Dr. Debbie Madhok’s pioneering new treatment at Zuckerberg San Francisco General Hospital is aiming to revolutionize emergency care for stroke patients
By Heather Wood Rudulph
A medical condition potentially threatening all of us is one that doesn’t get a lot of media attention. We all hear about the risks of heart disease and cancer—each with its own ribbons for awareness, and countless charity events, which keep treatment and prevention top of mind. But the nation’s No. 3 cause of death, and the leading cause of serious, long-term disability, is stroke. This silent, extremely serious condition occurs when a blood clot forms or a blood vessel bursts in the brain, cutting off its blood supply. Every year, nearly 800,000 people suffer a stroke in the United States.
A new procedure for stroke care being flagshipped at Zuckerberg San Francisco General Hospital aims to change the way stroke patients are treated throughout the nation, and perhaps the world. The brainchild of Debbie Yi Madhok MD, the Mission Protocol standardizes the way the entire emergency care team responds to a stroke patient—from paramedics and nurses to ER doctors and surgical specialists. When a paramedic picks up a patient, the hospital is instantly notified, mobilizing the staff to prep for immediate, emergency care. Space and resources are made available to the patient, who is greeted by stroke doctors at the ER—the first access point of the hospital—where a CT scanner now permanently resides. Once the scan determines the extent of the stroke, patients are given clot-busting IV medication and, if necessary, instantly booked for surgery that will remove the clot. The entire process from ambulance pickup to treatment takes about 90 minutes.
The most important aspect of stroke care is time. A matter of seconds can mean the difference between rehabilitation and permanent disability. “We know that 1.9 million brain cells are lost per minute that a stroke is left untreated,” says Madhok, a clinical attending physician of emergency medicine and neurocritical care, as well as an assistant professor of emergency medicine at UC San Francisco. “Because stroke [often] doesn’t come with pain, people stay at home and try to wait it out. I want to tell them: Come in immediately. But we can’t force people to call 911, so what I’m trying to do is reduce delays every step of the way once they do. We have control over that.”
The way this protocol differs from how stroke patients are treated anywhere else is that it’s mandated. Thanks to Mission Protocol, a stroke patient has the highest priority in the ER.
“It sounds so dramatic when a patient comes in with a knife sticking out of their chest or a gunshot wound,” Madhok says. “It’s really easy to notice those patients and for doctors to descend upon them. And they are very sick patients. But what I’m trying to make the hospital and the city realize is that a stroke patient is among the sickest patients that come into the emergency room. And they cannot afford to wait.”
Madhok’s passion is palpable when she talks about saving patients, which is a directive for all doctors, but for her, it feels even more personal. She decided to become an ER doctor after her sister was nearly killed in a subway accident—she was pinned between the platform and the train, and ended up losing a leg. At the time, Madhok worked a high-profile job on Wall Street. But she was inspired by the way the ICU staff cared for her sister, and decided she wanted to give back in a similar way.
It was during her residency at New York–Presbyterian Hospital—a time that brought a bit of fame, because the reality series NY Med was being shot there—that Madhok found her calling. She was stationed in the ER, which meant seeing every kind of patient that comes into the hospital. One patient changed her life.
“My second year, I had a patient come in with a very big stroke. She had a major blockage in the biggest blood vessel in the brain. She couldn’t move one side of her body, and she couldn’t talk. She was 50 years old,” Madhok recalls. “It was too late to get many medications to work on her, including a then-experimental therapy that goes into the brain to dissolve the clot. She ended up passing away a couple days later. As I was watching her, at 50 years old, with her husband there just in disbelief, I thought to myself, It’s not OK that this happened. I am not OK with this. I was very intent on figuring out how to be part of the change to take better care of stroke patients.”
Madhok attended a neurocritical care fellowship at the University of Pennsylvania, where she gained expertise in intensive care for brain injuries. She moved with her family to San Francisco in 2015, which turned out to be a landmark year for stroke care. Several big medical studies were published confirming the success of a new type of therapy called endovascular therapy, a laparoscopic clot removal treatment that was previously only used in trials, and unavailable to her patient back in New York.
“The way it works in medicine is that you experiment with treatments until something can be proven as better than the standard therapy,” Madhok explains. “These studies showed that you want to go in and get that clot out. Every field of medicine has its moment. For stroke care, this was ours.” Once this new procedure became the standard of care, U.S. hospitals were required to use it for stroke patients. Madhok’s Mission Protocol ensures that this happens as quickly as possible. And because SF General is the only public hospital in the area, it also means that more patients will have access to the best care.
“We know that women, people of color, and people who are uninsured get different medical care than white men. And it’s not to say that this is intentional,” Madhok says. “It can be a subconscious bias, but it can also be an issue of access. That’s why I’m at General, which we consider to be a safe space for everyone.”
After months of training, the Mission Protocol activated in June. Madhok recalls the first case in which they put the system to practice, a scenario that plays out like an intense episode of ER.
“I was sitting in the ER after a day of training and we got a call from an ambulance bringing in an 88-year-old woman who had a stroke. I turned to the nurses and said, ‘Are we ready? Let’s try it.’” Madhok recalls how it went down:
The patient arrived in the ER and within four minutes she had a CT scan. Within 20, she was given the clot-busting medication through IV. The scan determined she had a big blockage in one of her main arteries, so she went downstairs to the radiology suite and catheterization—the laparoscopic surgery that removes the clot—began. Ninety-two minutes after her arrival, that blocked blood vessel was reopened. She went from not being able to speak or move the left side of her body to being able to walk in, almost fully recovered, the following day.
“It was so exciting for me because this has been my labor of love for two years. I have spent every day working on this,” says Madhok, who lives with her husband and two small children in San Francisco. “It’s wonderful for me, but also for the paramedics who bring the patient in, the ER nurses who care for them, and the doctors. Everyone feels energized, and it’s an amazing way to show that we trust one another.”
“Our biggest challenge is getting the word out that if you experience any symptoms of stroke—weakness of your body, not being able to speak properly, a droop of your face, not being able to walk properly, slurring of your speech—you must come to the hospital immediately. We work with an extraordinarily ethnically diverse group of patients who speak many languages, who are underserved, and underinsured. I’m confident that if we can do it here, we can for sure do it anywhere.”