clot is maybe people have a hardening of the arteries in their maybe internal carotid arteries, maybe you had an uncle or an aunt or a grandmother or a grandfather who had surgery on their internal carotid arteries to make them open, that’s what happens in these areas. You get this blood, a tiny little piece of this clot breaks off, travels up into the brain and then the bleeding cascade begins, platelets stick around and you can’t get oxygen.

Where do they come from? These are all the types. These are the type of stuff that your emergency physician and your neurologist have to know. You don’t have to know but they come from different things in the heart, either heart disease, heart failure or maybe a dissection of the aorta, all that type of stuff.

Embolic strokes refer to an embolism and an embolism is a piece of debris or a clot that starts somewhere else and then travels to that area of the brain. So it will travel and what we have to do is figure out where the clot came from to solve the problem. We have to go backwards, figure out if there’s maybe there’s clots in the heart because the blood is too thick or part of the heart isn’t working well.

That’s something that we have to figure out down the line. These embolic strokes are broken into four different types, either from the heart, from the aorta, from an arterial source or sometimes we don’t know where the clots came. Systemic hypoperfusion happens when we have a circulatory problem.

So maybe somebody had a and it leads to ischemia in the heart, which leads to ischemia in the brain or a pulmonary embolism or not enough oxygen. So what happens here is let’s say, for example, somebody hung themselves and somebody finds that person and resuscitates that person and they have brain damage and stroke-like symptoms because they weren’t getting enough oxygen. So what is a stroke? And the old guy asks, what are the symptoms of the stroke? Slurred speech, droopiness, arm weakness, tingling.

What about tingling in the nether regions? And she goes, no, that’s yourself. All right. What other things can cause symptoms? What’s in the differential diagnosis? Meaning what else could it be? Here’s the big one for you guys.

Hypoglycemia, maybe drugs. So if somebody is suspected of having drugs, you might give them Narcan. You check their blood sugar, make sure it’s in a reasonable area.

If it’s 26, you give them some glucose and their symptoms might get better. But it could also be all these other things. Seizure, tumors.

Conversion reaction is what happens when people have a bad psychological reaction and they think they’re having a stroke, but it’s caused by something else like a hidden depression or an anxiety or something like that. These things are kind of up to the ER doc to figure out. This one is up to you to figure out.

Hypoglycemia, drugs. Try and figure that out. So again, injury or death from the brain tissue is because of interruption of blood.

It can be caused by ischemia or hemorrhage. Sudden loss of consciousness can also happen. So the initial assessment aimed at first the basic and focused neuro exam, quickly moving to diagnostic treatments and time is brain.

We like to get that golden hour taken care of from the onset of symptoms to some type of definitive treatment less than an hour. Not always possible. So again, vital signs, including a blood sugar, history, physical, and then the diagnostics happen sometimes in the ER.

Key considerations with the neuro exam. When was the person last seen normal? Do they have a history of bleeding or trauma? Have they had prior strokes? Again, do we check that blood glucose? So you should be sick and tired of that blood glucose, but believe me, I have been all the way to getting somebody in the CAT scan only to find out that the blood sugar wasn’t checked in the field. Are they taking blood thinners, which might make them much more susceptible to having a stroke? This BFAST is right in our protocols.

This exact if you want to cut and paste this, you can, but balance, finger to nose, eyes, face, arm extension, speech. We’ll go over all of these and then time of onset. So here’s the BFAST.

Can they take, let’s see if this is the doctor on the right and patient. Can the patient follow you? Can they take their finger and put it on your finger and then put it on their nose? Can they walk? Do they have balance or are they off balance and falling like a drunken sailor? Can they follow you? Can they, your finger moving to right to left, are the extra ocular muscles working? There are visual field deficits. You don’t know, have to know all of these, but you’re going to want to know if people lose vision way out here.

If they lose vision out here, it’s because maybe this area of the brain is not getting oxygen. So for example, watch this blue line here. All right.

Excuse me. I’m going to make it easier for you and say, watch the yellow line because the yellow line would give this picture on the right. Heminopsia means you only see half of things.

So person, we’re going to follow this back, follow this back, follow this back. And then maybe somewhere in here, they’re not getting enough oxygen and blood supply, which gives them this outside area where they can’t see. Those are what we call visual field deficits.

