Time Is Brain: Why Aren’t Mobile Stroke Units Everywhere? | Dr. May Nour

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And so when you're doing a startup, a new idea, a new company, anything outside of the box is met with a lot of opposition at first. Well, this is not c- Hmm... cannot be doable. This has never been done before.
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So we had to really negotiate that. Welcome to the show, everyone, where we talk about innovation in medicine before the outcomes are certain. I'm Timothy Wheeler, and I'm joined by my co-host, David Tsai. Dr.
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May Nour is an interventional neurologist, meaning she removes blood clots from inside the brain. Early in her career, she saw the same thing again and again. The patients who reached her in time got better.
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The ones who didn't often never would. So May built a hospital on wheels, California's first mobile stroke unit, deployed to the neighborhoods where strokes are most common and hospitals are farthest away.
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Her team proved it works: 40 minutes faster, measurably less disability. And still, mobile stroke units across the country have to fight for their survival.
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This is a conversation about what happens when the science is settled and the system isn't. Please enjoy Dr. May Nour.
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We're just beginning, so stay close at beforethecure.org, because at the end of the day, we're all patients, and we deserve better.
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Are you running from the operating room or from- I came home real quick and just will do this and then go back. [laughs] Oh my gosh. Do you ever, do you ever take a break? I don't take a break. That's the thing.
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I don't take a break. Do you have anything you try to incorporate for your, your personal health and wellbeing? And, and what would that be? I do. Do you, what- I do. It's Pilates.
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I, I, I wear heavy lead all day in the an- angiography suite, and so I'm always slouched over, hunched over. I always have back pain.
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So I said, "You know, I heard people said this Pilates thing is very good, so let's try it." I ended up loving it so much that I became a certified instructor. So- Wow... that's my outlet.
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Add that to the list that you have a Pilates certification in addition to everything else. [laughs] Yeah.
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It's funny, I think we actually met Henry Gluck, who at the time was chairman of the UCLA Health Board, introduced us. That's right.
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And when we were walking away from having lunch, he started to go on about, "You have no idea how many degrees this woman has." [laughs] I, I, I have a, a lot of, um, interests, I should say. [laughs] Interests?
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What are those? So I did a PhD in neuroscience, and I ended up doing that in gene theory th- gene therapy for inherited retinal degenerations. Hmm.
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So after I did that, my dad said, "I think you always have wanted to be a physician. Don't regret not doing it."
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I mean, I, I went into medicine because I had a great role model who was a physician, and that was my dad, and I saw how he treated his patients, what he did for them, uh, how much care he had for them and for their families, and the real genuine empathy he had towards them.
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And he was a liver transplant surgeon, pediatric liver transplant, so these are the type of patients you continue with for a lifetime. Hmm.
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And we-- I remember we went to all of their birthdays, we went to weddings, and we went to graduations, and- Oh, wow... they were really part of our family.
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So I quite very much took that to heart in my same practice, and that's why I really love medicine, the impact you can have on someone's life and being there for them at the moment that they need it the most.
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And his job was kind of emergent, like something I picked at the end. Many neurologists do desk, you know, uh, work at the office or, or whatnot.
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Um, but I guess I picked the one percent of neurology that's all emergencies all the time. [laughs] That's amazing, though.
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We, you know, we, we've been fortunate enough to have some guests on here that have those same drive and ethos to be involved with the patients' lives outside the moment of, you know, necessity, but having those con- con- continuing relationships.
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Yeah, absolutely. I think it makes all the difference because the, the jobs we do as physicians are, uh, emotionally, you know, taxing, physically taxing, takes away from your personal life, your family life. And
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if you don't love it so much and if your heart isn't in it for the right reasons, you burn out so much faster. And so I think really understanding the why drives you to work hard every day.
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So I, I actually worked in the hospital, May, uh, UC Davis Medical Center- Did you?... for five years. Oh, that's fantastic. And, uh, in clinical research with, where, with two P- PIs that are both chief of medicine.
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Incredible experience. Oh, that's great. I also have friends that are current physicians as well, radiology, and a lot of them are definitely getting burned out.
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What, what experience did you have that really wanted to make you go specifically into what you're doing now? I was on, um, a clinical rotation
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my fourth year of medical school, and I heard the, the stroke neurologist on that rotation actually telling the residents, "Well, you know, if I were to go back and do it again, I would do interventional neuroradiology.
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Why?
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Because I could see the patients in the ER, and I'm the neurologist who sees them outpatient, but I also could take them to the cath lab and physically remove the clot from their brain and give them restoration of blood flow."
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And so that was actually the t- the point for me. I decided I'm gonna be an interventionalist. I said, "This is the, the job I wanna do. How, how can I get there?"
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They said, "Be the best at the residency you specialize in." And that's what happened. So- Yeah, now talking about specialty, can you first outline to us what is a stroke and- Yeah... who do they impact? Absolutely.
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And I, I especially want to talk about that because I think we have our own vision and stereotypes of when and how a stroke is actually- Yeah... going to impact us. Yeah. So stroke can come in two different types.
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Stroke is basically dysfunction or death of brain tissue. And I like to say that s- the brain is like real estate. It's all about location, location, location.
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There could be very s- tiny eloquent areas of the brain that cause, you know, grave dysfunction if they're disabled, or there could be very large areas of the brain that are pretty mute and don't do, um, a lot if they have dysfunction.
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Hmm. So it's really about what happens and, and where it happens. And it could... The, the dysfunction in the brain can happen because of lack of blood flow to the tissue of the brain. That's the majority of stroke.
