Stroke is one of the leading causes of deaths taking away 650.000 lives in Europe annually [1].   After the first warning signs (e.g., sudden headache, weakness of an arm or leg, trouble of walking, seeing, loss of balance or dizziness) are detected there is a time window of approximately 3 hours when the damaged tissues could still be recovered. If the appropriate measures are not taken, the brain tissues can simply suffocate without the oxygen supply. Within those 3 hours a physician in the hospital has to make a computer tomography (CT) of the brain to determine the nature of the stroke. In case of ischemic (which is over 80% of all strokes), some of the blood vessels are blocked by a thrombus (fat or blood clot) that disrupts the blood flow from certain areas of the brain.  The thrombolytic drugs can reestablish the blood flow to the brain by dissolving the clots, which are blocking the flow. But the same treatment could be killing for patients with hemorrhage stroke when a weakened blood vessel ruptures and blood is spilling out into the brain. Unfortunately not all hospitals nowadays  have stoke units at their disposal or specialists who can provide a CT image and carefully read it. As our friend called us on Sunday evening suspecting stroke we knew we need to react immediately and have connected to the closest call center in the area. That was the first mistake. The person in the call center probably had some doubts in regard to the diagnosis and advised to call a home doctor. The home doctor arrived in 20 minutes. At that time the systolic blood pressure raised above 200, but nevertheless our friend had no problem with speech, movements or walking and could assess the situation very well. Since the blood pressure was still high the ambulance was summoned: the local hospital in Freising close to Munich, Germany, which was the regional center of the area.

That was the second mistake. Sunday evening is the worst time getting to the hospital: most of the specialists are spending time with their families and friends. A lonely and tired assistant doctor on duty was the only one left for the emergency cases. The doors of the admission department have opened swallowing our friend, with the family left behind. We were waiting outside watching some of the physicians and nurses silently wandering through the lobbies and looking through us. No information was available, but we hoped the appropriate measures were taken: after all, the doctors should know that the stroke has to be treated fast.  After 6 hours the wife was allowed to enter the intensive therapy.  Her husband was sitting on a coach pleading to the staff  “to do something”. The lady doctor on duty was a bit irritated since she was busy with writing, obviously preparing reports. She tried to convince the patient’s wife that there was no need to worry: after all “the rehabilitation system in Germany is so good, and moreover, three hours have already passed”. The CT equipment, although available in this hospital, but there was nobody to use it or, equally plausible, no one wanted to take a risk of a decision. The sleepy neurological team arrived the next morning after a well-deserved weekend. They made a CT and diagnosed the ischemic stroke. At that time there was no doubt: the patient had a full left side paresis.

The experience we went through was a classic example of a medical error due to the late provision of services. The conclusions we drew later: 1) Never call the local emergency number: go for any of the numbers in your country that connects to the central emergency services (US 999, UK 911, Germany 112, etc.). At least they will try to get you to the hospital with the available stroke unit. 2) Don’t be shy just sitting and waiting. Demand and insist on information about the actions taken – up to the decision of calling another emergency service. Although the doctors and the medical staff intensely dislike demanding patients, it is serious: you will not get another chance. 3) Always keep a bottle of a good Cognac at home: in case of a high blood pressure or of a peculiar sensation (e.g., numbing or an awkward sticky feeling in your head), 20 ml will quickly widen the vessels and the clot might get through. This does not exclude the call for a professional assistance, but may increase the chances for the recovery or survival.

Our experience with the German hospital in Freising was frustrating. Should the anti-stroke measures have been taken properly and on time, a patient could have gone out of the hospital in a couple of days. That would cost the health insurance about € 400-500 whereas getting into the full spiral of rehabilitation process could be roughly estimated within the range of € 50.000 – 60.000. If the governments want to address the cerebrovascular accidents (CVA) more seriously, they actually have all the means and technologies to do it. For example, in England, where stroke is costing the National Health Services (NHS) over £2.8 billion [2], the relevant strategy was launched in 2007 to set a clear direction for the development of stroke services over the next 10 years. The strategy was developed in partnership with representatives from stroke charities, stroke professionals in the NHS, social care professionals and those affected by stroke.

Using a telestroke solution designed by MultiSense Communications based on Polycom telemedicine platform, the NHS Cumbria and Lancashire Cardiac and Stroke Network (CSNLC) established the telestoke network. It enables a specialist to view remotely the latest patient MRI scans, vital signs and medical history and to confirm if they should be thrombolysed or not. As long as there is a wireless or mobile connection, experts and clinicians can be reached at their homes at any time of the day or night to remotely recommend treatment for a stroke victim. Once the CT scan results are ready, the remote expert receives a video call on his mobile device (Windows Phone, iPhone, iPad, MS Surface, etc.) where the nurse shares the scan image. The specialist can check the impact of the thrombolytic medication, for example, by viewing via his mobile device the dilation of the pupils, which indicates the treatment progress. 15 round the clock consultants in NHS trusts of Lancashire & Cumbria are on the call from their homes to support remotely approximately 2.2 million people across the region. Installed at the end of July 2011, the service has already positively impacted the treatment of 26 patients by providing out of hours thrombolysis treatment. In addition to huge patient benefits, the service is anticipated to save Lancashire & Cumbria NHS Trusts over £8 million a year. If proven examples already exist, why not to install similar remote consulting services for emergency case in every clinic as the standard part of their medical equipment pool? For sure, it would be less expensive than complicated rehabilitation treatments, without mentioning the patients who will have much better chances to walk out of the hospital with no long term disabilities? Since some local structures (hospitals, insurances, and rehabilitation centers) can oppose such modernization, this should be a governmental program – as it would save a lot of budget costs (taxpayers’ money).

It is here that the governmental regulatory functions can be useful and not stifling. For years we hear long discussions that health insurances are not sure how to compensate the telemedicine services. Well, they have to think faster. If it is finally us, the citizens and eventually patients who are paying to health insurance funds, directly or through our taxes. Is not our right to demand the better quality of services we anticipate?

References:

1. http://www.strokecenter.org/patients/about-stroke/stroke-statistics/
2. Statistics referenced from NHS, National Stroke Strategy