The First 90 Days: Understanding Stroke Recurrence Risk

Emily Brady (0:15): Hi, everyone. I'm Emily.

Eva Johnson (0:17): And this is Eva, and you're listening to Speech Talk.

Emily Brady (0:21): We are your research book club, so you can do evidence based practice in practice.

Eva Johnson (0:26): Let's start talking. Emily, what is something that happened for you this week?

Emily Brady (0:30): Okay. So remember back in grad school days so long ago, we used to do those roses and thorns.

Unknown Speaker (0:38): Oh, yeah.

Emily Brady (0:38): Yeah. Today was a rose and thorn day. So Okay. I have a patient who I've been trying to get a tablet speaking device, an AAC device, high-tech AAC device. And finally, all the paperwork has been submitted.

Unknown Speaker (0:54): It came in. Yes. Cheers.

Unknown Speaker (0:58): That is awesome.

Unknown Speaker (1:00): Hoorah. We did it.

Unknown Speaker (1:03): Like confetti everywhere in your life. Confetti everywhere. Love the shirt cannon.

Emily Brady (1:06): I'm so excited. So we get the things ready. I'm setting up the device. I'm trying to re put on all the programming I worked so hard on, calibrating. I'm super jazzed that my patient is, not incredibly jazzed, he's like meh about the device as adults learning how to use a tablet typically are.

Unknown Speaker (1:30): You're

Unknown Speaker (1:30): like, my excitement will eventually catch on.

Emily Brady (1:34): Eventually. So that was my rose. My thorn came in when I had to try and teach the CNA staff how to use the tablet and provide, you know, just a five minute education, which you don't think would elicit so many eye rolls. Oh. It wasn't everybody.

Emily Brady (1:56): Some people were equally excited, but it was just one of those times where you have to like step back and I guess realize like they have their own stuff going on. And even though shift change is the best time for you to give it in service because everybody is there and everybody is huddled, they do not care about this cool new device. They want to go home and Yeah. They will be mean to you about

Unknown Speaker (2:23): it. Mhmm.

Emily Brady (2:26): So maybe one day I will learn how to grow in a thick enough skin not to care when people yell at me down the hallway that this is not the time to be doing an in service, but today is not that day. That was a pretty bad thorn. So if you have ever loath to get an give an education because someone has given you a mean eye roll, I see you. I hear you. I am you.

Unknown Speaker (2:56): It's no fun to

Unknown Speaker (2:57): do in services when people don't wanna learn, which is most in services.

Emily Brady (3:03): Yes. It was a hard one. Eva, what about you? Tell me some tell me more roses. Give me two roses.

Eva Johnson (3:10): Well, one thing that was really fun is on Monday night, I went to CSU East Bay, and I got to talk at their research class where they all the grad students are basically learning how to read research and when to apply it. And we did some really fun activities. I took a article about thickened liquids and actually, the one that you and I reviewed, and I broke it out paragraph by paragraph, simplified the paragraphs, and then I gave it up to the groups. I had group one, read paragraph one, and I had the scale on the board. Are we team thin liquid or team thickened liquid?

Eva Johnson (3:46): And so there everyone started out like very pro thin liquids. And then the research got trickier and more nuanced, and they were like, oh, wait. Now we're more team thickened liquids. And then there were parts where of the article where it said, sometimes there's no difference in outcomes for patients. And they're like, I don't know anymore.

Eva Johnson (4:06): I was like, yeah. And that's part of the interesting point of reading research. You're not just suddenly gonna be, oh, I'm team thin. Oh, I'm team thick and liquids. It's about having a nuanced perspective on how to use thin and thickened liquids and decide who it's functional for.

Eva Johnson (4:24): It was really fun to kinda like do the meter. Like, where are we? How do we feel about this?

Unknown Speaker (4:29): I love that.

Eva Johnson (4:30): And oh, Instagram. I'm doing trying a lot more on Instagram, y'all. If you don't follow us on Instagram, please do. It's speech talk pod. I've been trying to put up more research based videos and I hope that that kind of gives these little, even tinier bite sized research snippets for folks to enjoy or inform their practice or just see what we really look like.

Eva Johnson (4:58): Those are my two roses. So deep breath, Emily. I'm about to ask you questions you don't know about. First one, which do you think is worse, a first stroke or a recurrent stroke?

