How NASA’s Challenger tragedy influenced the way we treat stroke victims
Televisions were strategically positioned in the Clear Lake High School hallways in suburban Houston on Jan. 28, 1986. The TVs were broadcasting the late-morning launch of the Space Shuttle Challenger.
Dion Graybeal was among those shuffling between classes and catching glimpses of the countdown with fellow student Scott Smith, the oldest child of mission pilot Michael J. Smith.
The excitement quickly turned into grief as the spacecraft disintegrated over the Atlantic Ocean 73 seconds after liftoff. Classrooms stood empty as students and teachers ran to pay phones to call friends and relatives at NASA to find out what had happened and the status of loved ones. NASA’s switchboard collapsed under the call volume.
Dion Graybeal, MD, now medical director of the Baylor University Medical Center stroke center and neurologist on the medical staff, later asked his father what happened.
The elder Graybeal was a NASA engineer who wrote protocols and policy manuals for space missions (Example: What do you do if the ants escape the ant farm while in orbit?).
His father’s analysis of the explosion? “A cascading failure only needs one bad decision to start.”
That answer stuck in the mind of Dr. Graybeal. He would inherit his father’s appreciation for process and eventually wrote the protocols for handling Baylor University Medical Center at Dallas stroke victims using tissue plaminogen activator (tPA), the standard clot-busting medication. This protocol just saved its 700th patient this month.
A patient loses 1.9 million neurons each minute a stroke is untreated.
Speed is everything in stroke treatment because “time is brain.” A patient loses 1.9 million neurons each minute a stroke is untreated. That means a stroke victim’s brain ages 3.6 years per hour.
Dr. Graybeal’s protocols ensure that the Baylor University Medical Center at Dallas’ comprehensive stroke center is built for speed, minimizing indecision and wasted motion.
Like his father, his focus is on consistency, safety, and building a system. It is also important not to administer the clot-busting drug when it is not warranted.
“We work to refine the process so that it will always work the same for each patient,” Dr. Graybeal said. “For example, we have certain inclusion and exclusion criteria to determine when to treat (with the clot buster, tPA). Maybe the patient is already on blood thinners or is too elderly. If we only decided on treatment with tPA based on their symptoms, we risk seeing brain hemorrhaging. Just like there were circumstances for the space shuttles that were triggers (for specific actions), it can be the same for stroke treatment.”
The American Heart Association has three levels of quality achievement for stroke centers regarding tPA treatment: honor roll, honor roll elite and honor roll elite plus. The elite plus category means patients receive tPA within 60 minutes at least 75 percent of the time and within 45 minutes at least 50 percent of the time.
Baylor University Medical Center achieved that performance for four of the last six months.
The original National Institute of Neurological Disorders and Stroke (NINDS) trial published in December 1995 led to the U.S. Food and Drug Administration’s approval of tPA. That study enrolled 624 tPA-eligible patients over nearly four years at 43 U.S. clinical centers. Baylor University Medical Center alone treated that many patients in about 10 years.
“It’s not about how big we are,” Dr. Graybeal said of the 700-patient milestone. “It’s about the impact on our community. It means there are 700 Baylor Scott & White Health patients we helped to save from disability from their strokes, many of whom had a chance to returned to work and a normal life. It has been an honor to be entrusted with that many patients over that period of time.”
Coincidentally, I am one of those 700. I had a stroke on Wednesday, Feb. 26, 2014, and was treated by Dr. Graybeal’s team.
I was patient No. 544.
Thanks to swift administration of tPA, I was doing 30 minutes on an elliptical machine and lifting weights five days later.
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