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Dr. David Fiorella

The four person MSU crew Patricia Babiam, Kristofer Martin, patient Bill Rothmeier, Anthony Papaleo and Frank Time, reunite for a reunion.

By Daniel Dunaief

Ralph Sabatino, a lawyer and St. James resident, was in his bedroom, sitting at his computer when he fell out of his chair.

Ralph Sabatino of St. James. Photo courtesy Stony Brook Medicine

When his sister Maria, who was visiting from New Jersey in April of 2023, came into the room, she immediately called his wife Claire, a registered nurse, to come check on him. 

“I noticed his left arm and left leg were paralyzed,” said Claire Sabatino, who has been married to Ralph for almost 44 years. “HIs speech was garbled.”

Claire called 911 and told the dispatcher that her husband was exhibiting the signs of a stroke. Within minutes, an EMS ambulance and one of the two Mobile Stroke Units from Stony Brook hospital arrived.

In the mobile stroke unit, technicians conducted a CAT scan, forwarding the results to Dr. David Fiorella, Director of the Stony Brook Cerebrovascular Center and Co-Director of the Stony Brook Cerebrovascular and Comprehensive Stroke Center at Stony Brook Medicine. When he arrived at the hospital, Sabatino bypassed the emergency room and went directly into an operating room.

Fearing the worst, Claire Sabatino called their adult daughter Gabrielle and told her to get to the hospital as quickly as possible.

“I never saw anybody with the symptoms my husband was exhibiting that fully recovered in the past,” she said. “When I saw him on the floor, I thought that would be the way he’d live for the rest of his life, if he survived. I wasn’t sure he would.”

After the stroke and the operation, Sabatino, who is now 68 years old, has no symptoms following what is far too often a life-altering condition.

“It’s sometimes hard for me to fathom how massive the stroke was because I have had no lingering effects,” he said.

Indeed, Sabatino estimates that the time between when he had the stroke until he was wheeled in the recovery room was about an hour and a half.

“Stroke is an emergency,” said Fiorella. “Although it’s not painful, numbness, weakness involving one side of the body, difficulty with speech, understanding speech, difficulty with vision, anything that presents acutely shouldn’t be ignored. It needs prompt attention.”

As a way to recognize the signs of stroke and the urgency to get help, doctors in this field suggest that people remember the acronym BE FAST, which stands for balance, eyes, face, arm, speech, time.

With seniors representing the fastest growing population on Long Island, residents and their families and caregivers need to be aware of stroke symptoms and, in the event of a stroke, to have an action plan in place.

“We have an aging population and the prevalence of stroke is increasing,” said Fiorella.

In Suffolk County, Stony Brook has two mobile stroke units, positioned on the Long Island Expressway at Exits 57 and 68. These units are located within 10 miles of 46 EMS territories.

Since Stony Brook started deploying these mobile stroke units in April of 2019, these specialized and life-saving ambulances have responded to about 8,000 stroke calls.

During those years, the hospital has demonstrated a significant reduction in time to treatment, with more patients receiving clot busting medications while in transit, and lower rates of mortality and morbidity, Fiorella explained.

A workup and diagnosis at other hospitals can take three or more hours, which a mobile stroke unit can perform with a CAT scan.

Additional benefits

David Fiorella, MD, PhD stand for photo at Stony Brook Hospital on Monday Sept. 12, 2022. (9/12/22)

Fiorella explained that the technicians in the ambulance share considerable information about the patient while in transit, including whatever contact numbers they could collect from family members on site.

Stony Brook Hospital can then begin a dialog with those family members, preparing them for any potential procedures and, if the patient is a candidate for a new treatment, receiving authorization.

A well-established and industry leading stroke unit, Stony Brook is involved in several experimental protocols designed to improve treatment.

“Whenever we can, we offer newer and better technologies,” said Fiorella. By participating, patients not only benefit from advances in the field, but also help the thousands who come after them. Patients can “make tremendous contributions to their own care and to medicine” amid developments and advanced technologies, he said.

In cases where patients or their representatives prefer not to use any advanced or newer technology, Stony Brook provides other life-saving services.

Fiorella added that the mobile stroke unit doesn’t only bring patients to Stony Brook, but also takes them to other comprehensive stroke centers for advanced treatment.

While strokes disproportionately affect the elderly, with the Medical University of South Carolina estimating that 75 percent of strokes occur in people 65 and older, certain conditions can increase the risk of strokes, such as smoking, vascular or heart disease, high blood pressure and peripheral vascular disease.