Emily Brady (5:11): I would probably say the first one.

Unknown Speaker (5:14): That's my buzzer sound. I don't know if that's a good buzzer sound. Whomp, whomp. Is that better?

Unknown Speaker (5:24): I like that one better.

Eva Johnson (5:25): Okay. It turns out recurrent strokes are more likely to be disabling or be fatal, which I did not know. That was a that was a kind of a fun reveal. If you wanna call that fun.

Unknown Speaker (5:38): That's back to our not really knowing the definition of fun. I

Eva Johnson (5:43): I feel like every time I get excited about a fact, I'm like, this is exciting. And it turns out it's not fun or really exciting. It's usually Deadly. This is deadly. Morbidity and mortality.

Unknown Speaker (5:57): Yeah. Okay. And then how many strokes, like, of this last year in strokes, how many of them do you think were recurrent strokes? Like, what percent?

Emily Brady (6:08): Out of all the strokes that have stroked, we're wondering how many were second strokes or more. Yeah. A million. No.

Eva Johnson (6:19): No. No. Not like the actual number of them, like what percentage of like this year's strokes?

Emily Brady (6:25): This is a hard question, Eva. I'm trying to think of math. Don't know. Probably seventy percent.

Eva Johnson (6:31): You think seventy percent is recurrent strokes? Yes. Dang girl, you bet high. It's thirty percent.

Emily Brady (6:38): I don't bet. I am like very bad at these questions.

Unknown Speaker (6:43): Well, admittedly, I had no idea what any of these things were. So if you had asked me, I would have gone really low. Be like,

Emily Brady (6:48): I don't know, like ten percent are recurrent. There's thirty. My guess was high because I feel like after someone has a stroke, they're more likely to have a secondary stroke, and then strokes are normally caused by those bad behaviors, smoking, drinking, unhealthy diet, lifestyle, and a high blood pressure. And if you're already clotting, you're probably more likely to have a secondary stroke if you're not taking care of those things.

Eva Johnson (7:16): Yeah. So definitely. And I feel like you're really hitting off the topic for today, which is, like, why is stroke recurrence so high? What can be we'd be looking for? What can we be doing education on?

Eva Johnson (7:27): So now that you've totally summarized what we're talking about, we can just end early. Okay. And then last question. How likely is someone to have a secondary or recurrent stroke within the first ninety days from their first stroke? It's like you had your first stroke within the first three months, the first ninety days.

Eva Johnson (7:49): What's your, like, percent risk of recurrence? Twenty percent. Oh, interesting. So you're actually pretty close. And this is kind of where we're gonna get into today's topic.

Eva Johnson (8:02): Depending on some definitions of what a recurrent stroke is, it's like six percent. Six percent risk of a recurrent stroke in ninety days.

Unknown Speaker (8:10): Girl, you said I was close. That's not close.

Eva Johnson (8:12): But according to other definitions of recurrent stroke, it's eighteen point three percent. Oh, that one's close. Yeah. And so the question becomes why these incredibly different, like, percentage risks Yeah. For stroke recurrence.

Eva Johnson (8:28): That's ridiculous. And so that's really what we're gonna be getting into is why these completely different percentages for recurrence risk. Before we get into it, let's pause for a quick commercial.

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Emily Brady (9:37): Welcome back. Today's article is underestimation of the early risk of recurrent stroke, evidence of the need for standard definition by Andrew Cowell and Peter Rothwell.

Eva Johnson (9:52): Yeah. So I really wanted to talk about this because a couple weeks ago, I feel like there was just code blues being called all the time at work. And that's probably an over exaggeration, but multiple of our stroke patients at the hospital went back to urgent care because they they stroked out again. And I was thinking to myself, like, what is the recurrence rate of secondary strokes? So that's why I chose this topic.

Eva Johnson (10:23): Anyways, here's how they actually did it. The researchers looked at two different population studies. One was the Oxfordshire Community Stroke Project and the other was the Oxford Vascular Study. And they looked at patient records for first and recurrent strokes. So they have all this data on patients who had a stroke, who had a second stroke.

Eva Johnson (10:44): Then they looked at a couple different standard definitions of a recurrent stroke, and they applied those definitions to the data that they received to determine how likely were people to have a recurrent stroke within the first ninety days from their initial one.

