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Thursday, April 06, 2006

And we still don't know about Ingrid 

This morning I was gleaning knowledge from the bathroom wall.

Specifically, I was in the bathroom of a faculty lounge, where the faculty had posted various e-mails and the like on the wall. One of the e-mails, worded approximately like this, caught my eye.

During a BBQ a friend stumbled and took a little fall - she assured everyone that she was fine (they offered to call paramedics) and just tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food - while she appeared a bit shaken up, Ingrid went about enjoying herself the rest of the evening. Ingrid's husband called later telling everyone that his wife had been taken to the hospital - (at 6:00pm, Ingrid passed away.) She had suffered a stroke at the BBQ - had they known how to identify the signs of a stroke perhaps Ingrid would be with us today.

It only takes a minute to read this-

----- A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke...totally. He said the trick was getting a stroke recognized, diagnosed and getting to the patient within 3 hours which is tough.


3 steps. Read and Learn!

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer brain damage when people nearby fail to recognize the symptoms of a stroke.

Now doctors say a bystander can recognize a stroke by asking three simple questions:

1. *Ask the individual to SMILE.

2. *Ask him or her to RAISE BOTH ARMS.

3. *Ask the person to SPEAK A SIMPLE SENTENCE (Coherently) (i.e. . It is sunny out today) If he or she has trouble with any of these tasks, call 9-1-1 immediately and describe the symptoms to the dispatcher.

After discovering that a group of non-medical volunteers could identify facial weakness, arm weakness and speech problems, researchers urged the general public to learn the three questions. They presented their conclusions at the American Stroke Association's annual meeting last February. Widespread use of this test could result in prompt diagnosis and treatment of the stroke and prevent brain damage.

A cardiologist says if everyone who gets this e-mail sends it to 10 people; you can bet that at least one life will be saved.


Once I read this, I knew I had to check out its veracity. When reading it, alarm bells went off in my head:
  • There is absolutely no information substantiating the claims of the first paragraph. Was there truly a barbecue? All that we know is that there was a woman named "Ingrid" - and even here, the last name, city, and date of death are unknown.

  • No one else in the article is identified at all. Who is the neurologist? Who are the doctors? Who are the researchers? Who is the cardiologist?

  • The big issue was the note at the bottom to send this to as many people as possible. Messages like this are always suspect, and usually result in me deleting, rather than forwarding, the message.

Can you say urban legend?

By the way, different versions of this letter are available here and here. The last page is at cellhealthmakeover.com, a place that sells anti-aging supplements - sounds high quality to me.

Well, when I run across such things, I usually refer to snopes.com, which discusses the "smile test" here. You can also look at hoax-slayers.com, which discusses this e-mail here.

It turns out this e-mail is based on some scientific research, which is discussed at the American Heart association website. This February 2003 article discusses the research (I've emphasized those portions of the article that are related to the e-mail that I saw):

Stroke Journal Report

Just a minute: Bystanders may identify stroke symptoms in 60 seconds

PHOENIX, Feb. 13 – A bystander may be able to spot someone having a stroke by giving the person a simple, quick test to see if they can smile, raise both arms and keep them up, and speak a simple sentence coherently, according to a report presented today at the American Stroke Association’s 28th International Stroke Conference. The American Stroke Association is a division of the American Heart Association.

The test, which takes less than one minute, has helped healthcare professionals accurately identify stroke patients. If bystanders can relay results of this test to an emergency dispatcher, it could speed treatment to stroke patients. Time is crucial in treating stroke.

A clot-busting drug has been shown to limit disability from strokes cause by clots (ischemic strokes), but the drug must be given within three hours of the onset of stroke symptoms. Because of this short time window, only a small percentage of patients are eligible to receive the drug.

“As the brain is deprived of oxygen during a stroke, it’s literally starving minute-by-minute. The sooner the patient receives proper treatment in the appropriate medical setting, the better the chances for a full recovery,” says Amy S. Hurwitz, a second-year medical student at the University of North Carolina-Chapel Hill School of Medicine in Chapel Hill, N.C.

Hurwitz is the lead author on a study designed by Jane H. Brice, M.D., assistant professor of emergency medicine at the same institution. The study examines whether members of the public can effectively administer the simple three-item examination that healthcare professionals use. It is known as the Cincinnati Prehospital Stroke Scale (CPSS).

Researchers modified the CPSS into a script for over-the-phone administration via a layperson intermediary. They recruited stroke survivors from the hospital’s support group. Some of these volunteers still had one, two or three of the unresolved symptoms identified from a previous stroke, such as facial weakness, arm weakness and/or speech deficits.

Researchers then recruited 100 non-patient visitors (bystanders) to the UNC hospital’s emergency department and brought the people to a quiet room where a stroke survivor and investigator were waiting. The bystanders were instructed to “answer the telephone when it rings” and to follow the directions given over the phone, using the stroke survivor as their mock patient. A researcher role-played a dispatcher implementing the CPSS script.

