Emergency care from the tele-emergency service or tele-stroke unit

In medical emergencies, every second often counts when it comes to saving lives or avoiding permanent damage. In rural areas in particular though, there are often no emergency medical centers or specialized stroke units in hospitals. Telemedicine and special emergency vehicles can be used to improve patient care in emergencies:

• Tele-emergency doctors in control centers support emergency responders at the scene. They help make diagnoses and direct the treatment remotely.
• The digital connection to stroke units in larger hospitals enables regional hospitals to make targeted diagnoses and treat stroke patients. In Germany, almost one in ten stroke patients is treated using telemedicine.
• Specially equipped emergency vehicles known as mobile stroke units (MSU) or Stroke-Einsatz-Mobile (STEMO) in German make it possible to diagnose strokes and start treatment even on route to a hospital.

When an ambulance is sent to an emergency, there is often no doctor on board. The control center uses the caller’s information to determine whether to request an emergency doctor in addition to the paramedics. The emergency doctor drives to the scene independently of the ambulance and often arrives later. In difficult situations, a tele-emergency doctor can remotely support the emergency responders at the scene. 

In Germany, paramedics have limited powers to treat patients and administer medication. By involving a tele-emergency service, the emergency situation can be assessed and the necessary treatment can be provided quickly and safely. The tele-emergency doctor is responsible for the treatment initiated.

In rural regions, there are often only a few emergency medical centers, which have to cover large areas. As a result, an increasing number of municipalities are setting up tele-emergency services in parallel with the conventional emergency services. 

How do tele-emergency doctors help?

Tele-emergency doctors provide the emergency responders at the scene with remote medical and organizational support. These are experienced and specially trained emergency doctors, who are connected to the ambulance by a live feed that provides both video and sound. Conversely, the emergency responders can give tele-emergency doctors important information and vital data about patients’ blood pressure, heart function (ECG) and breathing. This cooperation enables the tele-emergency doctor to provide the emergency responders at the scene with advice and guidance as they assess the emergency situation. 

What are the tasks of a tele-emergency doctor?

The main tasks of a tele-emergency doctor include offering advice and guidance to the emergency responders at the scene:

• If there is no emergency doctor on scene, the tele-emergency doctor helps make a diagnosis.
• If necessary, the tele-emergency doctor approves the treatment of the patient and the administration of medication.
• In consultation with the emergency services, the tele-emergency doctor can retrospectively order an emergency doctor to the scene.
• Tele-emergency doctors advise the emergency doctor at the scene on decisions regarding the type of treatment, its implementation and further examinations.
• They notify the hospital of a patients’ arrival.
• A further task of tele-emergency doctors is to provide advice and support during onward transportation and the transfer of patients to another hospital.

How is the treatment quality ensured?

Tele-emergency doctors are experienced, specially trained medical practitioners. The requirements include: 

• qualification as an anesthesiology specialist or other specialist training (at least 5th year of training)
• experience of over 500 emergencies
• additional qualification in emergency medicine from a Chamber of Physicians
• certification in resuscitation (advanced life support provider course)
• certification in trauma care

Tele-emergency doctors receive standardized training on the use of telemedicine communication media prior to their first job.

Treatment of patients by a tele-emergency doctor occurs in line with the current medical guidelines. Medical advice and treatment using telemedicine are also regulated by the professional code for physicians (Muster-Berufsordnung-Ärzte – MBO-Ä). Among other things, this contains provisions on diagnosis, consultation and treatment methods as well as on documentation.

A stroke unit is a special ward in a hospital that focuses on the treatment of stroke patients. Strokes cause permanent impairments for many people and are one of the most common causes of death. Stroke units play an important role in the rapid diagnosis and treatment of people who have had a stroke. The medical and nursing care is far more intensive than in a normal hospital ward. 

There are regional and national stroke units. National stroke units provide qualified teams of doctors and special diagnostic and treatment options twenty-four hours a day, seven days a week. They support the work of regional stroke units by providing advice and further treatment for patients. Some stroke units also offer telemedical care.

In Germany, there are more than 300 certified stroke units in hospitals. To obtain certification, stroke units have to fulfill multiple conditions in relation to diagnosis, personnel and workflows. Compliance with these is regularly checked. 

What happens on a stroke unit?