Emily Brady (11:01): Okay, Eva. I'm getting confused. You're gonna have to break down these different types of recurrent definitions more clearly. I don't get it.

Eva Johnson (11:11): Yeah. Okay. So here are the three definitions. We can count a stroke as being recurrent according to some definitions for any, like, neurological focal changes or, like, changes on a CT, new deficits, anything that happens after twenty eight days. So you have your initial stroke.

Eva Johnson (11:33): Twenty eight days later, we start counting. Anything that happens after those twenty eight days, that's a second stroke. And the second definition is similar. Anything that happens after twenty one days, that's a new stroke. Or if it happens before the twenty one days, you have to have, like, a big change.

Eva Johnson (11:50): It has to be a new focal deficit. There has to be, a bleed or an embolism in a different part of the brain. And finally, the most inclusive definition is anything that occurs 24 after your initial stroke. Does that make sense, those three definitions? So the most restrictive one is we're not counting anything in the first twenty eight days.

Eva Johnson (12:15): We're only counting recurrence after twenty eight days, or we're only counting recurrence after twenty one days unless you have some pretty serious changes. The most inclusive one is anything that happens twenty four hours after your first stroke.

Emily Brady (12:30): Yeah. I I think I'm following you. So why are we using these different definitions?

Eva Johnson (12:37): Well, one of the things that they really wanted to get at was when does the first stroke really end? So we know that people can have these side effects of a stroke or there can be kind of these evolving deficits out of after a stroke. Right? Somebody wakes up and they from their stroke and they have aphasia, but we don't realize that there's also cognitive deficits and maybe the dysphasia doesn't really show up for a few days because they weren't eating. And so they just wanted to make sure that, hey.

Eva Johnson (13:12): On that particularly on that twenty eight day definition, we're just gonna say anything that happened in those first twenty eight days is probably related to the first stroke. And that's a similar principle for the second definition with the twenty one days. But they tried to expand it, make it a little more inclusive by saying, well, if you have like some pretty significant new changes, we'll count it. But the first definition that twenty four hour one is like, no. No.

Eva Johnson (13:38): No. Anything that happens twenty four hours after you're stable, we're counting that. That's a potential new stroke.

Emily Brady (13:45): So are they marking these strokes with CT scans or MRIs? Are they

Eva Johnson (13:53): Yeah. So this is something that was kind of tricky for the researchers. They had to kind of just go through people's data from these population studies and take a look at what they had had for follow ups. And most of them are marked with XCTs or some kind of, like, imaging follow-up. What's really crazy, though, is how our measurement of risk changes based on each definition.

Eva Johnson (14:18): So for the one where it's like twenty eight days have to go by before we measure recurrence, turns out it looks like your risk for a secondary stroke is only like five or six percent. If we got that twenty one days, oh, your risk starts going up. It's like seven to eight percent. If we start measuring right after those first twenty four hours, it's like fourteen to eighteen percent risk. So the more time we're measuring, the more opportunities for stroke we're measuring.

Eva Johnson (14:51): So the most broad definition says, well, we're like almost at twenty percent likelihood of a recurrent stroke.

Emily Brady (14:58): Yeah. That's a that's a really big difference to think about if you have that first initial stroke and you're like, okay. Everything's peachy keen and something big happens and you're in that first wave of people where you're not counting that for twenty eight days, that person is definitely counting that. Like, that person says something's different. Like, I need more help over here.

Eva Johnson (15:24): Right. Exactly. It's like, could you imagine saying that to a patient? Like, oh, we're so glad you made it through your first stroke. And the person's like, oh, man.

Eva Johnson (15:32): That was so scary. How likely is it to happen again? Oh, only like five percent. Like, it's really low. And then like two weeks later they have a stroke and they're like, I thought it was only five percent.

Eva Johnson (15:42): Was like, oh, well, according to the definition I used, you're only five percent likely. According to other definitions, you were like twenty percent likely to have another stroke.

Emily Brady (15:52): Yeah, that's crazy. That's a really big difference. And that can be, I don't know, daunting, scary for people.

Eva Johnson (15:59): Yeah, absolutely. And I'm really glad you brought that up. I put down some notes for us to talk about how we deal with patients' emotions later, so I'm really excited to circle back to that.

