As the third leading cause of death in the United States, stroke affects all our lives and is an important topic for medical interpreters to understand. Stroke is also extremely complex, with numerous risk factors, warning signals, and types.
On Saturday, March 5, 2011, CultureSmart will host a medical interpreter training workshop with Judith Welch Clark, RN, BSN, the stroke service nurse at Boston Medical Center. Judith will discuss critical aspects of stroke – from risk factors to ongoing therapies after release – and look at the interpreter’s roles in caring for stroke patients.
The interview below introduces you to Judith and her tremendous clinical knowledge of stroke. We’ve bolded key terminology, linking some words to further information. To join us on Saturday, March 5, please visit this link to register.
1. What are the primary types of stroke? What are the most common causes and risk factors for stroke?
There’s embolic stroke, where the clot comes from a source other than the brain: it could be from the heart or carotid artery. The other type of ischemic stroke is thrombotic, from a localized source, cerebral arteries that are diseased or damaged. Hemorrhagic strokes are intracerebral, which could be from taking Coumadin, or subarachnoid, usually from an aneurysm or an arteriovenous valve malformation.
We manage stroke by managing risk factors. High blood pressure is the biggest cause so when patients come in, we monitor their blood pressure. We teach smoking cessation. Smoking affects your vascular function: it makes the vessels weaker. Diabetes and high blood cholesterol are important factors. Atrial fibrillation is another factor, as is illegal drug use.
2. What difficulties do providers face when discussing risk factors and lifestyle changes with patients?
Language barriers and cultural differences. With recovery, people often seem to feel that ‘Okay, I had the stroke, I’m going to do a good job.’ They get better, they’re taking the meds to make them better. And they are better: they’ve lost weight, they’ve exercised, and then they go off their meds. One of our biggest concerns is that they don’t understand that these meds are for the rest of their life. In our population, a lot of people are homeless or immigrants, and they don’t have health insurance, and a lot of the copays for the meds are very high.
3. Do you have any special advice for calling an ambulance in a case of suspected stroke?
When they call, people should say that they’re experiencing stroke symptoms. We teach patients about recognizing stroke symptoms using “FAST”: F=Facial droop, A=Arm movement, S=Speech abnormalities, and T=Time. Other symptoms could be lack of feeling, tingling, or sudden blindness on one side.
Time is very important. I tell people to call now because the EMS system is trained for triage. A stroke is considered a cardiac arrest. Patients go to the top of the line if they’re having stroke symptoms. We have a lot of time targets to meet in the Emergency Department with stroke patients, so it’s important to call 911 immediately if anyone has symptoms. If they show up within 3.5 hours of symptom onset, they may be eligible for a clot-busting drug called tPA.
4. How do providers assess patients suspected of having had a stroke?
Our physicians use the NIH Stroke Scale. It takes about eight minutes to do, and it’s important for interpreters to know. We ask the patient to do certain things, such as touching a finger to the nose, to help to determine where the stroke is. Certain symptoms go with different parts of the brain. Another symptom is sudden onset: stroke is usually sudden. We also get a history, both to determine when the patient was last without symptoms and because certain diagnoses ahead of time make you more at risk for a stroke.
5. What typical tests and analyses are conducted in the hospital? Is there a test that’s considered most definitive?
There’s some that we do right away: CT scan of the head, coagulation studies, and electrolytes, BUN, and then creatine. Then we do a urinalysis and a tox screen, kind of a drug screen for people. Later on that day we usually do an MRI, and then the next day we check cholesterol levels and HGBA1C. Then we do an echocardiogram. An MRI will tell you if you had a stroke, but an MRI doesn’t always show it until later so we don’t rush in most cases. We do the CT to make sure there’s no bleeding in the brain.
6. What are the most common treatments for patients immediately after a stroke, while in the hospital?
If they meet the criteria, they might be able to be given tPA. Interpreters are asked to help obtain consent for tPA because it puts patients more at risk for bleeding. A lot of times patients can’t talk so it’s very important that the family understands. The decision for tPA needs to be made quickly. The time target would be start the tPA within 60 minutes of crossing the ED’s threshold, so there’s no time to speak with everyone in the family. Sometimes it is a life or death matter, so it’s good to discuss in advance who would be the spokesperson and how aggressive they would want care to be, keeping in mind what the patient would want.
7. What are some of the typical therapies that patients undergo after hospitalization?
The most important would be antiplatelet therapy, aspirin, Plavix, or Aggrenox, or sometimes Coumadin, an anticoagulant. Other common meds are antihypertensives, to lower blood pressure, and statins, for cholesterol. Physical therapy (PT), occupational therapy (OT), and speech therapy might also be recommended. Most people need both PT and OT. A high percentage go to rehab hospitals after acute hospitalization.
8. What should interpreters and family members know about transferring stroke patients to home after hospitalization?
They need to be aware of ‘deficits’ and safety concerns. Some people are blind or have what’s called ‘neglect’ on one side, and they don’t realize they have this. OT teaches them about that. Some people lose sensation after a stroke so they need to be especially careful near the stove and hot and cold water. Some people are aphasic and lose their speech but others have cognitive deficits, like not being able to do math or read anymore. And you don’t find out until they come home.
9. What else do you think medical interpreters should consider when interpreting for stroke patients?
There are some common complications after stroke, like aspiration pneumonia and deep vein thrombosis. Some people who aren’t able to swallow without aspiration might need a feeding tube. Some of the things we need to teach patients in patient education before they leave are stroke warning signs and symptoms and how to call 911. We also talk about the meds we send them home with, risk factors that might have caused their stroke, and the need for follow up with their doctors. We stress to start taking their meds before talking with their doctor. For prevention: lose weight, eat a healthy diet, eat enough fruits and vegetables, enjoy regular physical activity, limit alcohol, take medicine as prescribed, and know what your blood pressure should be. Ideals can vary, so ask your physician where your blood pressure should be.