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So 87% of stroke are ischemic in nature, where there's lack of blood flow. If there's a blood, um, clot that blocks the tissue of the brain, a flow to the tissue of the brain, then that tissue dies.
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The second kind of stroke, and that's about 13% of stroke, is a hemorrhagic stroke, where there's bleeding into the tissue of the brain, and that also causes the cells to die and cause dysfunction.
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And stroke disproportionately affects older patients than younger patients. So the majority of stroke actually happens over the age of 65. However, stroke can happen at any age.
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That's something I really, really wanna underscore here. Mm-hmm. Stroke can happen to a child, stroke can happen to a young adult, stroke can happen to older adults. Mm-hmm.
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And that's because there are so many mechanisms for which clotting can happen or bleeding can happen. It can be something congenital, like we have a bleeding disorder.
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It could be something like our blood is too sticky and have clots. Mm-hmm. It could be, um, something like even mechanical damage. So we've had, you know, young children who are jumping on a trampoline- Wow...
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and damage to the blood vessels of the brain. And the blood vessels are like an onion with multiple skins. And so if you damage one of those skins, that's something we call dissection.
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Clots can form, uh, between those layers, and then fresh blood washes that clot up, and that dislodges in the brain, and that can cause is- you know, ischemic stroke. So I- That's frightening...
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I like to say what's really important is that we don't discriminate by age. If something looks like a stroke, we have to treat as a stroke. Mm-hmm.
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And, um, but w- but we do know that the majority of stroke occurs above age 65. That's frightening. My two-year-old loves the trampoline. [laughs] Oh my gosh. Be careful. Everything with care.
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[laughs] Everything with care. Yeah. I actually worked on a few DVT trials and Coumadin trials way back when- Oh, see. Yeah. Yeah. Yeah... testing INRs and all that, so. Yeah, exactly. And yeah.
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I, I remember one of the things that the doctor said is wear compression socks when you're flying because that's one of the- Mm...
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the key things about getting clots in your legs, and then obviously you travel, so [laughs] I always wear compression socks. You know, you'll laugh and there's this article by one of my mentors.
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It's middle c- middle seat or economy class syndrome, where patients who are on long overseas flights on the middle seat, they sleep with their neck twisted. Hmm. And that causes sometimes dissections in, in the neck.
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Oh, no. And, and I, I remember such a young patient. It was a very, very sad story.
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A young, uh, dentist traveling back from Dubai in his 30s gets off the plane, and then is completely paralyzed on the right side of the body, unable to speak, gets transported by 911 to a hospital.
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In fact, that's, you know, when he had a dissection and a clot and, and you know, what a life-changing event for a young person- Wow... with a family and a young baby.
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Well, you just pointed something out for me 'cause for some reason I have not liked those neck pillows. Yeah. [laughs] They just have not worked for me. Yeah. So I'm actually that guy. Yes. [laughs] You know?
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I'm the guy that's- Sleeves twisted... crick in my neck. Exactly. [laughs] Usually in economy. Yeah. You know? Yes. Documentary film, independent film- Yes. Yes... going long, long hauls. Mm-hmm.
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So, uh, maybe I'm gonna get a nick- neck pillow. Yeah. So thank you for that. I think that's smart. [laughs] Yeah. You know what? I don't wanna scare anyone because, uh, we all have different susceptibilities.
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We're all built differently. Our genetics are different, and some- Mm-hmm... some patients are more susceptible to having dissections or damage to the blood flow- Mm-hmm...
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um, the tissue of the, the, the blood vessels of the brain because of the building blocks of their, you know, the elastic properties of their vessels. And so we've seen very young patients who come in with...
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I had a patient who had a very severe cough and cold for three weeks, and dissected because of coughing so much. Hmm. But meanwhile, others do, you know, uh, acrobatic things and nothing happens to them.
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So it's not everyone- Sure... that it happens to. But when we, when we see someone who has that, then we say, "Be cautious with anything that involves rapid acceleration or deceleration movements of the neck."
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Yeah, I mean, uh, I think that's, it goes for everything. We don't wanna live- Right... our life in fear. Of course.
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But you're pointing out some, some very valuable information, you know, to, to know that this can impact us. Yeah. There's also a very important term around stroke called time is brain. Absolutely.
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Why is that so important? Well, with lack of blood flow to the tissue of the brain resulting from a major blockage of the blood vessels, for each minute that passes, over two million brain cells are dying. Hmm.
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So that's really impactful. And, and if it's the right two million, that can cost someone their speaking, their ability to swallow, their ability to walk, their ability to live and integrate. Mm-hmm.
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So that's why the essence in stroke is if someone, God forbid, has stroke-like symptoms, the answer is to call 911 immediately and to get to the hospital immediately. Hmm. Yeah.
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So you need to get intervention right away. Intervention right away, and that intervention may mean, um, medical intervention, and that may mean endovascular intervention.
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Medical intervention is we have for ischemic stroke clot-busting medications that we give, and these clot-busting medications are given within a certain time period.
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Because they thin the blood, you don't want to give them after the tissue's already died because then you have return of blood flow to dead tissue, which causes bleeding, so they can be harmful.
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So we wanna make sure that we get to the patient within four and a half hours of their last known normal.
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So the really, really critical thing is, let's say 911 ask the family when was the last time they were seeing their normal selves. When she woke up, her Left side was completely weak. Mm-hmm.
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Well, then sometimes people think, well, the last time they were normal was 6:00 AM when they woke up, and that's really not the right question. The right question was, when were they last their normal selves? Okay.