And you can, people can tell you that they can’t see something way out here as you’re moving your finger. Again, the BFAST face, this is obvious. Look at this guy.

He’s got a squint and a drooping of his mouth. This woman, for her arms, she hold it up. She’s, you try and get her to hold it up for a good 10 seconds, but in a couple of seconds, this arm is falling down.

And then speech. You can’t teach an old dog new tricks. So you say to the patient, repeat after me, you can’t teach an old dog new tricks.

Now, somebody who’s having a stroke might go, old dog, old dog, or that’s all they can say. Or they might look at you and laugh and you say, can you repeat that for me? And they go, old dog, old dog. And they can’t say, you can’t teach an old dog new tricks.

And then you want to know, when was the last time they were normal? Did that happen right when Vanna White was turning the letters? So it happened at 7 15 or between 7 and 7 30. You want to approximate as best you can what time all of this happened. All right.

So this is a picture of a large vessel occlusion. This is a stroke in the middle cerebral artery. So what happens here is, here is the, as you look at it, right is left.

This is your left internal carotid artery. And then it breaks off into the middle cerebral artery. And then it supplies this half of the brain.

But where the stroke is, you can’t see die. So all this area of the brain is not getting oxygen. So when a CAT scan is done, it’s done in two phases.

The first thing the doctor will do is take a regular CAT scan to see if there’s a big collection of blood. Then they’ll inject a die so that they can look and see where in this circle of Willis, the circle of Willis is at the base of the brain. So if you were to hold the brain in your hand, this circle of Willis would be on your palm.

This is where all the circulation goes. So you’ve got the communicating arteries and cerebral arteries. And this circle right here is what is determining what is giving you all the symptoms.

So this is just a big view of all the arteries in the brain. This is just for reference. You don’t have to remember these, but you’re going to want to know if you get an anterior cerebral artery stroke, stroke in the anterior cerebral artery will result in opposite leg weakness.

Now, that’s really something that a neurologist is going to know better than me or you, but we can try and pin down in the old days, they could figure out where the stroke was just by the symptoms. So there’s an anterior cerebral artery, a middle cerebral artery. This is the one that we see most often face, throat, hand and arm and speech.

The middle cerebral artery is also the most treatable of strokes. And we’ll talk about that in a few minutes. The posterior cerebral artery is going cause some weird things like colorblindness and not being able to see to and fro to the right and left.

You might get that word salad or hallucinations. And then you might wind up with opposite visual field defects where they can’t see things in the left eye. These again, a CAT scan will tell you these things much better, but in the old days, these neurologists, before we had CAT scan, could tell you where the stroke was just based on all the symptoms.

And then the lenticular system, these lacuna strokes or these tiny, tiny areas, these are usually much too small to do anything about. And these are the type of strokes that recur frequently and old folks may have what we call multi-infarct strokes. And over time, some people get what we call multi-infarct dementia, where they get Alzheimer’s type of symptoms from having too many strokes in this area.

Again, it’s not something that you’re going see on a test, but you’re certainly going to see that you may have heard this before, and they all come off this middle cerebral artery. So the area of the brain that gives symptoms is directly related to the circulation that is being inhibited. So what about the Cincinnati? We do that all the time.

We do gaze, arm weakness, and level of consciousness. And in our area, if a C-stat is positive, it’s defined as a score of greater than two, and we’ll try and get those people to a stroke center. All right, I’m going to look at a somebody mentioned Bell’s palsy.

Joe Dean mentioned Bell’s palsy. Bell’s palsy is a little bit different because the forehead is usually involved, and we kind of rule out other things first. So that’s a good thing to think about Bell’s palsy.

And believe me, I have scanned people with Bell’s palsy only because I wasn’t completely convinced that it was just Bell’s palsy. Is that helpful for the ER doc if we do a killer physical exam and localized symptoms, or does anyone get in the scanner and it doesn’t make a difference? Well, no, it’s really good if you can give the physician a killer physical exam, and you can tell them that, you know, this is weird when they’ve got colorblindness. That’s going to, oh man, this is probably something that I’m not going to be able to treat right away.

