Industry leaders discuss options for improving stroke care in Hawaii
Industry leaders discussed options for improving stroke care and how strokes are impacting Hawaiians during a community education webinar on Saturday.
The Hawaii Stroke Coalition hosted the event, which featured local data presented by doctors and advice on healthy post-stroke living from a stroke survivor who has become a competitive athlete.
Strokes are the top cause of chronic disability and the third-leading cause of death in Hawaii. Dr. Dan Galanis, Epidemiologist for the Hawaii Department of Health’s EMS & Injury Prevention Branch, said Hawaiians 85 or older made up the highest annual rate of hospital admissions for stroke among residents with a rate of 138.7 per 10,000 people from 2019 to 2021.
Hawaii healthcare facilities rank higher than the US state average for treating stroke patients with intravenous thrombolytic therapy within 45 minutes of arrival. The state’s annual proportion of ischemic stroke patients to receive that treatment within 45 minutes of arrival was 76.3% in 2022, compared to the US average of 63.5%. The state’s average was higher than the US average in every year since 2014.
“You can see going back to 2014, Hawaii has been better in this outcome than other states,” Galanis said. “The overall state numbers for Hawaii look really good mostly because [The Queen’s Medical Center] is hitting this at 88%.”
An area the state can improve on, according to Galanis, is increasing the number of patients who arrive at healthcare facilities using EMS for transport. Healthcare professionals aim to educate residents that stroke care starts sooner if they utilize an ambulance to transport a patient, rather than driving them to a hospital themselves.
“What we want to see is patients coming by EMS,” Galanis said. “Only about half the patients are arriving by EMS and that’s discouraging.”
Hawaii’s annual proportion of patients arriving by EMS was 55.3% in 2022, compared to a US average of 57.7%.
Dr. Matt Koenig, Neurointensivist at The Queen’s Medical Center in Honolulu, said doctors have a greater chance of successfully treating a stroke patient if treatment is started in the first 60 to 90 minutes of a stroke. That is why patient transportation by ambulance is important, he said.
“Every minute that goes by, you’re losing about two million brain cells,” Koenig said. “Don’t overthink things and think, ‘Can I drive faster to the hospital myself?’ Don’t drive to the hospital, and don’t wait. Instead, call 911. Care starts in the ambulance. Even if you think you can drive there faster, the personnel in the ambulance start patient care.”
In order to improve patient outcomes, Queen’s is rolling out a new initiative to deliver telemedicine care while a patient is in an ambulance, Koenig said.
“The goal is to speed up treatment, and get a lot of treatment done prior to the patient’s arrival to the hospital,” Koenig said. “We can use video to begin treatment with a patient in an ambulance.”
As doctors have improved care over the past couple years, a patient’s chance of dying from a stroke is decreasing, Koenig said.
“Stroke has become more treatable over time, and we’ve done a better job in caring for stroke victims,” Koenig said.
It is also important for Hawaiians to be able to recognize signs that might suggest a friend or family member is having a stroke, Koenig said. Those can include sudden numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion; difficulty speaking; difficulty understanding speech; decreased vision; dizziness; loss of balance; lack of coordination; and difficulty walking.
“It typically affects one side of the body and not both sides,” Koenig said. “Stroke can manifest in different ways so it’s important to recognize the signs. Ask for the patient to smile and look for symmetry. Check for speech problems. Minutes count and we need to be able to restore blood flow to the brain as fast as possible.”
Kevin Rhinehart, Executive Director of Stroke Survivors CAN!, had an acute stroke in January 2012. He recovered, and now runs in triathlons and marathons to help show other stroke survivors they can be successful. He said grieving is an important part of recovery.
“I found help through grieving, community, and vision,” Rhinehart said. “It’s a daily and lifelong process. I can stop any time and lose sight of hope. Occasionally, I take a break from hope, but overall I choose to pursue hope.”
Grieving occurs in several stages, Rhinehart said. The first stage is denial.
“I went through denial because the first few days I was in the ICU, people were talking about the stroke but I didn’t hear,” he said. “It wasn’t until I went to the rehab hospital that I came to see in black and white that I had a stroke. Another part of denial is [being] unaware that my life had been so altered.”
The second stage of grieving is anger, Rhinehart said. He was angry that his stroke interfered with his life of working at his psychotherapy practice and playing music.
“This is really about fear of being vulnerable, rejected, and useless,” he said. “And I really felt fear. I didn’t know if I would be able to live independently. I was afraid of losing my practice, and I did, but it’s all fear. And being a psychotherapist I recognized that anger is a disguise for fear.”
The third step of grieving is bargaining, and the fourth is depression, Rhinehart said.
“It took a while to have a new reality set in,” he said. “I wasn’t going to go back to work. I wasn’t going to be able to play bass. And the new reality, I rebelled against that because that was not what I wanted. This, for me, took the longest of the four stages. And I wasn’t visibly depressed. I wasn’t crying. But I was isolating, and that’s a warning sign.”
Once stroke survivors accept their new life circumstances, they can form a vision for their life, Rhinehart said.
“The final ingredient of finding hope is the role of vision,” he said. “So many stroke survivors lose their sense of vision. They are in a place of, ‘Life is over and I’m useless and I would rather die or watch TV 24/7.’ But what gave you vision before you had your stroke, and is there anything you can use here?
Go to a list of strengths before your stroke and apply them after your stroke because you are the same person. Granted, you are in a different place but your strengths have not left you. And look within. Although you have a stroke or work with someone who had a stroke, hope is an invaluable asset to maintain.”