Another success story

The four person MSU crew Patricia Babiam, Kristofer Martin, patient Bill Rothmeier, Anthony Papaleo and Frank Time, reunite for a reunion.

Bill Rothmeier, who lives in Oakdale, was coming back from upstate in 2019 when his wife Eileen recognized that he was driving strangely.

She asked him to pull over so she could use the restroom. When she returned, she took over the driving. By the time they got home, Rothmeier’s ability to speak had declined.

Eileen Rothmeier spoke to a next door neighbor, who was involved with a community ambulance in Sayville. He had heard about the stroke unit.

“The next thing I knew, two ambulances were in front of my house,” said Bill Rothmeier, who is now 68. The MSU did a CAT scan and gave him a shot on the way to the hospital.

When he was in the recovery room, Rothmeier said Fiorella came in and told him he put in a stent and pulled two blood clots out of his brain.

“He said it like I was going out to a deli to get lunch,” said Rothmeier, who, as it turns out has owned the Lake Grove Deli for 29 years. “If it wasn’t for those guys,” including the MSU crew and Fiorella, “I could be in a nursing home or worse right now.”

Rothmeier was one of the first to receive life saving treatment through the mobile stroke unit and at the hospital.

A rewarding job

While the mobile stroke unit provides an important service for people battling a stroke, it doesn’t add any cost for the patient.

Stony Brook provides the units “free of charge,” because the “outcomes are so much better,” Fiorella said.

Patients who have untreated strokes or whose strokes are treated much later can have an irreversible brain injury, which could involve hospitalizations that last for months.

Stony Brook receives the same flat rate from Medicare for stroke victims, which helps provide financial support for the ambulance and is a “home run” for the patient, Fiorella added.

From Fiorella’s perspective, the opportunity to help people more than compensates for the 2 am calls he sometimes gets when he needs to come in for emergency surgery.

In the 25 years he’s been involved in stroke care, Fiorella has “never lost the fascination in how great the technology has become and how quickly it’s advanced,” he said. After treatment, people who couldn’t speak or understand speech and who couldn’t move the dominant side of their body can return to normal activities.

“It’s such a wonderful experience being involved with this,” he said. “I wouldn’t be able to do this without the support of Stony Brook.”

As for Claire Sabatino, who had never heard of the mobile stroke unit before the ambulance was parked on her driveway last April, the benefit of the rapid transit and the Stony Brook team is “nothing short of a miracle.

From left to right, physician assistants Michelle Rosa and Katherine Malloy, Dr. David Fiorella and Dr. Jason Mathew visit Joseph Annunziata in his hospital bed. Photo from Stony Brook Medicine

By Daniel Dunaief

Joseph “Bob” Annunziata, a resident of Kings Park, wants you not to be like him.

An army veteran, Annunziata urges residents and, in particular, other veterans, to pay attention to their medical needs and to take action when they find out they have a problem. 

A self-described “tough guy” who grew up in Bay Ridge, Brooklyn, Annunziata put off medical care for a partially blocked left carotid artery and it caused a medical crisis.

“My brother and sister vets, if you got a pain or the doctor tells you to do something, do it,” he said. “It almost cost me my life. I don’t want that to happen to anyone else.”

Joseph Annunziata at his 80th birthday party

Annunziata, 80, was driving to the supermarket on Veterans Day when his right hand became limp and he was slurring his speech. Knowing he was in trouble, he turned the car around and drove 10 minutes to the Northport VA Medical Center.

The doctors evaluated him and rushed him to Stony Brook University Hospital, which is well equipped to handle stroke-related emergencies and is the only hospital in the state named one of America’s 100 Best Hospitals for Stroke Care for eight years in a row. 

Several doctors evaluated Annunziata, including by Dr. David Fiorella, Director of the Stony Brook Cerebrovascular Center and Co-Director of the Stony Brook Cerebrovascular and Comprehensive Stroke Center, and Jason Mathew, stroke neurologist.

“We identified that there was a severe blockage in the left side of his brain,” said Dr. Mathew. “If blood flow is not returned to this area, the patient is at risk for a larger area of stroke.”

Indeed, a larger stroke could have caused right side paralysis and could have robbed Annunziata of his ability to speak or worse.

Performing emergency surgery could protect endangered brain cells, but also presented some risk. If not removed carefully and completely, the clot in the carotid artery could travel into the brain or the stroke could expand over time due to a lack of sufficient blood flow to the left side of the brain.