TIAs, that’s a whole nother symptom group. TIAs are temporary, and what happens is the body actually breaks the clot down on its own, and we get only temporary symptoms. Is there any data suggesting that part of the brain that they originate from? They originate from all different places.

However, if someone has a TIA, there is a 10 to 20% chance that in the next three months they will have another stroke. That’s why we take TIAs so seriously, and TIAs should be taken to the ER. Most people really shouldn’t refuse transport.

You should go, you know what, there’s a 20% chance you’re going to have another stroke, and we need to find out where the problem is. Possible lacuna strokes come with TIAs, yes. Data suggests that a history of TIAs, yes, is more likely to suffer, and the answer is yes, 20%.

So burn that in your memory. You’ve got a 20% chance of having a stroke in the next three months. You need to go to the hospital.

Very good question, Tim. All right, so here’s a C-STAT exam. Gaze, inability to look both ways, the arm weakness, level of consciousness.

Do you know what today is? Can they follow directions like squeeze my hand or repeat after me or touch your finger to your nose? These are all part of consciousness. So treatment by EMS, what do you guys do? Number one, you recognize the stroke. ABCs, establish onset in history.

You perform a killer exam, as someone said. That’s great. Check the glucose.

Let the hospital know very early that you’ve got a stroke and rapid transport to the appropriate center. Now, sometimes, what’s the appropriate center? Let’s say two hospitals have CAT scans and MRIs and only one of them has an interventional person who can actually get that clot. It might be just as good to get them to the closest CAT scanner so that they can diagnose that it’s not a bleed and they can figure out where it is, and as you’re going to transport them to the other hospital, they can give clot busters.

That’s also a possibility. All right, so diagnostics immediately. What does the ER doctor do? If you haven’t done an EKG, they’re going to do it.

We’re going to get blood work ready. We’re going to get that CAT scan with or without contrast, and don’t worry about that. I’ll show you these so you have something in your mind that you can see.

Immediate diagnostics are aimed at ruling out other causes of stroke and mimics. So, for example, we might find that’s a really high white count with a fever, and maybe this is an infection in the brain and not a stroke. Maybe we’re dealing with sepsis, or maybe old folks have stroke-like symptoms when they’ve got bad urinary tract infections.

So, all our diagnostics are looking at other possibilities. So, here is a really good example. Here’s a regular CAT scan.

A CAT scan, and you can see that there’s no bleeding in this CAT scan. So, then we go on to give dye, and then the radiologist with this nice arrow here is telling us this area is suffering a clot. Then we do an MRI, and we can see this penumbra, and we can see that area of the stroke with the MRI.

Then our interventional radiologist, interventional neurologist, or interventional neurosurgeon snakes a tiny little catheter in here, finds the clot, pulls it out, and then look, yeah, circulation’s back. So, when we do a CAT scan and an MRI a day later, you can see that the area of the penumbra has shrunk and not as much brain tissue has died. So, that’s an aim.

So, the CAT scan reveals no bleeding. CT with contrast reveals an artery occlusion. MRI reveals a large penumbra.

Angiogram is done after the removal of the clot, and we show a rest of the stroke, and the cause was secondary to atrial fibrillation. So, maybe they put the person on a blood thinner, and maybe they shocked the heart to put it back in a normal sinus rhythm, or they put them on medicine to prevent the atrial fibrillation to go too fast. So, here’s interventions for stroke.

Watch this video. Hopefully, it’s going good. Here we go.

Let me see. Go back. Here we go.

All right. Here is a patient who is having a stroke, and through the CT scan, we’re going to find that this area right here is where the clot is. So, the interventional doctor goes in.

They find the clot, and now they got to get rid of that clot, and they go through the clot. They pierce it, and then they put this leave through it, and then on the other edge, they’re going to pull back the wire. Now, they’re going to feed another little cage in, and this cage is going to open up as they pull that back.

Now, the cage has grabbed the clot. You can see a little bit of circulation is happening. They close that off, and then they’re going to pull that clot right down the drain, and they get rid of the clot, and voila.

You’ve got re-established circulation, and that’s the difference between intervention and a regular stroke center. So, you get a call from your grandfather that grandma’s had a stroke, and she’s in Louisville. You say, well, is there an interventional person there? You talk to the ER doctor, and they go, well, the interventional person is across town.