Emily Brady (16:09): So were these percentages the same across the different types of strokes?

Eva Johnson (16:13): Yeah. Okay. So the numbers I just read you were generalized across all of the strokes. But for patients who had a partial anterior or posterior infarct or stroke, they had the highest risk of recurrence. Their likelihood was more like nineteen to twenty two percent.

Eva Johnson (16:32): So, basically, patients who had an infarct or a stroke that affected the, like, frontal region or posterior region or the back portion of their brain were the highest for recurrence, which is more like nineteen to twenty two percent. There were others that were more minor, like a completely front part of your brain or a lacunar infarct or stroke or very low risk of recurrence.

Emily Brady (16:57): Okay. So, obviously, strokes are bad overall, but we mentioned recurrent strokes can be worse than the initial ones. So this really impacts how seriously we want patients to be aware of stroke risk and what contributes to a stroke.

Eva Johnson (17:12): Yeah. Do you guys do stroke edit your sniff?

Emily Brady (17:15): No. Not formally. I do some stroke education in general as it pertains to, like, an increased risk of strokes or I train B. F. A.

Emily Brady (17:28): T, which is that an acronym for signs of symptoms of having a stroke, but nothing that has like a protocol or procedure, just something that we might talk off the cuff about to make sure that they're increasing their safety overall. What about you? Do you have a program?

Eva Johnson (17:47): First of all, do wanna do the BE FAST challenge? Can you say it? Can you do it all by heart? Go.

Emily Brady (17:53): So be fast. B is balance. So are are you walking evenly? Do you feel dizzy? E is for eyes.

Emily Brady (18:02): So how is your vision? Is it blurry? Can you see okay? F is for face, looking for facial droop. A is for arms.

Emily Brady (18:12): Do you have one-sided weakness? S is for speech. Are you slurring? And t is for time, you gotta hurry up and get your butt to the hospital.

Unknown Speaker (18:20): Time to call. Wow, Emily, that was good.

Emily Brady (18:25): It helps to have the word, the letters b fast in front of you so you can think about what each one stands

Eva Johnson (18:31): for as you're talking about the one before. Hashtag memory strategies. Yeah. So before, I didn't really do stroke education about strokes. I just educated people about what their stroke had done to them.

Eva Johnson (18:48): And since I've been at the hospital, they have a very big emphasis on stroke education. Like, if you had a stroke, you get a little booklet. We tell you the difference between whether or not you had a hemorrhagic or a bleed or an ischemic, like, block stroke. We talk about contributors. So changing your diet, what can contribute to, you know, plaque in your arteries, things like that.

Eva Johnson (19:15): Oh, and we definitely do the BFAST. We're like, you gotta And so one of the big things that we educate people on is like, Look. You had a stroke. You are more likely to have one than somebody who hasn't had a stroke. Mhmm.

Eva Johnson (19:28): And now that you know what a stroke feels like or maybe you'll have new symptoms this time, you gotta be the one to call because, you know, when someone has a stroke, it's just time. Like, you're just fighting time. It's as quick as you can get treated. It has a direct correlation with how well your outcomes are gonna be. We're really big on that now.

Eva Johnson (19:45): Or I should say, I'm really big on that now. They were always doing it.

Emily Brady (19:48): Yeah. No. That's good because it can kinda feel like this is stepping out of our scope, so to speak, right? Like, we are not medical professionals. We are not diagnosing strokes.

Emily Brady (20:00): We treat people who've had strokes, so it does feel like, I don't know. Maybe like a nurse's thing or a doctor's thing, but it doesn't mean we don't know a lot about strokes. It is something that we can still very much talk about, and it has to do with your speech and communication. So that's one of those big signs that you're having a stroke. So we can talk about it.

Eva Johnson (20:21): Yeah. I was doing BFAST education with somebody, and I was like, alright. T is you're like, time to call or go to the hospital. I was like, I was like, okay. Great.

Unknown Speaker (20:31): So if you have any of these symptoms, what should you do? And they're like, I'm not really sure. And I was like, you just had it.

Unknown Speaker (20:37): You just had it. You just said it. What's tea? You tell me.

