Physician at Work: Working rapidly to treat strokes
Joseph Schindler would like more patients to respond quickly to symptoms
Time is brain for vascular neurologist Joseph Schindler, MD. The doctor and his colleagues on the Acute Stroke Team at Yale-New Haven Hospital care for about 1,000 stroke patients a year, and for a fraction of those patients, they have a short time frame in which to administer treatment options.The standard therapy for ischemic stroke is tissue plasminogen activator, or tPA, a clot-busting medication that can be given intravenously within four-and-a-half hours after the onset of stroke symptoms. Doctors usually have less time than that since patients don’t readily recognize their symptoms as being potentially due to a stroke and don’t seek help right away.“Unfortunately most patients aren’t coming to the emergency department in a timely manner because they’re usually not educated on the importance of calling 9-1-1 and coming in quickly,” Dr. Schindler said.
Round the clock care
The neurologist began his career at Yale working under the late Lawrence Brass, MD, an internationally recognized stroke expert. Now Dr. Schindler is the clinical director of the Yale-New Haven Stroke Center, which is one of two major stroke centers in Connecticut. In addition to IV thrombolytics, the center offers investigative approaches for acute stroke that may not be available elsewhere.
He and four stroke team colleagues typically respond to two or three urgent stroke calls a day. If tPA is not an option, he and his team may use diagnostic imaging to pinpoint the clot and then use a catheter designed to remove it. They use this interventional approach two or three times each month for selected patients who may benefit from this procedure.
While 80 percent of strokes are caused by clots that block a blood vessel in the brain, about 20 percent are caused by a hemorrhage due to longstanding hypertension or a ruptured aneurysm. Dr. Schindler monitors these patients in the neuro-intensive care unit with the goal of driving down their blood pressure and managing other complications associated with stroke.
Treating stroke remotely
While many Connecticut hospitals lack access to round-the-clock neurologists for stroke patients, Dr. Schindler and his team are available to evaluate stroke patients at outlying hospitals 24/7, using high-definition videoconferencing equipment and image-sharing technology.
Jeanne Munnelly was the first patient in Connecticut to benefit from this innovative approach to acute care. In 2008, she went to Lawrence & Memorial (L&M) Hospital in New London after becoming weak on her right side and unable to speak during her morning swim. The staff at L&M called Dr. Schindler, and he gave the go-ahead to use tPA just 37 minutes after Munnelly arrived the hospital. This evaluation and treatment decision happened much more quickly than it would have if she had been transported 50 miles to Yale-New Haven Hospital.
Although Yale’s telestroke network extends only to L&M and Sharon Hospital, in Sharon, Connecticut, Dr. Schindler expects the program to expand. The program has been a great success at L&M, with data showing a 90 percent increase in the rate of IV tPA administration and a reduction in the rate of symptomatic hemorrhage in patients after the telestroke service was launched.
“The use of telemedicine is becoming more widespread, helping hospitals without neurological expertise provide acute stroke care,” he said. “However, this technological feat is of no value if the patient cannot recognize stroke symptoms and get to the hospital as soon as possible.”
Name: Joseph Laurence Schindler, MD
Title: Clinical director, Yale-New Haven Stroke Center; assistant professor of neurology and neurosurgery
Area of expertise: Vascular neurology
Place of birth: Brooklyn, NY
College: Tufts University
Med School: Tufts University School of Medicine
Training: Chief resident in neurology, Yale-New Haven Hospital
Family: Micaela, 7; Nicholas, 5
What do you like most about your practice? I enjoy the varied aspects of my role, which includes providing acute care to critically ill stroke patients, teaching residents and students, providing neurological care in the outpatient setting, participating in and directing research studies including clinical trials, and having the autonomy to develop the process by which it gets done.
Personal interests or pastimes: Spending quality time with my children, culinary enthusiast, world soccer fanatic
Last book read: "Townie: A Memoir," by Andre Dubus III
What would you do to improve our clinical environment if you had a magic wand? For those patients with diseases that require multiple specialties to diagnose and develop a treatment/management plan, I would create opportunities for better acute care collaboration, and more accessible multidisciplinary clinics.