Stroke- Quicker treatment

Another look

But first, how often do we read or hear the phrase “Mr. “X” died of a massive stroke’? Not often. But it must happen to keep up the 20% or 25% death rate.

The “patient” moves through the parts of the stroke system, each with its own set of variables. Uncertainly is the rule.

Let’s have a look at Melbourne supplied stats. In a press release.

About 3k. Stroke death in Vic. 2014. Plenty of scope for action there.

With M.S.U expect about 3k p.a. patients treated!!

Pause. Extrapolating results from projections may not be accurate.

Moving on – the Stroke Foundation

S.F. has issued a leaflet asking for money to support the second iteration $1.5M, of the M.S.U which failed its first release date but which, we are told, is on the road. Well done. I will concentrate on only one claim in the leaflet. “Ground-breaking research initiative.”

The M.S.U – “is also an innovative research laboratory”

Let’s go straight to some of this “research”

“Testing new treatments for both major types of stroke – blocked blood vessel and bleeding – that are likely to be more effective when delivered early”

We can look on the silly unsubstantiated research claims of the M.S.U as metaphorical, for effect till clots and bleeding are mentioned above. I hope that no medical person allows any treatment for brain blood bleeds outside a surgical hospital in the care of neuro surgeons.

Remember that the S.F. article is a plea for funds, even from a will – hardly a randomized source!

Now to the main game of clot stroke. Universal view that the sooner the clot is dissolved, the less impairment to the patient. Treatment awaits in the stroke unit of a major hospital and a speeding ambulance delivers the potential stroke patient to be assessed and treated.

Home to hospital – simple

Hospital to home – revolutionary

The second method has been put into practice by fitting an “ambulance” with C.T. equipment and real time communications to hospital and with the staff led by a neurologist who is in charge of clot bursting. All this costing multiples of $M. so, how did it get off the ground?

1. An important ingredient I don’t disclose
2. It works, even in a limited fashion.

So why the low take up of 12-13 over a handful of years? Simple answer – staff!

Neurologists would be accustomed to being at call as patients arrive, but this system has them on call the same as the ambos, permanent shift workers. Clots are their only work. How long do we expect specialist with higher qualifications to work in such restrictions?

I Rest

However, my comment do not rule out support for medical innovations. Take keyhole and robotic surgery.

It is well known in medical circles that if it can be done, it will be done. Just having a go is part of progress, not always linear.

I still haven’t answered the question about quicker stroke treatment with an aim restricted to blood clots in the brain, and disinterest in other bodily functions, to the extent that their publicity states that their client/patients can bypass A &E and go straight to stroke dept. To save time, on arrival at the hospital - what more needs to be said about this bip on brain treatment.

So, what to do? See future article?

Treat the steps from home to hospital bed as seamless and improve sections which look after their own part without knowing what happens next. Starting with 000 triage. And the best people to help are those just before the hospital bed – the A& E doctors – more specifically emergency doctors.

“Dr. E”

So am I supporting doctors to the home? Yes, but wait. The doctors in the emergency section of the hospital “Dr. E” meet with the ambulance management to co-operate on what’s to get “patients” from home to hospital bed safely and sooner. Shared knowledge is the oil which makes the system run smoothly.

So, to operator without special training, perhaps like mine in “Recovery from stroke” “Why did you phone?” “I fell over and can’t feel a pulse” “How can you speak then?” “Anyway I can’t get up” “I’ll send an ambulance – give me your age, name and address. Get your family to make you comfortable – wait about 20 minutes” (The phone no. is recorded on a screen)

Now how does our “Dr. E” handle a call?

“Hello, ambulance calling, can I help you? … Then, old Fred’s wife says he has fallen down and can’t get up.

“Your name and address please – could I speak to Mr. Fred? Are you in pain?!” … “Terrible, at the top of my left leg” …. “At the hip?”…. “Any pain in the stomach?”… “No”…. “In the chest?”… “Yes”… “Can you raise both hands?”…. “No, I’m lying on one”…. “Is you head sore?” …. “It’s not too bad”…. “Put a blanket over Mr. Fred but don’t move him. An ambulance is on the way, and should be at your house in 20 minutes” “Your nearest cross st. would help”……Son has joined and asks how this message gets to a moving ambulance……“Our phone has an open line to the ambo!” “Now, are you diabetic or is there any history of stroke in your family?”……“Nothing”……“Do you take tablets for your heart?”…… “No”……Wife: “He takes tablets for high blood pressure and cholesterol”……“Collect them and put them in a bag for hospital, as well as shaving and washing stuff. Collect his Medicare card, pensioner’s concession card, and D.V.A. card. Can anyone feel his pulse?”……“Don’t know”……“Just try, dig your fingers hard into his wrist – on the thumb side” “I will type a report direct to the ambo. First, Mr. Fred’s name then a request for a pain killing injection to his left hip.”

Report could read—“suspect broken left hip, no internal problems seen, chest pain – we took blood samples to look for sign of heart attack, X-Ray Ribs, and skull, appears lucid, run our E.C.G., trace to see if any anomalies.

This last test is routine in ambulances. If it shows problems it could show the need to get to the hospital cardio ward and let the broken hip wait.

So, what is the nub of this argument? Simple – to take the knowledge and experience of our Dr. E.s to the first link in the chain, the 000 operator triage. As in the example above, by direct example and then by training.

This is making use of the 15 or so minutes the ambulance takes to reach the home.

The ambos need little more training to give a comprehensive view of what ward needs to expect a patient – as in the sample. Rouse the duty C.t radiographer for head scan and full chest X.ray.

All this achieved in about 30 minutes which would otherwise be lost.

Costs? Perhaps a few more 000 ambulance staff and ambos, being more productive and deserving more pay.

To our Dr. E, more whole patient experience leading to appointments as senior physicians.

Oh, we can get any latest communication gear from the chaps who suppled it to M.S.U’s.

Any flaws in this lot?

P.S. Three paramedics (ambos) could be routine per ambulance. Facilities should be available for blood collection into vials for rapid handover to pathology at the hospital. This is particularly so for the test of heart attack.

Angus