Eva Johnson (20:44): Anyways, but I think one of the things that I was nervous about in terms of having this conversation with patients is I didn't want to scare the bejesus out of them. They just got over this terrifying event. A lot of people, I think, have varying degrees with which they're willing to share, with their health care providers how their experience was having a stroke or anxieties they feel afterwards. But, I mean, you're just, like, walking around doing something normal. All of a sudden, your your body starts to go out on you.

Eva Johnson (21:16): Like, it's really scary. I say that for some people, some people, their body goes out on them and it's really scary. Other people drive themselves places and they're like, I don't know, my foot was tingly. So I didn't think too much about it. I eventually found out that I had a stroke and I'm like, oh my god, you were on the road for thirty minutes.

Emily Brady (21:40): It is so interesting how wildly different people can be affected by a stroke. Like, depending on how big it is, what kind it is, where it happens, but that is so true. Like, some people are immediately loss of language, half of their body is depleted, other people are they got tinglies in their one side of their fingers and toes, and that's it. Like, it's goes numb sometimes.

Eva Johnson (22:11): I had a patient a couple of weeks ago who I was doing the BPAS education with him and I knew that he had driven while having symptoms. I was like, so should you do that again? He was like, well, I know what I can handle. You've never had a stroke before. Maybe you're the problem.

Eva Johnson (22:26): What's your car like? I'm gonna avoid you. And I was like, well, really turn that around, Nafim, but also please don't drive again if you're having a stroke.

Emily Brady (22:35): Oh my gosh. That's that's mean. Going after your car. Not just you are dangerous on the road, now your car is offensive. The whole thing.

Eva Johnson (22:48): Well, he he definitely had some executive function issues where he could verbalize safety awareness issues, but then, like, I need to lock my wheels. Everyone should lock their wheels on their wheelchair because if you tried to stand up and your wheels weren't locked, they could shoot out from behind you and you could fall. Ten seconds later, tries to stand up without locked wheels and is telling me it's fine while he's like wobbling and I'm trying to get him to sit back down. And I'm like, ah, safety rules are for everybody.

Unknown Speaker (23:21): You're not

Unknown Speaker (23:22): excluded. Please sit down.

Unknown Speaker (23:26): That's funny.

Eva Johnson (23:27): Yeah. It was kind of part of that whole that whole picture. But anyways, circling back to patient's anxiety. Like, didn't I don't wanna scare people with the potential for a secondary stroke, I also began to realize maybe I'm doing them a disservice by not being frank with them about their potential risks and why we do stroke education, why we do risk education.

Emily Brady (23:48): Yeah. I think that is so important that we're doing education to the point that the patient can handle, but we are giving them all just blatantly accurate information and trying to take our anxiety out of it. Right? We are anxious to tell people about what's gonna happen because we don't know how they're gonna react to what we're saying. So, like, what if I tell them they have a twenty percent risk and they just crumple on the floor like a used tissue?

Emily Brady (24:17): Like, that is that's not something I am very comfortable, you know, dealing with or helping somebody through or what do you do once someone is in that emotional state? So

Eva Johnson (24:31): Yeah. My holding your hand or, like, gentle hand on the shoulder bedside manner has gotten better over the last couple years, I would say, in terms of, like, when you tell somebody something and they they start crying and you're like, okay. One, I I don't think I should cry. I'm gonna rule that out because then I I can't help anybody if I'm crying. Two, realizing being in medical facilities is a very vulnerable place, so not everybody wants to be touched or, you know, things that we might do for a friend are not necessarily appropriate in, a medical setting where you're their care provider.

Eva Johnson (25:10): So I think my go to move now is to be like, you like to hold a hand? And some people will shake their head and other people will just quietly reach out and hold my hand.

Unknown Speaker (25:19): Aw, that's sweet.

Eva Johnson (25:20): But yeah, I think we've, a lot of times, talk about those first three months post stroke is this is your time to make a lot of therapy gains. If you do a lot of work in rehab, you can see a lot of progress. But I think what this article also showed me is that this is also an incredibly risky time. That first ninety days, we're both trying to make a lot of gains and we need to really be aware of what's happening for our patient.

Unknown Speaker (25:47): Truthfully, that makes me feel a little bit better about them hanging out in my facility for as long as my facility will keep them. Man. You're like, up on the extra eyes on them for a little bit.

