This story begins in April 2022 in Poland’s Podkarpackie province, ahead of two days of intensive training for EMS members. The training is the first step towards addressing treatment delays at the region’s hospitals, which an earlier meeting has laid at the door of the ambulance service. Ambulance staff in the province are thought to lack the ability to diagnose stroke except in the most obvious cases; and the use of neurological evaluation scales and prenotification are inconsistent at best.
Working on a hunch, Angels consultant Katarzyna Putyło makes dozens of calls to the phone numbers supplied for prenotification. In the majority of cases, her calls go unanswered. By the time 60 EMS members arrive in the provincial capital Rzeszów for training, Kasia has had an updated and verified list of phone numbers printed on enough stickers for every ambulance in the province. The sticker is more than a prenotification tool: it is also a trigger for an action that saves lives.
The sticker turns our to be a small thing that makes a big difference. Not only do hospitals start reporting better treatment times, but in Q3 of 2022, Wojewódzka Stacja Pogotowia Ratunkowego w Rzeszowie becomes the first EMS in the province to win a platinum award.
Change begets change, and by early 2023, the Rzeszów ambulance service has converted its platinum to a diamond award. In November, two paramedics from this unit attend the first Advanced Stroke Life Support (ASLS) training in Poland. From this event, two bright spots emerge that will rewrite the story of prehospital stroke care in Podkarpackie.
Podkarpackie Part 2: A metal detector for stroke
Wojciech Filip and Marcin Warchoł of Rzeszów ambulance service attended the ASLS training and came away energized. They were struck by how complex stroke was and became interested in a more thorough exploration of the symptoms. And they were particularly impressed with the MEND scale and its potential for detecting both anterior and posterior circulation strokes, as well as identifying patients with large vessel occlusion.
Wojciech and Marcin became convinced that using the FAST scale to diagnose stroke was not enough as symptoms of brainstem and cerebellum strokes could easily be missed. They started implementing the MEND scale in their own work to detect less obvious cases of strokes. Soon they had a number of cases that showed that it worked.
A patient in her sixties had been found on the floor by her family who, knowing she suffered from diabetes, measured her blood sugar level. Finding the result was a dangerous 400 mg/dL, they immediately contacted the Rzeszów ambulance service.
The ambulance team’s suspicions were raised when the patient’s relatives reported she was somehow “different” although she continued to insist nothing was wrong. Within three minutes the MEND test revealed a strength deficit in her left limbs and concluded, accurately, that the patient was having a stroke.
On another occasion they were called out to attend to a patient who reported nausea and vomiting. Nothing but a touch of food poisoning, the patient insisted, the unfortunate result of a grilled meat dinner. But the finger-to-nose test in the MEND scale confirmed intention tremor, which was the result of cerebellar dysfunction.
“Too often I meet patients who had TIA’s before their stroke and the statistics are merciless,” Wojciech Filip says. “Too many patients escape us through this diagnostic sieve. For me, working in emergency medical services is a bit like treasure hunting with a metal detector. In order not to search aimlessly, you need to have a tool. The MEND scale for me is like this metal detector. It is a tool. The test takes only a few minutes, but for the patient it’s the rest of their life.”
Wojciech has been a rescuer for 20 years. In 2022 he was among three rescuers who took the Rzeszów service to their first victory in the International Winter Emergency Medical Championships in Bielsko-Biała.
He wants suspected stroke patients to be treated like those with suspected myocardial infarction, he says.
“Virtually every patient with chest pain goes to the hospital for diagnostics. I would like the same to happen to patients with symptoms suggesting a cerebral infarction.”
Marcin Warchoł became a rescuer when getting into pharmacy didn’t work out. “As it turns out, plan B was something that excited me, and it’s no less thrilling after almost 16 years. What’s exciting about this profession is the need for constant development, the absence of boredom and above all the people. Not only the patients but also the other rescuers, doctors and nurses. You can learn something interesting from every medic you meet.”
The more he learnt about stroke, the more Marcin became aware of how much more there was to know. “And then Angels entered the scene. This allowed me to expand my knowledge about many aspects of stroke and to share the knowledge and experience with other rescuers.”
Marcin is deputy director for Training Organization at the Rescue School of the Rzeszów ambulance station, and earlier this year he and Wojciech took the lead in an initiative to implement the MEND scale throughout the Rzeszów service.
Podkarpackie Part 3: Not quite a sticker
Wojciech and Marcin took responsibility for the entire programme, Katarzyna says of the training event at the end of February. “They did a deep dive into stroke symptoms, introduced the MEND scale, presented their cases, and lead a practical workshop so everyone could try it. A doctor from the thrombectomy centre also attended, so the biggest stroke centre in the region was aware of the change in protocol, and everyone was very receptive to a new tool being put to use.”
The result of the training and the discussion that followed is a combination of the MEND scale, the Angels prehospital checklist, and the criteria for the EMS Angels Awards.
This “pocket checklist”, Kasia says, “will ensure that they don’t miss or forget anything, and the MEND scale allows them to dig deeper in cases where the diagnosis isn’t clear.”
It’s not exactly a sticker, she says of the laminated checklist that is being disseminated to paramedics across the region. But like the one with prenotification phone numbers, this will be a tool and a trigger inside every ambulance.