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Mm-hmm. That was 10:00 PM before they went to bed. So you can see how it can get very misconstrued. They were found with symptoms at 6:00, that's very, very different. Mm-hmm.
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And that is critical to giving the medication that busts the clots. Oh, yeah. So that's one thing. A second thing is understanding what medications they're on. Mm-hmm.
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Because to give those blood thinners, they have to be not on other strong blood thinners. Mm-hmm. Uh, so it's really critical to make sure that that's the case. So knowing our loved one's meds is very important.
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Knowing their baseline, what, what is grandma usually like? Does she normally walk and talk? Does she normally recognize the date and time and where she is? Does she feed herself? Does she bathe herself? Does she...
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All of these things, and basically what is different from her normal today? Hmm. So these are really critical things. And so- Yeah. Go ahead. I wanna get de- I wanna get deep into your experience with your actual- Yes...
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MCU. Paint the picture for a second first, though. When and where did the idea of mobile stroke units come from, and why? Yeah. Yeah, so mobile stroke units actually originated in Germany.
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The concept is not so far-fetched there because actually in Europe, in many countries, there are physicians on the ambulances. Hmm. So any advanced life support call or critical call, there's a physician there.
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There's either- Wow... emergency physician or anesthesiologist or other type of physician. Imagine that. And so the first thing you need to do to treat stroke is to diagnosis, and you can't do that without imaging.
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That's why in the past, patients had to come to the hospital to start that journey, right? Mm-hmm. And they're losing- There was a very-... critical time. [laughs] Yes, yes.
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And there was a very remarkable young man, engineer. Unfortunately, his brother was skiing and had a ski accident, and he was in an area where the brain imaging was not available. Hmm.
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And he ended up having a hemorrhage and passing away from that. And so this brilliant engineer decided to make a tiny scanner that would fit- Hmm... anywhere, that's portable. Wow. A tiny CT scanner.
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So think of this concept, the hospital comes to the patient, and that's where we say a mobile stroke unit is bringing the hospital to the patient.
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And because the time starts at the patient's home, at the gym, at the beach, anywhere where they have these symptoms, not after they're transported. So that happened, you know, now a little, little while ago, 2011.
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That was the first- Yeah, the, it-... mobile stroke unit. That, um, story, the German, Germany story is very Before the Cure. We may have to have him on- Yes... as well, right? Yes. Yes, yes, yes.
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You know, the personal, the personal motivation of, "I, I need to do, do something about this." Speaking of personal motivation, you did establish the first mobile stroke unit with your team here in California.
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When and why did that come up and, and become important for you? Yeah, thanks for asking that question.
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And this has been, uh, really a big passion of mine, and it, it was one of these, again, forks in the road that I didn't expect.
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So I finished my vascular neurology training and my endovascular training, and I thought, you know, I, just like all my other colleagues, would work in a hospital and would do, um, neurointerventions and, and see stroke patients as well and so forth.
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And the idea came up because there was a philanthropist who was, um... and that's Henry Gluck, our, our friend- Right... who we have in common, who's wonderful and a visionary.
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And, and the idea and the concept was, do you wanna give towards something that saves people's lives today? Hmm.
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And he was inspired because h- his father had a stroke, and he saw the effects of the stroke on his father's life. Hmm. And he gave a donation to do that, and they didn't have a champion to build that program yet.
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So when I was finishing my fellowship training, I was offered the position to come in and do all of the clinical things I do in addition to starting this program, and that was in 2016. Wow.
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And believe it or not, the day I started, I didn't know what this program was. [laughs] So I learned everything from scratch. I had some money. I needed more money, and I needed to build a program to do this.
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What are the... who are the ambulance vendors? How do I get the scanner? Who's on the team? So you ran a mini startup, basically. Yeah. [laughs] How do we integrate this within the fabric of EMS?
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That's something unheard of. Mm-hmm. What are the logistics? W- you know, what are the obstacles? We had everything ahead of us. Mm-hmm.
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And so that was such a very unique experience for me, um, you know, coming out of clinical training.
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I don't have any experience in, you know, David, you know, [laughs] this is like managing people and, and changing laws and getting, um, money, but I learned fast. I'm just more impressed that all this was pre-COVID too.
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Yeah. Before everything got decentralized. [laughs] Pre-COVID, exactly. Exactly. And so we were- And that is really the analogy. You know, David comes from the world of start- startups. Startups, yeah.
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The, the, you were, you were a startup, but within the more formal system of U- Right... UCLA Health, correct? Right, right, right, right.
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And, and I would, I would even venture say within the formal system of Los Angeles County. Right. Because we are not, as a academic institution, part of the EMS system. Wow.
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So we had to understand even what are the allowances to allow us to pick up a patient and transport. That was a hurdle. Hmm. Another thing was a hurdle. Another thing was a hurdle.
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So many, and it's really u- unique, and, and David understands when you're doing a startup, a new idea, a new company, is that anything outside of the box is met with a lot of opposition at first. Hmm.
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"Well, this is not c- cannot be doable. This has never been done before. This is the..." So we had to really negotiate that, and, and I think that takes a lot of skill because there's a balance.
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You know, you don't want it- Mm-hmm... to be too, come on too strong. There's a just-right balance to make that happen, and we were- We don't-... very fortunate.
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We don't usually get too into process, but I'm actually- Yeah... curious You know- I was about to ask this too... between the time that you started- Yeah...