We’ll transfer grandma there. I want that clot taken out. So, that’s the way to go.

So, what we’re trying to do in the ER while we’re doing these CAT scans is in that very, very limited time is figure out if it’s anything else other than a big stroke, something that we can do something about. So, this is a nice picture of what the American Heart Association wants us to do. Door to needle in 60 minutes, and that needle is going to be giving clot-busting agents, and what I would like to see is, well, maybe we can give that clot-busting agents, but within that 45 to 60-minute window, can they be in a place where the neurosurgeon or the radiologist or the neurologist can pull that clot out like I just showed? And here we go.

Here’s tick, tick, tick when you guys show up, and then the doctor, you call a stroke, and the stroke team is there to meet the patient, and very quickly, we get them into the CAT scan. We get results back, and we’re ready to give clot-busting agents within the hour. So, stroke treatment and intervention is now regionalized into protocols.

So, you’re going to say if you’ve got a stroke going on in Mrs. Jones, then she is going to go to Mercy instead of St. Mary’s, or she’s going to go to the university instead of somewhere else. So, TPA and clot, this TPA is the clot-busting agent, and then clot retrieval are all part of stroke centers. So, the 10-minute neuro exam.

What’s happening at 10 minutes? Someone else has a question. Let’s see. Oh, okay.

Looks like Jane might have answered a question there. Okay. All right.

So, after you return from the CT, you’re going to go back and look at the person and do a little bit better exam. Listen to the heart and their lungs, and you’re going to do an extended neurologic exam. You’re going to try and figure it out before the CAT scan figures it out, and you’re going to look and see if these people can walk or talk or if they can do things, and then determine the workflow in the next 10 to 24 hours.

Do I keep this person here? Do I send them to a stroke center? Do I get neurology involved? Do her surgery? Do I get an echo done, an ultrasound of the carotid vessels? Do I talk to the rehab doctor? All these things and things that the ER doctor’s going to do to kind of direct traffic as to what’s going on. Back to our questions. All right.

What would a stroke lead to if left untreated for a large period of time? Well, I’ll tell you about my neighbor. Bill, my neighbor had a stroke, and I was just a little kid at the time, so I’m going to say this is greater than 50 years ago, and he sat on the front porch. He couldn’t talk.

He couldn’t move his left arm, couldn’t move his left leg, and that’s what they did with strokes at that time. Grandpa had a stroke, and he was wheelchair-bound for the rest of his life, etc. Okay.

A 10-hour neuro exam is going to be done by the hospitalist or the neurologist who’s taking care of the patient and is figuring out what’s going on and what do we want to do. Can we get this person into rehab? Are they worsening over the next 24 hours? Have we got their atrial fibrillation under control? Are they on medications for high cholesterol? Are they on medicines for their high blood pressure that caused the stroke to begin with? Are they going to go to a rehab center when they’re done? They’re discharged, and do they go to the rehab center where they can make this personal function again? You’ve all seen these patients. They might be in your own family who’s had a stroke, and they’ve had miraculous recovery or in between.

Some of our best efforts are heroic, and they’re back to normal, or some of them still have a weak arm or a leg. So, there we go. Any questions, any further questions? I think maybe everybody asked a question, but if there’s any other questions, it’ll help you get credit for this.

I have a question, doctor. What is the future, you think, of stroke care? Obviously, it’s changed so much in the last few years. Do you think there’s any trends that’s going to happen in the next decade or so that we might start seeing in EMS? Well, in EMS, maybe CAT scans in the ambulance, but what’s going to happen is getting further down the line.

Let me go back to a picture where we talked about a clot, and we’ll go over those. So, here’s your middle cerebral artery, which they can get to, but if you break it into, there’s three parts of it. There’s the first part, the second part, and the third part.

Right now, they can get clots in the first part and maybe part of the second part. I’m thinking that someday they’re going to have much better treatment by getting maybe nanobots in that can go after the clot. Wouldn’t it be great to inject some kind of nanoprobe that can go to a clot and chew it up? Possibility.

I bet you they’re working on those types of things all the time. So, that’s where I see the future is, getting to these areas that are tiny. Right now, you’ve got to really stretch to get to here, but can we get to here? Can we get to here? That’s, I think, the future.