On a stroke unit, stroke patients are treated by a multidisciplinary team of doctors. These include neurologists, cardiologists, radiologists and, in some cases, neurosurgeons and vascular surgeons. Stroke units not only have specially trained nursing staff but also the necessary medical equipment to diagnose, treat and monitor patients. The most important tasks of a stroke unit include:

• performing scans to determine the cause of the stroke using computed tomography (CT) or duplex sonography (ultrasound)
• dissolving blood clots through the use of medication (systemic thrombolysis)
• removing blood clots and treating vascular occlusions through surgery (mechanical thrombectomy)
• stopping brain bleeds (hemorrhages) and removing hematomas
• closely monitoring neurological functions and cardiovascular results
• providing early rehabilitation to reduce complications

An estimated 70 to 80 percent of stroke patients in Germany are treated in certified stroke units.

What are the benefits of being treated in a stroke unit?

For people who are suspected of having had a stroke, treatment in a stroke unit reduces the risk of permanent impairments and increases the chance of survival. Strokes are triggered by a brain bleed (hemorrhage) or circulatory disorders in the brain and are always emergencies.

The specialization of the doctors and the equipment in a stroke unit make it possible to quickly determine the cause and best method of treatment: if the stroke is triggered by a blood clot, this can often be dissolved with medication. If the stroke has been caused by a brain hemorrhage, this method must not be used as it could increase the bleeding.

A stroke unit has the necessary imaging devices to distinguish between the causes and enables examinations around the clock. The necessary treatment starts immediately. In many cases, this can prevent permanent damage after a stroke and patient deaths.

The intensive monitoring of patients makes it possible to quickly react to changes in their condition. Stroke units have the necessary medical equipment and specially trained nurses to do this.

Patients benefit from stroke units working with speech therapists, occupational therapists and physiotherapists. These can start treating any speech, cognitive or physical impairments very shortly after a stroke. The quicker therapy is used to regain lost abilities after a stroke, the greater the chances of recovery.

A tele-stroke unit provides remote support for stroke patients: as not all hospitals are able to guarantee special stroke care round the clock, a growing number of them are coming together to form telemedical networks. The medical experts from a national stroke unit are available 24 hours a day. Thanks to their support, even hospitals without a neurological department can provide a high level of stroke care. Germany now has over 20 telemedical networks, involving over 200 hospitals/clinics. 

How do tele-stroke units work?

If a patient has had a stroke, the neurological experts from a tele-stroke unit advise and support the attending doctors on site. By using digital media, they can get involved in both examining and treating the patients. For example, with the support of the on-site doctor, they can use a remote-controlled, high-resolution camera to perform examinations remotely. This makes it possible to jointly determine and initiate the best form of treatment. This often eliminates the need for patients to be transported to a further away hospital with a stroke unit.
Tele-stroke units are also subject to a certification procedure. This acts as the quality seal for regional and national stroke units.

The sooner the exact cause of a stroke is determined and treated, the greater the chance of preventing permanent damage and patient death. As a result, specially equipped emergency vehicles were developed for stroke patients. These are known as STEMO, from the German “Stroke-Einsatz-Mobile”, meaning “mobile stroke unit” (MSU).

STEMO or MSU are equipped with a computer tomograph (CT), an X-ray machine and a mini laboratory. Their crew comprises not only paramedics but also a neurologist who is trained in emergency care. The CT enables the crew to determine whether the stroke has been caused by a brain bleed (hemorrhage) or a blood clot while still at the scene. In the case of a blood clot, patients can be given an infusion with a drug for dissolving the clot even while on route to the hospital (thrombolysis).

This significantly improves their chances of survival and recovery: According to a study by the German Stroke Society (DSG) and a Berlin research team, the risk of people dying or developing disabilities from a stroke reduced by a quarter if they were treated in the ambulance. More than half of MSU patients are treated with thrombolysis. In addition, treatment was initiated an average of 20 minutes faster than in patients who had to wait to get to hospital for treatment.

At present, the number of STEMO/MSU in permanent use in Germany is still very low. This is due to the special requirements they have to meet: as computer tomographs are large, heavy devices, they cannot be retrofitted in normal ambulances but instead need custom-made basis vehicles.

Despite the high procurement costs, the German Stroke Society (DSG) recommends the increased use of STEMO/MSU, especially in rural areas, due to their proven benefits.