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talking about this, you know, mobile stroke unit and that you actually served that first patient- Yeah... what was there... what was the biggest hurdle of all of these big obstacles?
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How do we become part of the EMS system? Hmm. We are not part of EMS, and there are very strict laws, um, and regulations, and we call EOAs or exclusive operating areas for emergency medical services. Hmm. And how
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as a non, uh, EMS, non-911 transport, uh, do we dispatch to a 911 call? Do we pick up a patient without breaking these EOAs? Hmm. And how do we work with multiple fire departments?
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'Cause each of them have their restricted areas. And we got very, very, very, very fortunate to have a good champion for our cause. And actually- Hmm... that was Supervisor Janice Hahn of the County Board- Wow...
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of Supervisors. While we were building this program, we saw a press release in the news that Supervisor Hahn w- wants to start a mobile stroke unit. And we said, "What? How? Where?" [laughs] "How?
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We're starting a mobile stroke unit." [laughs] So we reached out to her deputy health chief, "Hello, we, we would like to work with you," and- Oh, okay...
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and it was at the, at the beginning, w- we didn't know how even she found out about it, and then we later learned that she was- Wait, wait. Was... So they were starting something not, not the same as you?
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Like, they didn't realize you were starting it? Well, they, they, they were not starting. They were just expressed interest in starting. They put a press release to say- Oh, wow... "Supervisor Hahn- Perfect timing...
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is interested in starting this unit- Serendipitous... in Los Angeles County." Yeah. Extremely serendipitous. And, and how she found out is because there was a 20/20 special on the Cleveland Clinic program. Oh, wow.
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She watched it on the news, and she said, "Wow, I want to start this." And actually, her story is remarkable. See, people also... This is, this...
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You know, people harp on the media, but, you know, that's a perfect example of, of, of, of- Thank you... some good media in action. Yeah, yeah.
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A- a- and, and, and if you allow me, I want to tell you her story because it's the neatest one, and she, she tells it so beautifully. But her father was Supervisor Kenny Hahn, okay? He's- Okay. Oh, right...
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very famous in Los Angeles County. Yeah. For sure. There's a whole- Many things are named after him... area of Los Angeles called Kenny Hahn. Yeah, Kenny Hahn. There's a park. Exactly. We hike in it. Exactly.
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[laughs] And so h- he was r- uh, a county supervisor at the time. Uh, Reagan was the governor. And he went to his cardiologist one day, and his cardiologist said, "Do you wanna save an hour or save a life?" Hmm.
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And he said, "Oh, I don't know. What's, what's this mean?" He said, "Well, you know what? Heart attacks should be treated much sooner than they really are.
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And what if the ambulances that come to transport a patient start some therapy for heart attacks in the field?" That was not heard of. There were fire services. There were EMS transport services.
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There were no treatment services in the entire United States.
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And so actually, one of our donors used to be the medical director of the LA City Fire Department at the time, and he said he was getting death threats to his home. Like, "No, we don't wanna do this."
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The fire chief- Wow... at the time said, "My men are men of fire. We're not men of medicine. We are not doing this." And actually- Death threats?... Reagan... Yeah. That seems extreme. [laughs] Seems very extreme.
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Oh, wow. And actually, Reagan at the time said, "When this comes to my desk, I will veto it. I, I don't, I don't approve of this."
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And a couple of weeks before this was supposed to come to his desk, he actually called Kenny Hahn to come to Sacramento, and he told him, "I want to tell you a story.
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Last week, my dad was having symptoms of heart attack," Reagan's dad, "and the mom called 911, and the ambulance came. And when the ambulance came, they said, 'Sorry, this is not within our district.
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We'll send you another ambulance.' And that n- other ambulance never came, and he died." Hmm. And he said, "I want to do this." That's wild. And that's the genesis of paramedicine in the United States. Can you imagine?
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Just like, again, so many reasons, again, that story is very before the cure. It's like once these- Yeah... things touch you and once you realize- Yes... the, the importance of them, then you're like- Yeah...
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"Oh, that- Yeah... seems like it seems like an obvious." So the ironic thing is that Supervisor Kenny Hahn, the last years of his life, lived debilitated from a stroke. Wow.
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So when his daughter saw that, she said, "I want to change. Just like my dad brought p- paramedicine to the country, I want to bring mobile stroke units." And she is our biggest champion.
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And because of that, things worked. You know, you gotta have champions. Mm-hmm. Well, that's just incredible. And obviously, you had the team. You n- you had the- Absolutely...
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the people that are, you know, in government, uh, to, to do this. You had philanthropic donors. Nevertheless, it sounds like you are constantly needing to prove the worth of the program, prove the science.
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You took part of a study. What was that study for, and, and what did it prove? Yeah. So like everything in medicine, we always work with evidence base.
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And so anecdotally, we know when we treat patients sooner, they do better, right? But it still has to be proven. So there were two studies actually happening side by side.
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One was Be Proud out of Berlin, Germany, with our colleagues, and the other one called Best MSU out of the U.S.
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And Best MSU had seven different, uh, mobile stroke units participating, including our Los Angeles County Mobile Stroke Unit.
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And it asked the question, if we give clot-busting medications earlier in the field, uh, versus later in the emergency department, will these patients do better, the same, worse, or whatnot?
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And together, combined, over 3,000 patients in these studies showed that when giving clot-busting medications to stroke patients earlier, even by 30 minutes, by 40 minutes, that out of 100 patients who get treated earlier in the mobile stroke units rather than later in the ER, 27 will have a less final disabled outcome, including 11 of whom who will be completely disability free.