Time pressure

Stony Brook doctors discussed the particulars of the case together and explained the situation to Annunziata, who could understand what they were describing and respond despite symptoms that threatened to deteriorate.

The hospital, which does between 200 and 250 interventional stroke treatments per year and handles many more strokes than that annually, has a group of health care specialists who can provide accessible information to patients who are not experts in the field and who need to make an informed decision under time pressure.

Stony Brook has become adept at “conveying this complex information in a time-sensitive way,” Dr. Fiorella said. In those cases for which surgery is the best option, each minute that the doctors don’t open up a blood vessel reduces the benefits and increases the risk of longer-term damage.

Stony Brook sees about one to two of these kinds of cases per month. As a whole, the hospital, which is a large referral center, sees numerous complex and unusual cerebrovascular cases of all types, Dr. Fiorella said.

Annunziata and the doctors decided to have the emergency surgery.

Dr. Fiorella used a balloon guiding catheter, which is a long tube with a working inner lumen that has a soft balloon on the outside of it that is designed to temporarily block flow. He deploys these occlusion balloons in most all stroke cases. 

The particular way he used it in these complete carotid occlusions is unique. The balloon guiding catheter makes interventional stroke procedures more efficient, safer, and the outcomes better, according to data for thrombectomy, Dr. Fiorella said. 

The occlusion balloon enabled Dr. Fiorella to control blow flow the entire time, which makes the procedure safer. The surgery took under an hour and involved a small incision in Annunziata’s right wrist.

Joseph Annunziata with his girlfriend Rosemarie Madrose

After the surgery, Annunziata was able to speak to doctors and call Rosemarie Madrose, his girlfriend of five and a half years. “He came out talking,” said Madrose. “I could understand him. I was relieved.” Four days after the emergency operation, Annunziata, who also received post operative care from Dr. Yuehjien Gu, Neurocritical Care Unit Director, left the hospital and returned to his home, where he spent the next morning preparing a welcome meal of a scrambled egg and two slices of toast.

The doctors attribute Annunziata’s quick recovery to a host of factors. Getting himself to the hospital as soon as symptoms started saved precious minutes, Dr. Fiorella said, as “time is brain.” He also advised against driving for people having stroke-like symptoms, which can include slurred speech, numbness, weakening of the arm or leg and loss of vision in one eye.

Dr. Fiorella urged people to call for help or to get a ride in an ambulance. Stony Brook has two mobile stroke unit ambulances, which are equipped with technology to assess patients while en route, saving time and alerting doctors in the hospital to patients who might need immediate attention and intervention.

These mobile units, which are available from 8 a.m. to 8 p.m., have helped reduce death and disability for stroke and have cut down the length of stays in the hospital.

People or family and friends who are observing someone who might be having a stroke can call 911 and indicate that the patient is having stroke-like symptoms. The emergency operator will alert the mobile stroke unit of a possible case if the unit is available and the patient is in range.

Helping a veteran

The doctors involved in Annunziata’s care were well aware of the fact that they were treating a veteran on Veterans Day.

“Oftentimes, we think about how we can give back more than just a thank you” to people like Annunziata, who “risked his life and helped his country the way he could,” said Dr. Mathew. “I’m helping him the way I can help.”

Dr. Fiorella added that he thought it was “wonderful” to “help someone who’s given so much to our country on Veterans Day.”

Army origin

Annunziata explained that he wound up in the Army through a circuitous route.  “We watched all the war movies” when he was young and wanted to join the Marines, he said.

When he went to enlist in 1962, he was told there was a two and a half year wait. He and his young friends got the same reception at the Air Force, Navy and the Army. As they were leaving the Army building on Whitehall Street, he and his friends ran into a sergeant with numerous medals on his uniform. The sergeant urged them to go back up the hallway and enter the first door on the right and indicate that they wanted to expedite the draft. About a week later, Annunziata was drafted and got a 15 cent token in the mail for a train trip to Wall Street.

After basic training at Fort Dix, he was stationed in Greenland, where Annunziata operated a radar at the top of a mountain for two years. He participated in drills in which he had to catch American planes flying overhead.

Fortunately, he said, even during the height of the Cold War and just months after the Cuban Missile Crisis, Annunziata never spotted a Russian threat, even though the base was just 20 minutes from Russian air space.

Having gone through emergency surgery that likely saved his life, Annunziata urges residents to pay attention to any medical needs on their radar.