Eva Johnson (25:58): Yeah. I think like you've maybe gotten better and you're maybe plateauing in therapy. But if you're hanging out here, at least we've got eyes on the situation. I think we're to that point. I mean, when we're saying, oh, maybe have six percent risk of stroke recurrence versus twenty percent, you know, like twenty percent is one in five.

Unknown Speaker (26:19): And I think that if somebody told me, oh, you have like six percent chance, I'd be like, oh, well, I feel comfortable going home. I'm not scared. Somebody told me I have a one in five chance. Be like, I never want to go home. Keep me here.

Unknown Speaker (26:32): Keep me here the full ninety days.

Unknown Speaker (26:34): I know.

Unknown Speaker (26:34): You

Emily Brady (26:35): know? You can definitely give me that cafeteria pizza for a little bit until it's safe to

Unknown Speaker (26:42): go home.

Unknown Speaker (26:43): I'll deal with

Eva Johnson (26:44): the mechanical soft food. The institutional food. So yeah. And I think that that kind of brings us back to, like, clinical takeaways. Like, what are we telling people?

Eva Johnson (26:54): What is our stroke education? Stroke education is now really important. We're understanding that we don't want them just to know what happened to them, but what could happen to them again and for them to be prepared.

Emily Brady (27:04): So, yes, the stroke education, now we have medication adherence. So why does that matter? Their blood thinners, their blood pressure manage management, are they taking their their pills at the same time every single day using their memory strategies to make sure that their blood thinners and their blood pressure medications are working the way that they should.

Eva Johnson (27:28): A 100%. I one time did a ton of medication education with somebody and I was like, here's what you gotta take. Here's when you gotta take them. What are these for? They're like, keeping my blood pressure down.

Eva Johnson (27:38): Was like, alright. Great. Why is that important? I because could have another stroke. Okay.

Eva Johnson (27:42): Great. I'm like, so what happens if you skip a medication? They're like, it's probably fine. It's like, How often do you think you could skip a medication? They're like, oh, no.

Eva Johnson (27:53): I think I just should take it whenever I remember. And I was like, no. No. Nope.

Unknown Speaker (28:01): Smack your hand. Nope. Yes. Nope.

Eva Johnson (28:04): I said, nope. You take your medication where you're supposed to take it. And you and I have talked about this in a previous episode with medication adherence for mild cognitive impairments. People with mild cognitive impairments are more likely to have errors with their medication management. And guess who might have cognitive impairments?

Eva Johnson (28:23): Strokes. Strokes are not people. People who've had strokes might have difficulty with that.

Emily Brady (28:30): And you know what's interesting about this population is that insight. Like you were talking about your patient who has the executive functioning issue. Our new stroke patients are not thinking about their life post this new thing. Right? Like, this is a a brand new stroke.

Emily Brady (28:52): Maybe they had the recurrent strokes we were talking about, but maybe before coming in here, they were just a a vitamin person. All that they took was a couple vitamins, gummies every now and again. Now after their stroke, they realize, oh, I have high blood pressure and now I have to be on these medications. Well, that won't be a problem. I don't have to learn anything new.

Emily Brady (29:14): I'm used to taking medications. Now they've gone from taking one to two to 10. That's a big And they It's a huge leap. And they have time restrictions and all the things. So being very specific about medication adherence and the importance of taking them when you're supposed to and reading the labels.

Eva Johnson (29:35): Yeah. And whether you are a speech therapist or someone who is a caregiver for a stroke survivor, you can a 100% help them with that. You can get them set up with their pill box. You can have a picture above their pillbox so they can compare maybe does what I'm taking today look like the picture. If you're a therapist, you can administer the MediCog, which can assess somebody's, you know, ability to adhere to their own medications.

Eva Johnson (30:02): If you're a caregiver, you can also set someone up with a medication tracker. Like, here's my little chart, and I check off the medications that I took today so that the person can be more independent and be more aware of what they're doing. That alarms on people's phones. Mhmm. You know?

Unknown Speaker (30:19): Like, you don't have to remember everything. That's a ridiculous premise. Anyways, really, I got I got more amped up than I anticipated talking about that.

Unknown Speaker (30:29): It's serious business.