So, that’s a good question. I have one. Can you briefly go over the difference between distinguishing stroke versus Bell’s palsy? I know that one distinguishing factor between the two is the raising of the eyebrows.

Is there anything else that you can definitive distinguish between the two? Yeah. I’m going to, let me see. Where’s my video? Look at my video here.

Let me see. Can you see my face? There we go. All right.

The facial nerve has five branches, and the five branches go like this, and it’s the temporal branch and subocular branch. You don’t have to know all these, but Bell’s palsy, it’s the facial nerve that’s affected. So, people who have Bell’s palsy will have just the facial nerve that’s involved, and they won’t have symptoms in their hands and their legs and in their speech.

Usually, they wake up with these. Sometimes, I’ve been convinced that this looks like a facial palsy, and I’ll make sure by getting a CAT scan just to make sure. Sometimes, these people are put on steroids, which are helpful.

Sometimes, they’re put on anti-herpes medicine because sometimes it’s a herpes virus that has affected the facial nerve. So, as you look at that, as you go on the diagnosing and you google Bell’s palsy, it’s the facial nerve that’s affected, and it goes just like this. My thumb goes up to here and down to here.

So, it takes a lot of time, and sometimes you’re still not 100% sure. Thank you. You’re welcome.

Thank you, doctor. I have another question for you, if that’s all right. Sure.

What’s the I stand for? It stands for Ireland. Ireland, okay. All right.

Thank you. You said something very interesting before about decisions to what a hospital to go to, and that it might be better to go to a hospital that’s closer rather than one that has an interventionalist or something like that because they can transfer them with the drip, so to speak, while on the way maybe to have better care. I was wondering if you could talk more about that and what we should be aware of when making that decision because I know it’s also very important they go to the interventionalist in some cases.

Your medical director will have made that decision for you. In our area, we have a group of medical directors that get together and say what’s best for the patient. So, let’s say, for example, that you can get to this point at hospital A, all right, from zero to 60 minutes, you can get to this point and push the, this says, alter place.

That’s a generic for clot busting agent, and then it takes 15 minutes by helicopter to get them to the place where someone’s going to go in and grab that clot. So, your medical director in concert with other medical directors will look at and decide where is the best treatment happening. If we can get, if we’re five minutes away from St. Mary’s and we can get all of this done in 45 minutes, and we’ve got a stroke plan and a stroke unit, and we’ve got a way to transport them for intervention if they need it.

Sometimes they don’t need intervention. Sometimes there’s no one who can do the intervention. Sometimes there are contraindications to doing this heroic intervention because they might have had two or three strokes before, they’ve got terminal cancer or something like that.

So, your medical director with the other medical directors will say, okay, get them to St. Mary’s and then St. Mary’s to then transport them, and St. Mary’s will have an agreement with, let’s say, university hospital to transport these people within 60 minutes. Or they might say, you know what, take the extra half hour to get them to university, but now we’re that much further down the line because there are so many other things other than a stroke that they can actually do something about that might lead to that discussion. So, leave it up to your medical director and hopefully universal regional protocols that say take them here, there, or go there.

In our region, for example, trauma and heart attacks that are diagnosed by in-the-field EKGs that show a STEMI bypass the smaller hospitals and go directly to the trauma center and go directly to the place where someone can take them right to the cath lab if they’re having a STEMI. Strokes are a little bit different. It’s sometimes a little bit different thing.

I hope that answers your question. Thank you. That helped a lot.

All right. Lovanda, did you want? Someone asked about, yes, Lovanda asked, could a stroke lead to death? And the answer is, you bet. In those strokes where there’s bleeds going on, big bleeds, those types of things can happen when we get those bleeds, like that’s a thrombotic, but people have died from strokes with these bleeds because the pressure gets so big that too much brain dies.

And that is, Lovanda, that is definitely something that can happen. Thank you so much. You’re welcome.

Anybody else got anything? Okay, Dr. Eshelbach, thank you so much. And I appreciate you being patient with me tonight all. I hope you feel better, Jane.

I appreciate that. I’m supposed to be heading for Oklahoma City tomorrow for the COAMPS conference, so I sure hope so. Everybody, take your positive energy and send it Jane’s way for quick healing.

It’ll be awesome. Thank you. Good night, everybody.

Good night, everybody.