Results indicate that the bystanders correctly administered CPSS directions 96 percent of the time. When stroke patients were told to raise both arms and keep them up, bystanders were 97 percent accurate in detecting arm weakness, and 72 percent accurate in determining the lack of arm weakness. When patients were asked to repeat a sentence, bystanders were 96 percent accurate at detecting speech deficits and 96 percent accurate in detecting a lack of speech deficit. The bystanders were 74 percent accurate in finding facial weakness based on the stroke patient’s smile and 94 percent accurate on the absence of facial weakness.

“While treating stroke patients may require extensive training and expensive equipment, our study shows that untrained adults can successfully detect stroke symptoms. This ability can allow a bystander to act as ‘eyes and ears’ for a 9-1-1 dispatcher who may be miles away,” Hurwitz says. “Unlike other investigations that strive to improve the treatment of stroke within the hospital setting, this study taps into the general public as a first-line resource in the diagnosis and triage of possible stroke victims.”

The bystanders in the study scored high when detecting arm weakness and slurred speech – two key symptoms suggesting a patient may have had a stroke. They were less successful detecting facial weakness, probably because it’s hard to assess a stranger’s smile, according to Hurwitz. If the possible stroke patient was the bystander’s spouse, it’s likely the bystander would more readily detect an abrupt change in the quality of the smile, she says.

“The general public should remember the three items tested by the CPSS. Therefore, if a family member’s speech unexpectedly becomes slurred or incomprehensible, you should call 9-1-1 immediately. Similarly, if one side of someone’s body ‘goes numb’ or if one side of the face droops down, you should call for help immediately,” Hurwitz says.

Delaying medical attention is dangerous when someone is having a stroke, since continued oxygen deprivation can cause brain damage. “As the medical profession strives to improve the diagnosis and treatment of stroke, so should the general public aim to access this medical attention as quickly as possible,” she says.

Hurwitz says the next step is to test layperson administration of the test in the field with real patients and emergency dispatchers. “We will train dispatchers to lead callers through the CPSS assessment of the stroke victim. We will then compare the survival and symptom outcomes of patients who are screened with the CPSS with a subset of patients who do not receive the screening. By statistically comparing the patient outcomes … we can assess whether the addition of the CPSS to the dispatcher’s repertoire would benefit future stroke victims and their families,” she says.

Co-authors of the study are Barbara A. Overby, R.N., and Kelly R. Evenson, Ph.D. The study was partly funded by the American Stroke Association and the UNC Medical Alumni Foundation.

NR03 –1007 (ISC03/Hurwitz)

But another page at the American Heart Association website offers some cautions (emphasis theirs):

"A Simple Test for Stroke"

The American Stroke Association does not endorse “The Smile Test,” also known as “a simple test for stroke,” – which was widely distributed through emails.

The facts: A scientific poster presented at the 2003 International Stroke Conference titled “Untrained Adults Can Identify Symptoms of Stroke by Directed Use of the Cincinnati Prehospital Stroke Scale” suggested that asking three questions could help bystanders identify a stroke:

1. Ask the individual to smile
2. Ask him or her to raise both arms
3. Ask the person to speak a simple sentence coherently.

This presentation by researchers at the University of North Carolina-Chapel Hill School of Medicine was one of 450 presentations made at the conference hosted by the American Stroke Association. The poster showed positive results but was a very small study. The research was funded by a grant from the American Stroke Association. However, the American Stroke Association has not taken a position on this topic nor endorsed this test.

Incidentally, the Cincinnati Prehospital Stroke Scale has been tested with emergency medical technicians, with "excellent intraclass correlation between the physician and the prehospital providers." So if you're an EMT, go for it.

And Chrome, in a March 23 post in a thread devoted to the topic, not only deplored how the e-mail changed some of the facts ("limit disability from strokes" became "totally reverse the effects of a stroke"), but also made this additional observation:

If someone came up to me at a BBQ (especially if they were serving alcoholic beverages) and asked me to do the above I would probably...

3. SPEAK A VERY SIMPLE TWO WORD SENTENCE (I'll leave you to guess what!)

I would then be extremely suprised when a bunch of Paramedics rush up and start to administer further tests.

However, while the test may (or may not) have some validity, we still don't know whether Ingrid was real. But I have concluded that I don't want any of my children or grandchildren to be named Ingrid; it's too deadly:

If a consumer reports to a dietary supplement manufacturer that Aunt Ingrid, who just died, was taking the manufacturer's vitamin C, will a vitamin C witch-hunt ensue? What if Aunt Ingrid was taking Crestor and undergoing treatment with Avastin while taking vitamin C? Will the required reporting data compiled by FDA reflect that a death was "linked" to ingestion of vitamin C?

From the Ontario Empoblog (Latest OVVA news here)

I just realized the biggest problem with the whole Ingrid e-mail. Note the portions I've emphasized:

Ingrid went about enjoying herself the rest of the evening. Ingrid's husband called later telling everyone that his wife had been taken to the hospital - (at 6:00pm, Ingrid passed away.)
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