Eva Johnson (30:32): Yeah. What else should we be doing for clinical takeaways?

Emily Brady (30:36): So we have to make sure that our patients can get help if they need it. So they're going home alone. Do they have a call button in case they need it? They're not gonna be able to drive themselves to the hospital, so making sure they have either help I've fallen button or help I'm stroking out button or a smart speaker that says that that you can talk to and say, Alexa, I think I'm having a stroke. Call 911.

Emily Brady (31:04): Be warned for your Alexa.

Eva Johnson (31:08): Am right. If you're listening on a speaker, Alexa about to call 911. But I think about that all the time. Like, when I watched my grandparents age and pass, was like, they couldn't really figure out Alexa, but like, if they shout loud enough for her, maybe she'll help. Yeah.

Eva Johnson (31:29): I I think it's a great strategy. That and if they're still at the hospital, making sure that they know how to press their call button. I think we talked last episode about a patient I had who told no one when he was having a hypotensive episode until we kinda were able to prompt it. And it's like, yeah, some people just aren't putting that together. They're like, yeah, my speech is starting to sound weird, but they're not communicating for help.

Eva Johnson (31:56): Mhmm. You know? So we gotta we gotta help connect those dots for them. Mhmm. These are your signs and symptoms.

Eva Johnson (32:02): What do you do if you feel one? You call for help. How do you call for help? You press the call button. Like, leave nothing undiscussed.

Eva Johnson (32:10): It has to be explicitly stated for our cog patients.

Emily Brady (32:13): Yeah. Especially maybe even that go talking about caregivers, maybe as a caregiver or, you know, a concerned kid, you're calling mom and dad every night at the same time to just check-in. How do they sound? Does their voice sound the same as yesterday? If not, maybe drive up there.

Eva Johnson (32:36): Yeah. Actually, that's a really good one. I've definitely had patients tell me I was on the phone with my kid and I fell. Like, what they had was limb numbness Mhmm. Or their speech started to sound weird and their, you know, children were able to call.

Eva Johnson (32:52): Mhmm. It always feels so weird saying children when I'm like, yeah. They're like in their fifties. Yeah. That's why they're calling their parents, not living with them.

Eva Johnson (33:00): Yeah. And they have and another big thing that I would put out there for folks is if you are on the phone with somebody who is having a stroke, stay on the phone. You know, when EMT services get there, you can provide information. You can give timelines. Do not hang up.

Eva Johnson (33:20): Call on a different line or call back as soon as possible because being able to talk the person through their experience and wait until EMTs get there will, you know, a lot more context for when they get to the hospital. And you're ensuring that someone is getting there, like you're staying on the phone until help gets there.

Emily Brady (33:38): Yeah. This is gonna be the hardest conversation that we have. It's the what to cut out all of the fun things.

Unknown Speaker (33:50): Stop doing those drugs.

Emily Brady (33:51): No Stop smoking. Drugs are bad. No drugs for you. No drugs, stop smoking, cut down on fat, sugar and start exercising or exercise more often.

Eva Johnson (34:06): Yeah. It's funny. The students on Monday, somebody asked me it was about thickened and thin liquids. They're like, well, what if you do? What do you do when you have a recommendation and the person just won't follow it?

Eva Johnson (34:20): And I asked them, how many of you know that you should be working out more?

Emily Brady (34:24): Mhmm.

Eva Johnson (34:25): And almost everybody raised their hands. Like, we can make recommendations, and we know what we should be doing for our health as clinicians, as people, and we regularly ignore that advice. So why should somebody after a stroke pay attention to the advice? You know? This is probably not the first conversation they've heard about their their habits, you know, what they're eating, if they're smoking or drinking, things like that, people have probably told them that those things are bad for them.

Eva Johnson (34:55): Mhmm. And they need to get their blood pressure under control. They need to get their cholesterol levels down. Guess what? After a stroke, some people take that really seriously, and some people take it seriously for a few months.

Unknown Speaker (35:07): Mhmm.

Eva Johnson (35:08): And then it gets really hard to keep doing those things.

Unknown Speaker (35:12): Mhmm.

Unknown Speaker (35:13): So they kinda stop.

