He thought he could change stroke care in Houston with the stroke center idea. The first step went well — the
city’s ambulance services agreed to take all patients with stroke symptoms to designated stroke centers.
Then, Dr. David E. Persse, the city’s director of emergency medical services, asked every one of Houston’s 25
hospitals if it wanted to be a stroke center. While seven said yes, others have declined.
Stroke patients, unlike heart attack patients, are not moneymakers. Because of the way medical care is
reimbursed, most hospitals either lose money or do little more than break even with stroke care but can often
make several thousand dollars opening the arteries of a heart attack patient. And being a stroke center means
finding and paying stroke specialists to be available around the clock.
Soon another problem emerged. As many as a third of the patients refused to let the ambulance take them to
a stroke center, demanding to go to their local hospital.
“By law in Texas, we cannot take that man to another hospital against his will,” Dr. Persse said. “We could be
charged with assault and battery and kidnapping and unlawful imprisonment.”
The Joint Commission, which accredits hospitals, recently started certifying stroke centers, requiring that the
hospitals be willing to treat stroke patients aggressively. But only 322 of the 4,280 accredited hospitals in the
nation qualify, and most patients and doctors have no idea whether a hospital nearby is among them. (The
list is available on the site http://www.jointcommission.org/CertificationPrograms/Disease-
SpecificCare/DSCOrgs/ under “primary stroke centers.”) Some states, like New York, Massachusetts and
Florida, do their own certifying of stroke centers.
Nonetheless, most ambulances do not consider stroke center designations when they transport patients. And,
said John Becknell, a spokesman for the National Association of Emergency Medical Technicians, national
programs can be difficult because every community has its own rules for which ambulances pick up patients
and where they take them.
As a result, most stroke patients have no access to the recommended care and even fewer get M.R.I.’s, a
situation Dr. Warach said he found appalling.
“How can it ever be in the patient’s best interest to have an inferior diagnosis?” he asked. “It borders on
malpractice that given a choice between two noninvasive tests, one of which is clearly superior, the worse test
is the one that is preferred.”
In those awful moments when she realized she had had a stroke, Dr. Fite, unlike most patients, knew what to
do. She told the ambulance crew to take her to Memorial Hermann Hospital, even though it was about an
hour away. She knew that it was one of the Houston stroke centers, that Dr. Grotta worked there, and that its
doctors had experience diagnosing strokes and giving tPA.
When she arrived, Dr. Grotta asked if she was sure she wanted the drug. Did she want to risk bleeding in the
brain? Dr. Fite did not hesitate. The stroke, she said, “was just so devastating that I would rather die of a
hemorrhage in the brain than be left completely paralyzed in my right side.”