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Wow. Wow. Well, it's huge. Well, I know, you know, my- Speak for myself. Yeah. Mm-hmm... my wife is a neurophysical therapist specializing in stroke.
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And so she is the physical therapist when they're fresh out of the ER and, and helps them regain their faculties. Yeah. Right? And she is so excited- About the mobile stroke unit.
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She was just saying, "You don't understand how important time is brain." Yes. And how you can literally see someone that just had a stroke, starts losing those faculties, and regains them- Yes...
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you know, in, in those moments. Yes. So paint us a picture. When, when did it become so obvious how important this is? Was there a particular patient, a particular experience?
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I think this is a lesson, honestly, we learn every day.
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There are so many countless meaningful patient interactions we've had, but one that really comes to mind, and I was really, really, really touched by, is that we were dispatched to a call a few years ago now with, uh, one of the fire departments in our county, and we arrived to a dentist office for a patient that when she was paying for her dental services, all of a sudden she be- had a facial droop develop.
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Mm-hmm. And they called 911. She was young. She was a young Black woman, 40 years old, and you know we don't tend to think stroke happens in young.
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And when we arrived on scene, the fire department actually discounted us. They said, "Thanks so much for coming. This is not for you. Uh, it's just from her Novocaine shot, you know, that she got for her dental work."
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Yeah. And we said, "Okay. Well, thank you so much. Is it okay if we just take a peek and say hello to the patient?"
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So started to talk to the patient, and she had facial droop on one side and her eyelid closed on the other side, and this is a very specific stroke syndrome. Wow.
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And we asked the question, "H- hey, have you ever had any miscarriages?" "Oh, yes. In fact, I've had seven miscarriages. Oh, I also had a pulmonary embolus.
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Uh, actually I was on Coumadin, and now I stopped it one year ago." Okay. Hmm. Guys, we're gonna admit the patient. Why did we ask these questions?
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Because in some times when we have we call hypercoagulable state or more sticky blood if we wanna say it in layman term- Mm-hmm...
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that, um, these patients often have, commonly have miscarriages, and that's one clue, okay? Then she also had a pulmonary embolism, like David knows about, something very dangerous.
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And so these patients can also have clotting elsewhere like in the brain. Hmm. And nothing in her clinical exam can be explained from what happened at the dentist office,
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and that's where it for the first time it takes a second to say, wow, bringing expertise to the field. I'm not talking about bringing imaging.
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Bringing acumen, clinical acumen to the field, you understand what is a stroke, what is not, not because- Yeah... we are enlightened. It's because we've seen thousands and thousands. That w- Yeah... that's what we do.
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It's by pattern recognition, right? Mm-hmm. So our team admitted the patient to the unit, and once she was admitted to the unit, she became paralyzed in her leg. And so you see how things can evolve- Wow... very fast.
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Wow. But you guys- 40-year-old woman... literally saved her life, basically. Because we gave the clot-busting medication, and her fiance said, "Please save her. She has a son.
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She has another son, this and this, our family. Give her the clot-busting medication." By the time she arrived to the hospital, she walked to the restroom. Wow. It was so touching for me.
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And you know, that was another day at work, and couple of weeks passed by.
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And I have an Instagram account where I share some of the mobile stroke unit stories, and I got a, a direct message and it said, "Well, I'm a high school student. Thanks for saving my mom. She's a, a, a single mom.
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She's raised us." Wow. "She's everything to us, and now she's able to go back to work." That was so touching for me. That's amazing. So touching.
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You know, hearing this story, it's like, seems like an obvious why do we not have a mobile stroke unit- Yeah... in every single community? Yes. Uh, so- Yes... w- what is the answer to that?
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[laughs] So, um, that, that's a great question, and, and I think the answer is complicated.
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We've been able to keep such a program alive for now over nine years by philanthropic donations and funds and support, um, also from the Los Angeles County Board of Supervisors with philanthropic funding from them. Hmm.
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Um, and the reality is everything that happens need evidence base, and then based on that, you need legislative change. Mm-hmm. And what we don't have right now- Okay...
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is the ability to bill for services we render on mobile stroke units because- Wow... they are something new. They're something outside of the box. They're not just a transport ambulance. They're not just an imaging unit.
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They're not just a hospital on wheels. They're a combination of all of the above. So all those separate categories exist for each, nothing exists for all. C- CPT codes. [laughs] Exactly. It's really about CPT codes.
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Yeah. Sadly- That's it. I remember that... people's lives are about CPT codes. [laughs] It's billing codes- It's massive-... to hospitals... to sustain for the longevity- Yeah, yeah...
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even for your program in a major metropolis, right? Yeah, yeah. I mean, I can imagine these units are not cheap.
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So you managed to ri- raise a lot of funds philanthropically, but then y- so what you're saying, you actually... Those philanthropic fund- funds h- also have to extend to paying for the, the patient care?
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There's not a- Oh, absolutely... a system beyond that, that pays for that? Oh, wow. No. Uh, so far everything that we've done, we've not billed the patients for. The only thing that happened- That is incredible...
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in 2022- It's unheard of. Yeah. So in 2022, th- there was a, a bill, a bipartisan bill that, that g- got signed that recognized mobile stroke units as a p- a place of service for telehealth encounters.
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Um, so that's the only thing you can bill for. Ironically, I love, as you know, Tim, to be there in person on the mobile stroke unit.
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That's for me much more meaningful to have the physician in the field, not just taking care of the patients, talking with the families, but also educating the MS, um- Sure... crews. Yeah.