Emily Brady (35:15): I'll need to look up where I learned this, but I learned that it takes ninety days to create a habit out of doing something. So we talk about our patients to, like, stop drinking, stop doing drugs. We got thirty days under our belt already. We've got two more months, and you're, you know, you're doing something good for yourself. So it it's just taking it day by day.

Emily Brady (35:42): And if you, like, miss a day, don't, like, you know, self loathe and doom spiral, but, you know, take that to be like, okay. Do you know? Start back on. Ninety days. I'm making myself ninety days to really commit to this.

Eva Johnson (35:58): Yeah. Exactly. And I think part of what can be hard for people is in a really emotionally vulnerable time after a stroke, you wanna do those things that make you feel comfortable again. Mhmm. Right?

Eva Johnson (36:09): People wanna get home. They wanna have those meals that feel good. They wanna have that glass of wine or that cigarette that's gonna make them feel less stressed. And those are now I mean, they weren't good for them before.

Unknown Speaker (36:21): Mhmm.

Eva Johnson (36:22): But now they're really not good for them. And it so you're kinda happy you have these competing needs. You have that I want comfort. I want to, you know, feel like I'm back to myself again, and I shouldn't be doing these things. So it's it's hard.

Eva Johnson (36:38): And I'm not saying that that is great, but just recognizing where patients are coming from. The patients are only gonna follow things as much as you follow your own recommendations in your life. And, you know, what happens happens. I don't know. Always feel like I'm coming back to this.

Eva Johnson (36:54): It's whatever. Because you can change, you can't, you can't change things. You can get people started on the right foot and hope it carries over when they go home. That's a different environment.

Emily Brady (37:05): Yeah. Yeah. You're you're nobody's you know, you're nobody's parent, and I am somebody's parent, and I can't even make them do stuff that I want them to do. So good luck. Seriously.

Eva Johnson (37:21): And I mean, some people start those habits while they're still in the hospital. You go in and they're vaping and you're like, seriously? Okay. I guess that means I didn't do stroke education well enough with you. Security.

Eva Johnson (37:37): Security. Somebody please take that away. But you can't because it's theirs and you can't take patients' belongings, so it's complicated.

Emily Brady (37:45): It's confiscated until discharge. It's confiscated until discharge.

Eva Johnson (37:52): Man, whenever I see people going out for their allotted number of cigarettes for the day, I'm like, this is an interesting system.

Emily Brady (38:00): I know. Don't you be late for smoke break in a nursing home. Holy cow.

Eva Johnson (38:06): It's like Jeopardy, the price is right, bingo and cigarettes. That is what keeps things going.

Unknown Speaker (38:15): And Gilmore Girls lately. I don't know what's going on with Gilmore We can't miss it.

Eva Johnson (38:20): Hey. I'm here for Gilmore Girls. It's like the the family version of the West Wing. It's very lots of quick banter talking on the move. But instead of international decisions being made, it's who likes who and small town drama.

Eva Johnson (38:38): I'm into it. I I think secretly, Erin Sorkin wrote Gilmore Girls is what I'm trying to say.

Unknown Speaker (38:44): Who? The writer of

Unknown Speaker (38:45): the West Wing or the producer of the West Wing. You know what? I think that's right. I frankly don't know.

Unknown Speaker (38:50): Yeah. You you you would watch The West Wing well enough to know the writers and producers of The West Wing.

Unknown Speaker (38:56): Watched that show.

Unknown Speaker (38:57): No one watched that show that you walk in and your parents are watching, and you're like, I guess I'll go back to my room.

Unknown Speaker (39:05): Yeah. Pretty much.

Emily Brady (39:07): Bullet points to our stroke reoccurrence episode. What matters the most is early action. Get your butt to the hospital. Having consistent rehab and then having your patient understand their risks and things that they can do to lessen those risks.

Eva Johnson (39:31): Yeah, and to keep themselves safe. What can they be doing to improve their own outcomes, putting them in the driver's seat again? And honestly, think the conversations that we're having with patients about their risk of stroke, risk of reoccurrence, what they can be doing to be more in charge of their, you know, prognostic outcomes is just as important as the rest of the therapy itself.

Unknown Speaker (39:51): Alright, guys. Thank you for listening, and we'll catch you next time. Goodbye. You've been listening to Speech Talk.

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Unknown Speaker (40:57): Eva Johnson and Emily Brady.

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