Dr. Fiorella was amazed at how quickly Annunziata expressed concern for his fellow veterans during his recovery.

“One of the first things he talked about was, ‘How can I use what happened to me to help other vets?’” Dr. Fiorella said.

Annunziata’s girlfriend Madrose, who is grateful that the procedure saved his life, said he “didn’t listen to me. He knew he had to do this. I kept saying, ‘When are you going to do it?’ He said, ‘I will, I will, I will.’ He learned the hard way.” She added that they both know he is “extremely lucky.”

SC Legislators join Dr. David Fiorella, fourth from right, in congratulating the Mobile Stroke Unit’s efforts after it was launched last year. Photo from William Spencer’s office

In March of last year, Dr. David Fiorella went before the Suffolk County Health Committee chaired by Legislator William “Doc” Spencer (D-Centerport) and announced the launch of Long Island’s first Mobile Stroke Unit program aimed at reducing death of stroke victims. Fast forward 18 months and Fiorella has reported to the same committee Oct. 1 that since deployment, the MSU has been on over 1000 total calls. Findings during the first-year show Stony Brook Medicine’s units have successfully facilitated the diagnosis and rapid delivery of time-critical therapies to stroke patients at the point of care resulting in substantially improved outcomes.

“We are also very grateful to all of the members for the Suffolk County Legislature for their help in promoting the program’s success and look forward to further improving upon these outcomes and expanding this program to service even more residents of Suffolk County in the future,” said Fiorella, a neurointerventionalist and Director of the Stony Brook Cerebrovascular Center and Co-Director of the Stony Brook Cerebrovascular and Comprehensive Stroke Center.  

Fiorella also mentioned their intent to locate two more stroke units to add to the current slate located at Long Island Expressway Exits 57 and 68. Each unit is equipped with telehealth capability to communicate with physicians at Stony Brook University Hospital. When a suspected stroke call comes in, the mobile stroke unit is dispatched and the team works quickly to determine the type of stroke the patient is experiencing using the features on board including a CT scanner and CT angiogram. Once that is determined, first responders in the unit can begin administering time-sensitive stroke treatments.

Data from the program further shows stroke patients transported by the MSU had much greater rates of discharges directly from the hospital to home after treatment, higher rates of independent clinical outcomes after stroke and much lower rates of death from stroke when compared to national averages, county average, and Stony Brook’s own data preceding the MSU program.   

“The work that Dr. Fiorella and his team are doing is extraordinary,” Spencer said. “The reduced time it takes their units to reach and care for stroke victims is yielding measurable improvements to the lives they touch.”

Spencer also noted the legislature’s goal in expanding the program. 

Strokes are a major public health concern nationwide. Every 40 seconds, someone in the United States suffers a stroke and every four minutes someone dies on one, according to the American heart Association.

Dr. David Fiorella and Dr. Eric Niegelberg are spearheading the Mobile Stroke Unit Program. Photo provided by Stony Brook University

By Daniel Dunaief

In June, Diana Squitieri of Holbrook wasn’t making sense. Her son Joe noticed that she was also stumbling while her face was drooping.

When he brought her to his car to take her to the hospital, she became so disoriented that he asked his wife, Erin, to call 911. That decision, and the new vehicle that arrived, may have saved her life.

A Stony Brook University Hospital mobile stroke unit, which went into service two months before Squitieri’s symptoms developed, immediately started assessing her symptoms.

Each of the two units is a mobile stroke emergency room, which allows Stony Brook doctors to determine whether the patient has a blocked vessel or bleeding in the brain.

If the process of getting to the hospital and determining her condition had taken any longer, Joe Squitieri is convinced he “could have been burying her.”

For bringing these two stroke units to Suffolk County, the TBR News Media is pleased to recognize the team of medical professionals at Stony Brook Medicine who provide life-saving care for stroke victims.

The Squitieri family. Photo provided by the Squitieri family

Suffolk County is “one of only a few places in the entire United States to have these units,” said Dr. David Fiorella, the co-director of the Stony Brook Cerebrovascular Center.

Stony Brook hopes to add a third unit within the next year.

Through the end of September, the two units had received 550 calls. Of those, about half of the patients had a stroke. Some received anti-clotting drugs while in transit to the hospital, while an evaluation of others en route alerted surgeons to the need for rapid intervention.

Every minute during a stroke could endanger as many as two million brain cells, Fiorella said. That means cutting down on the time to receive medicine or to have surgery potentially saves millions of brain cells, which can improve the quality and quantity of a person’s life.