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And having that interchange is so valuable 'cause they take that knowledge to their next run. They're amazing people who really- Mm-hmm... care about the outcome of the patients.
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Um, and so if I'm there in person, I can't bill. Ironically, I can bill by telemedicine, but if I- Wow... provide better service, I can't bill. So even with all of this proof, there's, the data's there, but- Yes...
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still to this day we're stuck, the system is stuck and is not able to support this. It, it takes time. I think we're making some strides. There's a organization called PRESTO- Mm-hmm...
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Prehospital Stroke Treatment Organization. That's actually an international organization that includes mobile stroke units from all over the world. Mm-hmm.
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And there's also a coalition of which I'm the vice president of, called PRESTO Coalition, and we are working with lawmakers and lobbyists to make the legislative change. Mm-hmm. We need champions.
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We need Republican champions. We need Democratic champions. We need a, um, a mechanism to move forward, and we've been doing this for five, six years, but everything takes a lot of time.
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And when we're talking about- So... time is brain, we're talking about- Yes... seconds matter. Yes. And with each person. Yes. Yes. So where are we at now with all of this, getting the legislative change that you need?
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We're not there yet. I think we, we are making good strides and putting samples of what the bills should look like.
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We still need Republican champions, but at the same time, many programs are shutting down 'cause they can't sustain. Right. That's the difficult part. That- It's the expense... and, and the...
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It's expense, and the communities they serve suffer, so. But, but Jesse- The crazy part of this, this is like life-saving treatment. [laughs] Yeah. It just makes sense. Well, and not just life-saving.
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Uh, it, it, it seems these things are always just so backward within our- Yeah... quote, unquote- Yeah... health system, right? Right. But if we do intervene earlier,
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then we're not needing the very expensive care that comes on the heels of that, right? So, you know, how do you even compare? Is it more expensive to not be doing the mobile stroke units?
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What an outstanding point you bring up, that you see, uh, again, out of those 100 patients, 20 are less disabled, 11 are disability free.
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We talk about savings for the direct medical costs of someone who has a stroke is huge.
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The amount of resources they need in the hospital, the amount of resources, as your wife knows, outside of the hospital, somebody who's now dependent on a feeding tube, somebody who's now dependent on a respirator, somebody who's in a skilled nursing facilit- facility for a big part of their life.
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Live, lived for decades with their family- Yes. Yes... and debilitated. I mean, uh, she's a, has a client she's been seeing for years now. Wow. He's 6'5", massive guy. Wow. You know, his family, he's got...
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Bless this guy. He's got a heart- It's really difficult... and perseverance and everything- Yeah... but he's bedridden, right? Yeah. He's now living with it for, mm, 15 to 20 years. Wow.
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So, so there, of course there are the direct medical costs, but also don't forget about the indirect medical costs. Mm-hmm.
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These patients were a part of our ecosystem, were a part, paying taxes and, and getting wages and part of the community, and now that's lost. So you're absolutely right.
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I mean, it makes no sense that we, we pay for these services half an hour later in the hospital- Mm-hmm...
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but we can't pay for them 'cause we can't find a mechanism half an hour earlier and save the health system so many resources. Mm-hmm. Mm-hmm. So.
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I'm curious about, in the ideal scenario, like everything went your way- Uh-huh... what would your vision be? Like, should every hospital have one? Should these mobile stroke units be parked, you know, every few blocks?
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Like, what, what would you ideally do to have a bigger impact? Yeah. Great, great question, David.
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So in order to operate these, they are most effective in about a 10-mile radius or a 20-minute radius as the traffic may be.
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You know, in places less, like, say, Los Angeles County, we have to think about traffic really, not distance. And so we always wanna add to the care. We never wanna take away from the care. What does that mean?
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We, we are dispatched jointly with the regular crews. We are not replacing the dispatch. The issue is that there's a lot of inaccuracy in the dispatches in 911 all over the world, not just- Mm-hmm...
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in our system, not e- even just in our country. All over the world. Because the call taker, in reality, has a few seconds to make an impression. "Grand- Uh, hi, my grandma fell out of bed. She's weak on the left side."
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Okay, this may be as a trauma run. Mm-hmm. Okay? "Oh, okay, my grandmother was weak and then fell out of the bed." That may be a stroke run. Right. So how does the mobile stroke unit attach to the right call?
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And so we need to work on accuracy of dispatch. There are many, many ways to do that with new AI co-pilots, with education of dispatchers.
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In, in Los Angeles County, for example, we have 28 911 responding services, each dispatch differently with different algorithms, with different rules. There should be ho- homogeneity somewhere.
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It's when, when dispatchers dispatch for an advanced versus basic life support call, they are making the correct call 99% of the time. But they are not used to having to dispatch for a specialized service.
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It doesn't matter. Once you get the right type of ambulance to them, the paramedics will understand what's happening on scene and, and work accordingly. But if you have a specialized resource, you can't afford that time.
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You need to, to do the correct dispatch at the get-go so these units can be tagged to them. So my ideal situation would be these have to be integrated as part of EMS system, not as part of a hospital system.
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They have to be non-denominational in what they do. They have to be a community resource. That's what I really pride ourselves in, in our program- Yeah...
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at UCLA, is that this is a community resource for Los Angeles County. This is not a UCLA Health transporting rig. This is operated clinically by UCLA Health. Mm-hmm.
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But it is a shared regional resource of Los Angeles County EMS, and that's one of the laws or rules or regulations we had to change to be able to do this, to be able to transport, to be able to work with multiple fire departments.
