Acute Stroke Management - A Race Against Time

Did you know that every 3.3 minutes someone dies of stroke, or that stroke is the third leading cause of death and adult disability worldwide!

In India, 1 person suffers from stroke every minute.

The word Stroke (Paralysis or lakva) is derived from the word ‘Strike’ – an analogue to the sudden, severe attack with which it affects the patient and changes their mortality and morbidity completely, if not treated in time.

It is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts (hemorrhagic) or is blocked by a clot (Ischaemic). This cuts off the supply of oxygen and nutrients to the brain, causing damage to the brain tissue. Ischaemic strokes account for approximately 85% of all strokes whereas 15 % are hemorrhagic strokes.

Treatment of Acute Ischaemic stroke and its outcome is time dependent. Every second a person has stroke symptoms, brain cells die. As seconds tick away, permanent cognitive (mental process involved in knowing, learning, and understanding things) and physical abilities are lost, and the risk of death looms. A stroke can have a profound effect on patients, their spouses and other family members.

Rapid injection of recombinant tissue-type plasminogen activator (r-tPA – a thrombolytic / clot dissolving injection) in blood is the early treatment. It should be administered within 3 – 4.5 hours of onset of above mentioned symptoms. International guidelines recommend a ‘door-to-needle time’ of 60 minutes or less (the time from entry of patient in emergency to administration of drug).

Lack of knowledge about stroke among the general public delays the initiation of immediate management of stroke. Delay in arrival of patient to the hospital, delayed consent by relatives for thrombolysis and unavailability of emergency ambulance services (especially in rural India) are the major reasons of treatment delay. The proportion of stroke patients reaching hospital within 3 hours in India is only 15%. Less than 20% of the general physicians are aware that r-tPA should be administered within the first 3 to 4.5 hours of stroke onset.

New drugs, advanced surgical techniques and interventional neuro-radiology procedures are among the effective new medical options available for stroke patients. These therapies have the potential to reverse the effects of stroke, significantly reduce permanent disability from stroke and lead to an optimal recovery, if administered within the first few hours after the onset of stroke symptoms.

On recognizing symptoms of stroke, patients should be rushed to any nearby hospital equipped to provide care for stroke management - 24/7, with a stroke team, 24 hour MRI / CT imaging facility, a laboratory and a Cathlab. A Stroke Team is a highly specialized, multidisciplinary team working round-the-clock to combat stroke emergencies. It includes the Emergency Physicians, Neurologists, Neurosurgeons, Neuro-Intervention radiologists, Intensivists, Rehabilitation specialists and the nursing team.

Unfortunately, in India, most patients present to the Emergency Departments beyond the 3 - 4.5 hour guideline from symptom onset, thereby missing the important brain and life-saving treatment.

Stroke is a life-changing event that affects not only the person who may be disabled, but their family and caregivers. This year, stroke will affect 4 out of 5 families in India - don't let yours be one of them.

City gynecologists unhappy as COVID plays spoilsport during Navratri.

Mumbai: The BMC's refusal to permit garba dandiya within city limits for the second consecutive year has evoked disappointment among obstetricians and gynaecologists. Expressing displeasure over the BMC's decision, city doctors shot off a letter to PM Modi demanding compensation from the central government against the losses due to the acute patient deficiency seen during 2 years of COVID affected Navratri festival.

It is a well known fact that apart from being the celebration of dance & life, and being Falguni Pathak’s bread and butter, the 9 day festival is also a breeding ground for young couples looking for a casual physical relationship. A study conducted at the Quackdoses Multispeciality Hospital had found that the sale of contraceptive devices and pills in Mumbai jump by a whopping 75 % during the 9 day celebration.

In an exclusive interview with the Quackdoses, Dr. Unglikar, a leading gynecologist in Mumbai said, “Like winter is the season for Chest Physicians and dentists with the increased number of patients coming with LRTI, exacerbation of Bronchial Asthma and COPD or tooth ache respectively, Navratri is a season for the obstetricians and gynecologists. Looking at the statistics of casual and unprotected sex people have after a garba-dandiya session, the 9 day festival is a boon for the obstetrician and gynecologists. Such couples come to us for abortions and even delivery after 9 months in select cases. Last 2 years have been so dry that even OPD consultation of couples with Questions like ‘kuch tension ki baat toh nai haina?’ has gone down.”

Unconfirmed sources have claimed that the National Association of Wicketkeepers (Obstetricians) and gynecologists are planning to organize a ‘yagya’ to please the Gods above and pray for a COVID-less Navratri next year.

Emergency Medicine – My Love, my passion & everything in between my Vows.

They say, “You have to be crazy to be a goalkeeper”. I say, “You have to be crazier to be an Emergency Physician!”