Squitieri is one of 23 people transported in the stroke unit who had an emergency surgical procedure to remove the clot.

Numerous people contributed to bringing these mobile units to Stony Brook, including Eric Niegelberg, the associate director of Operations for Emergency Services and Internal Medicine; Michael Guido, the co-director of the Stroke Center; Eileen Conlon, the RN coordinator of the stroke unit; and Carol Gomes, the interim CEO of Stony Brook Hospital.

Niegelberg appreciated Fiorella’s efforts.

“It was only through [Fiorella’s] leadership and perseverance that we were able to launch this program,” Niegelberg said in an email. Fiorella spent considerable time meeting with county legislators, EMS committees and EMS agencies to rally support for this program.

Fiorella appreciated the joint effort that made this lifesaving service possible. He was grateful that Gomes “saw the value” of this service. “Without her dedication, this would never have happened.”

Gomes believes the stroke units provide “an extraordinary medical service” while improving the quality of life for the community, she wrote in an email.

The mobile stroke units, which have four specialized personnel on board, are equipped with technology that allows Stony Brook neurologists to examine and diagnose each patient.

The outcomes for patients are better because of the earlier delivery of care, Fiorella said. Hospital stays are also shorter, lowering the cost of care.

Squitieri and her son Joe are thankful that the mobile stroke unit arrived at her home when it did.

Diana Squitieri recalled being scared during her stroke and said the crew took “wonderful care of me.”

Joe Squitieri called the stroke unit a “godsend.”

 

 

Dr. David Fiorella and Eric Niegelberg. Photo from Stony Brook Medicine

As American Heart Month kicks off in February, Stony Brook Medicine is finalizing plans to provide speedy help to stroke victims in Suffolk County.

“When a blood vessel supplying the brain is blocked, it is estimated that nearly two million brain cells are lost for each minute that passes, making stroke the most time sensitive diagnosis we have in medicine.”

— Dr. David Fiorella

The Stony Brook Cerebrovascular and Comprehensive Stroke Center and the Stony Brook Renaissance School of Medicine’s Department of Emergency Medicine will launch Long Island’s first mobile stroke unit program in March. The program will include specially equipped ambulances that will be strategically based along the length of the Long Island Expressway, taking calls within 10 miles of their bases.

The hope is to ensure response times of 20 minutes or less.

“When a blood vessel supplying the brain is blocked, it is estimated that nearly two million brain cells are lost for each minute that passes, making stroke the most time sensitive diagnosis we have in medicine,” said Dr. David Fiorella, director of the stroke center and professor of neurological surgery and radiology at the Renaissance School of Medicine. “The faster we can restore blood flow to the brain the more likely that the patient will have a full recovery.”

The units will be available seven days a week from 8 a.m. to 8 p.m., which is the window of time when most stroke calls are received.

Eric Niegelberg, associate director of Operations for Emergency Services and Internal Medicine, said an evaluation was completed to choose what time frame the mobile units would be available.

“We evaluated 911 ambulance call volume by area in the county and combined that data with what we felt was a reasonable response distance and time.”

— Eric Niegelberg,

“We looked at actual data for five years and historically the highest percentage of stroke calls come in during that time frame,” he said, adding once the program begins Stony Brook Medicine will continue to evaluate data and modify the hours based upon current call volume.

While the first unit will be deployed at Exit 57 on the LIE sometime between mid-to-late March, the second will not be in use until April and will be set up at Exit 68.

“The locations were chosen based upon call volume,” Niegelberg said. “We evaluated 911 ambulance call volume by area in the county and combined that data with what we felt was a reasonable response distance and time. Based upon this analysis the two locations were chosen. We did want locations that would provide easy North-South and East-West access.”

The units will include an in-ambulance care team, telemedicine system that enables emergency physicians and neurologists to see the patient via audio/visual conferencing, CT scanner for a standard scan and CT scan angiogram, which allows doctors to check for bleeding in the brain immediately.

Robert Simpson, district manager of Medford Volunteer Ambulance, said the mobile stroke units would be valuable to emergency response workers.

“As an EMS provider, we are always looking for ways to enhance treatment to patients,” Simpson said. “I think that it will definitely be an asset to us, especially for patients with strokes. As they say, ‘Saving time, saves the brain.’ Minutes count when someone is having a stroke as far as being able to enhance their chances of survival.”

According to Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, stroke is the fifth leading cause of death in the United States, killing about 140,000 Americans each year.