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We went from working with one fire department in one community in Santa Monica to working now with nine different fire departments over
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30-some cities, and we deliver to 20-some stroke centers, to the nearest stroke center that's most appropriate. So- Yeah, so you transport throughout Los Angeles to various hospitals- Oh, yeah...
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depending on- Of course... their location, depending on their needs Yes, depending on the level of care of the hospital. So really the key here is that these should be community resources.
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They should give access to all patients who need them. They should also take the patients to the nearest, most appropriate center because that's what's good for the patient.
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And so I think that's the landscape in which we should work and which we should advocate, and I think they should be available to anybody in our community.
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But we have to also recognize that communities in need are different. Mm. What does that mean? When we do geospatial mapping of stroke occurrence throughout Los Angeles County, we see very clear patterns. Mm.
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We see high increase of stroke incidence in San Fernando Valley, where there are primarily Hispanic population of patients. Mm-hmm. High in San Gabriel Va- Valley, where primarily Asian population of patients. Yeah.
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High in, in Inglewood and around Inglewood, where primarily Black Americans live. And why is that important? Because the genetics actually dictate our stroke risk, believe it or not. Wow.
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Black Americans have earlier onset stroke, and usually from high blood pressure and hemorrhages and so forth. Mm.
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Asian Americans have high propensity of ischemic stroke related to hardening of the blood vessels of the brain. Caucasians have hardening more of the blood vessels of the neck. Mm.
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It's based on our genetics that we have sometimes earlier stroke and that we have, um, you know, different patterns of stroke.
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But also the thing one has to think about is that, um, affluence and access to primary prevention and secondary prevention. Sure.
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You know, in many of these communities, the patients are unable to afford medications or don't see a doctor routinely and so forth.
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And that's what we have done more recently when we've expanded our fleet, is to go to communities who are really high in es- incidence in communities of need.
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And since we've launched in the San Fernando Valley, I can't tell you how much our, our MSU lives have changed. We see real stroke patients- Wow...
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all day long, treat many every week, and it's really rewarding 'cause these are the communities who need us. That's incredible. That's what keeps you going day after day and- Absolutely... n- not getting sleep and- Yes.
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[laughs]... foregoing time with your family and whatnot. So we know that this has an impact on real people.
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Given the limitations that you have today, what does that actually mean for the reality of what kind of footprint you can have on Los Angeles, and what is it that you need? Yeah, yeah.
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So right now we have three units operating within Los Angeles County in different geographic areas, and they kind of rotate around these geographic areas. We are restricted by funds. We can't operate twenty-four seven.
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We're currently operating 7 a.m. to 7 p.m.
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How we chose those times, as part of our geospatial mapping, we looked at the nine one one calls which were dispatched and which resulted in a final hospital diagnosis of stroke, and the majority happened between, uh, 7 a.m.
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and 10 p.m. So that's why we picked seven to seven. Mm-hmm. That's a natural shift for a nurse or a technologist or a paramedic. And, um, we are limited by, uh, resources to expand that because of funding.
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We are limited by, by, uh, staffing, to be honest.
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You know, we're limited because every department is short paramedics, and we've had such wonderful collaboration with our firefighters and, and fire departments in our communities.
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We started with staffing from Santa Monica Fire Department.
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We-- when they couldn't afford to give us staffing anymore because of their taxed resources, Torrance Fire stepped in, and we have staffing from Torrance Fire Department.
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We have staffing with two medics from Long Beach Fire Department. Wow. We have staffing from Culver City Fire Department. And at the end of the day, our limitation in expanding is not just money.
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It's about how many paramedics we can get to staff these, these resources. Well, and to illustrate this in a very personal way, you and your entire team are just working tirelessly.
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Uh, David, uh, we haven't really talked about this, but I actually look at Mahnoor as kind of like Superwoman. Um, she- [laughs]... she has been known from time to time to have to do
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two operations at the same time, right? I mean, what, what is that- Right... reality for you and, and- Yeah...
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and, and, and your workflow, and how would you like that to change so that you could really optimize your value to the mobile stroke unit? Yeah.
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I, I think, um, we have to think of these things as an economy of scales, right? It's not realistic to put just one physician on one mobile stroke unit because now we have something, the reach of telemedicine, right?
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So we can be at multiple places at the same time. And so for example, today I'm also covering the mobile stroke unit, and one of my colleagues is covering me for this hour that we're speaking.
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And there are many days where I'm covering the mobile stroke units by telemedicine and also covering, um, as an interventionalist in the angio suite. And those are really rewarding days.
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I've had multiple of these days where I'm on the camera w- with, w- you know, with our team and, and we see a patient, and they have a blockage of a large blood vessel.
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And that patient ends up being just by proximity closer to the hospital where I'm working, and they bring the patient to us.
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And, and not only do I have the telemedicine encounter with the patient, have the rapport with the family and so forth, but then I'm the one who brings the patient to the angiography suite and removes the clot.
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And, and I've had such a patient very recently at Long Beach Memorial Hospital.
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It's just was so rewarding 'cause immediately this patient comes with, um, left-sided weakness and, and neglect her environment and, and extremely debilitated to completely normal. And right afterwards- Wow...
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the family was so grateful. "Oh, wow, this mobile stroke unit thing is a miracle." But you know what?
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It also connected us to the, um, phins- physicians at the hospital, and that- that's what we do for all patients we drop off, is that we let the receiving hospital know, "Hey, there's a large blood vessel blockage.