My interest in Emergency Medicine started very early, in the 2nd year of MBBS itself to be precise. The EMS & the Trauma centre at Sion hospital, Mumbai where it all started is among the best in the country, dealing with the entire spectrum of medical and surgical emergencies.

I still distinctly remember and smile, thinking about the time spent as a medical student / intern putting hundreds of IV lines, collecting blood samples, inserting Ryle’s tubes, Foley’s catheters, collecting ABGs, taking ECGs, accompanying trauma patients to CT scans, counseling patients, etc. Whenever I was free after daily lectures or while taking a break from the library, I would hang around in the EMS. I would look forward to the ‘Emerg-Double Emerg-and Triple Emerg’ where the unit in which you were posted had the call day for the weekend and the following weekday/s and you would end up continuously working 56-60 hours at a stretch in the EMS.

No matter how busy it got, the Doctors, nurses, the mamas and maushis, security continued to do their best – day after day.

Over time, I realized that being a government hospital, with the limited resources and the financial capability of most patients presenting there in the EMS, they were not being offered the best modality of treatment, nor was the treatment protocol based– Eg. There was no PAMI for an acute STEMI or thrombolysis for an Acute Stroke, no management of trauma patients as per ATLS protocol, procedural sedation, drug assisted intubation, etc.

At the same time, there was lack of communication skills, compassion, empathy & sympathy towards patients and their relatives by the resident doctors.

There were many instances during treatment by my peers which shook me and had a huge subconscious impact – seeing amputation of the hand being done under local anaesthesia with the patient howling in pain, pneumothorax while doing blind central lines, breaking multiple teeth while intubation, intubating awake patients with just a shot of Midazolam, patients requiring emergency surgery spending hours for an OT slot, etc to just name a few.

I had kind of made my mind then and there - the people deserve good Emergency care, which does not include only the medical aspect, but of the overall patient experience, satisfaction and quality in terms of ethical and affordable treatment, protocol based, supported by the latest equipment and cutting edge technology. I had vowed to practice ethically, not being money oriented, for the best interest of the people and provide them with the highest level of care. Not even once did I ever think of working abroad where it is possible to earn 4-5 times more money than in India, just because people here too deserve good emergency care.

Over the last 11 years, I have worked exclusively in the Emergency Departments of the top hospitals in the country, setting up 4 Emergency Departments so far, being actively involved in the teaching and training of young doctors, nurses and healthcare professionals. And the journey has been satisfying. More so because I have seen myself grow and learn, everyday.

Even to this day, I remain excited and enthusiastic about going to work. I look forward to the patients I would be seeing in my department. A well managed resuscitation, a smooth intubation, emergency procedures, STEMI, strokes, and everything in the Emergency – THE DRAMA, THE TRAGEDY, THE WORK PRESSURE, THE STRESS & THE URGENCY still excites me like it used to 15 years ago and keeps me going.

If ever I feel low, there are 2 feedbacks that reverberate in my ears. One was by my security guard who after seeing the many post CPR ROSCs said, “Sir, aap toh murda ko bhi zinda kar dete ho” and the other by another hospital staff, “Sir, God forbid, kabhi mujhe ya mere kisi family wale ko kuch ho gaya, I wish you are present on duty in the emergency”.

My current focus is on developing Emergency Medicine as a specialization, providing world class-quality care to my patients and to train healthcare professionals of tomorrow – of integrity, passion, honesty and discipline.

I now have confidence in my Emergency department, our current protocols and policies, the excellent team of Consultants and staff, that in a life and death situation, if we can’t save a life, nobody else can!

Doctor spot diagnosed with encephalitis after returning pen to nurse.

Mumbai: In a never before incident in the history of modern medicine, a doctor was spot diagnosed with encephalitis after presenting with the ultimate sign of brain damage when he returned a pen to the nurse. The news has sent shock waves across the medical fraternity.

It is a well-known fact that most doctors never carry their own pen and end up borrowing one from their nurses to put patient notes. On most occasions, doctors pocket the pen, knowingly or unknowingly, and often forget or misplace pens in wards, patient rooms, operating theater, patient's abdomen or anus but never return them to anyone.

In an exclusive interview with the Quackdoses, Sister Pen-de, the nurse who was felicitated with the clinical acumen award for making this spot diagnosis of encephalitis said, “Doctors get this habit of borrowing pens from nurses right from their internship days. I was in utter disbelief and shock when the doctor came back and handed over my pen back to me. In all my years, I have shouted at and been shouted by many doctors but I have never seen them return a pen. That contributed to making the diagnosis as I knew he was in altered sensorium.”

Unconfirmed sources have claimed that Sister Pende is hopeful to spot diagnose her second case of encephalitis, and is now waiting for another doctor to return the stethoscope borrowed from the nursing counter.