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Hematopathology Moment

BAT Attack

Bruce T. ADORNATO

Imagine a warm summer evening - crickets chirping, and a lone light burning in an unnamed academic hallway. An aging neurologist is working after hours, sorting yellowed diagrams on a work board for his morning lecture to the medical students. Out of the inky darkness comes a light rap, then two light raps hit the closed glass door of his office.

"Come in", the neurologist offers.
A small white-haired man in a tan duster inquires,
"Are you a neurologist?"
"Yes, how may I help you?"
"I think I am a moth."
The neurologist, slightly annoyed by the interruption, replies,
"You don't need a neurologist if you think you're a moth.
You need a psychiatrist. And," he adds after a moment of reconsideration, "the psychiatry department is just down the lane next to the stream."
The white-haired man thanks him for the directions and is just about to exit, when the neurologist adds:
"Wait. By the way, why did you stop in here?"
So the man replies: "I saw the light on."

- - - - -

The story demonstrates, among other things, the patient care value of interdepartmental cooperation. And one of the remarkable attributes of the clinical neurosciences program at Stanford is the interdisciplinary cooperation among clinical neurology, neurosurgery, neuroradiology and neuropathology. This was the opinion of the JCAHO which in August recognized our Medical Center as one of the first certified Stroke Centers in the country.

One of the derivatives of the Stroke Center is the development of a Brain Attack Team (BAT), which is on call 24/7for strokes at the hospital. The stroke team will be available to anyone at the medical center to evaluate and treat suspected brain ischemia.

"Brain attack" is a takeoff on "heart attack" in an attempt to convey to the public and health care workers that stroke is not necessarily a fait accompli. There is at least one demonstrated intervention, TPA, that helps, and many other factors need evaluation and monitoring to move toward a successful outcome. In many ways, the situation is analogous to the mid-60's when hospitals began installing coronary care units and myocardial ischemia became an urgency. Up until then, heart attacks were treated with bed rest, diet and comfort care. Over the years interventional cardiology has become life saving and heart attacks are treated as code 3 events. We predict the same will occur with stroke.

One of the important aspects of brain ischemia as well as myocardial ischemia is timing. Intravenous TPA currently has a three-hour window and the window for intra-arterial thrombolysis is six hours. The sooner appropriate patients are treated with TPA, the more likely they are to have a favorable outcome. In an effort to speed up the diagnosis and treatment of strokes that occur in hospitalized patients at Stanford, the Medical Board recently passed a proposal to allow nurses to activate a new "stroke code" system. Activation of the system will lead to an immediate visit from the in-house neurology resident who will assess the patient. If a stroke appears to be the most likely diagnosis, then the Brain Attack Team (BAT) will be paged urgently. Concurrently, the housestaff or attending physician will be notified.

The BAT consists of the stroke fellow in neurology and the stroke service attending as well as the crisis nurse, the CT tech, nursing supervisor and patient transport. This group will expedite the evaluation of the patient and, in conjunction with the patient's regular attending physician, institute emergency therapy if appropriate.

There is no charge to the patient for this service. While, at first glance, this might seem an unnecessary incursion into the patient-physician relation, I feel it is not. Delay in diagnosis is a significant problem in intervention. This immediate access to expert consultation will be a benefit to our patients and an extension of the hospitalist concept which has been mutually beneficial to patients and staff. Hopefully, more patients will be candidates for intervention by this early warning system.

See you next month. Same BAT time, same BAT channel

badornato@stanfordmed.org