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Get your cath lab ready." We call the interventionalists, and not only do we save them time in the field, but also time- That's huge... in the hospital. Yeah. It's huge. Yeah. It's huge.
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I, I ran a bunch of sickle cell studies, uh- Mm-hmm... out of the ED as well. We're trying to tr- treat the vaso-occlusive crisis, so I completely- Oh... understand the- Yeah... the timing- You get it...
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and, and the blood clots. And I, I think one of the things I miss the most, 'cause I'm in drug development now, is the patient care. I, I just- Yes... I miss that so much. I, I know how...
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motivating and inspiring can be. So I, I love that you're sharing the stories 'cause I'm getting inspired just listening to it. [laughs] Oh, thank you. Thank you so much. The, like I said, that's our why.
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That's what keeps us going and, um, and yeah, you have many days which are tough and many long nights and a lot of charting to do, you know, after the fact and- Yeah, yeah...
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but, um, at the end, what keeps you going is the few minutes you can serve and sa- somebody's life can completely change the outcome of their life. We have an international audience here.
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What would be your vision for, for the world as far as the future of mobile stroke units? I can even give you a broader perspective. What is my vision for stroke and stroke survivors in the world? Mm.
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And I think one really important thing for the audience to know, in spite of all the amazing strides we're making in stroke care, one in four will have a stroke in their lifetime. 80% of stroke is actually preventable.
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So if you think about it, we have a lot to do in terms of educating about risk factors for stroke and working on primary prevention and secondary prevention when someone has a stroke.
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But also, I think the future is gonna be in AI, and it's gonna be in wearables. Mm-hmm. A big percentage of stroke patients who have a stroke don't recognize their symptoms. Why? Mm.
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Because stroke causes that can be neglectful of their symptoms. It's not like a heart attack, "Oh, I have some chest pain."
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So when patients don't recognize their symptoms and don't go to the hospital on time, they may be outside of a, a window for treatment.
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So I think two big things that we can work on, in addition, of course, to acute response with mobile stroke units, is that education about signs and symptoms of stroke, and second one is about
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automated detection of stroke once it happens. I mean, many of us are wearing Apple Watches. They have a fall detection. Hmm.
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Why can't it be that when someone we know has a risk of aneurysm rupture who we are just monitoring, if this algorithm finds that their heart rate increases and they have a fall and something happens with their blood pressure, then that doesn't automatically call 911 and allocate the resources.
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Or, um, someone who has a high risk of stroke. Mm-hmm. What if there are slave sensors to the main sens- you know- Right... that says, well, grandma's not moving the right side as she normally does. Mm-hmm.
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A lot of the stroke related to irregular heart rhythm called atrial fibrillation happens in the middle of the night.
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And so instead of that pa- patient being a wake-up stroke and not being able to be treated, what if we can detect it and automatically dispatch EMS resources for treatment?
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I think that's gonna be the future of stroke care. Y- that's huge. I'm glad we tapped into that because a huge part of it is prevention, as you're saying. True healthcare. Yes.
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Preventing these things before, before- Yes... they actually happen. It needs to happen side by side with what you're doing, the, the intervention as well. So I think- Absolutely... that's a, a wonderful ending point.
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Again, we wanna thank you so much for your time. We wish you the best of luck.
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I wanna see in Los Angeles mobile stroke unit really, really thrive and, you know, just you continuing to be an example for other communities out there so people can get that help and- I'm, I'm in the Bay Area, May.
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Is there any up here? [laughs] Actually, there's, uh, one in San Mateo County. [laughs] Oh, wow. Southern San Mateo County. They're very far away from me. [laughs] I'm gonna have to advocate for a closer one.
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[laughs] Well, it's such a genuine pleasure. Thank you for shining a light on innovations and keep f- uh, pushing forward the message and education to your audience. I think that's really critical. Thank you.
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Another great episode, right? [laughs] Fantastic. Yeah. This one was like, first of all, it's very near and dear to my heart. I had a friend that passed away from something similar last year, right? So- Oh, wow...
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knowing about the timing of... And I saw him on life support. You know, he, he's, he's- Oh, man. Yeah. And just knowing that something could've been done sooner, it just- Yeah...
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it makes me wanna scream 'cause I'm like, why isn't this being done? Why isn't there more mobile stroke units out there? And- Sure... incredible that she's providing this for free.
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It's unheard of in, in healthcare, in, in medicine. Right. Like, that just blows my mind.
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It is fr- I- it is free and, you know, w- why I really felt this episode was very Before the Cure is, in a lot of cases, we're catching stories where the science is still in motion, but the science is actually proven here.
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Yeah. But the system hasn't caught up, right? And that's- That's so true. That's so true... that's the case with the mobile stroke unit. It's, um- Yeah... you know, we have what it takes.
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We have the technology and it's, and, and it's there, and yes, it's expensive, but really it's to sustain it, you know?
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Like, like what we said, like, what is the cost of a life or a cost of a lifetime of debil- debilitating disabilities, right? A- and yeah, and you're right.
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It's, it's breakthroughs happening so fast the system hasn't caught up yet. [laughs] That's right. Yeah. That's right. [gentle music] This is Before the Cure. I'm Timothy Wheeler, joined by my co-host, David Tsai.
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Together, we explore innovation in healthcare before outcomes are certain. Because progress doesn't happen in isolation. It takes trust, it takes courage, and it takes community.
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We're just beginning, so stay close at beforethecure.org. Because at the end of the day, we're all patients, and we can do better.