Treating strokes: A race against time

Treating strokes: A race against time

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Stroke patients who call for an emergency ambulance are more likely to get medical help within the treatment window. (Photo: Corine Tiah)

SINGAPORE: When Richard Chew woke up one Thursday morning feeling “a weakness” on the right side of his body, he didn't think it was anything out of the ordinary.

“I tried to grab onto my bed but I slipped to the floor,” the 57-year-old retiree recalled.

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The stroke caused weakness on the right side of the body and till now, his right hand remains swollen. (Photo: Corine Tiah)

“So I told my wife, I think I'm still quite okay,” Mr Chew said matter-of-factly. “Then she said, okay you take care, and went on to work.

“I was thinking, for whatever reason, I have this weakness and it may go away at night.”

But when his wife came home from work that evening, she noticed that the features on the right side of his face “were twisted”, and his speech had become slurred.

These were the typical signs of a stroke.

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Richard Chew had suffered a wake-up stroke, known as the situation where a patient awakens with stroke symptoms that were not present prior to falling asleep. (Photo: Corine Tiah)

“We didn't know how to react to this," said Mr Chew. "Of course, the first thing is to go to the hospital. But should we go straight?”

Eventually, they decided to go to Singapore General Hospital’s accident and emergency department (A&E), but in their own car, driven by Mrs Chew.

When they reached the hospital, they had to register and go through triage, before the A&E nurse found out that Mr Chew has had a stroke and immediately activated the acute stroke team.

By the time the team attended to Mr Chew, more than 12 hours had passed since the time he woke up with that tell-tale "weakness".

Due to the delay, the team couldn't administer treatments which would have helped him if they were administered within six hours after onset of the symptoms. He was sent to the stroke unit for monitoring to prevent further complications. 

Fast forward three months, Mr Chew is now wheelchair-bound and unable to use cutlery with his right hand.

It was only after his experience that he realised that he had made two mistakes - not going to the hospital immediately, and going to the A&E by car.

CALL 995, EVEN WHEN YOU ARE OUTSIDE A HOSPITAL

While more patients are arriving at the hospital "early enough" for timely treatment since the first Spot Stroke campaign in 2016, only around 50 to 60 per cent came in by ambulance, according to Associate Professor Deidre Anne De Silva.

READ: More stroke patients arriving within crucial time period for treatment: Study

The senior consultant at the National Neuroscience Institute said that Singapore still has “a ways to go", adding that getting stroke patients to call the ambulance will be the focus of the next campaign.

“In comparison to other developed countries where 80 to 85 per cent of stroke patients come in by ambulance, that’s a bad figure because if you look at the other way around, it means 50 per cent are not coming in by ambulance," said Dr De Silva.

We still do see people who will go the next day to a GP (General Practitioner) first. We still see people who will wait for their daughter or son to come home from work. We still see people say I will take some Panadol and sleep and hope it goes away.

“I think partly it's a lack of awareness of stroke symptoms. It's a lack of awareness that stroke is treatable, and that time is of the essence," added Dr De Silva.

Even if you are next to the hospital, just call 995, she stressed.

It might seem counterintuitive to call for an ambulance if you are right outside the hospital, but calling 995 triggers a chain of events.

The Singapore Civil Defence Force (SCDF) paramedics are trained to identify stroke symptoms and will notify the emergency department en-route so that patients receive immediate medical attention upon their arrival at the hospital.

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The SCDF paramedics will assess the patient onsite to determine symptoms and alert the acute stroke team on the way to the hospital so the transfer is seamless. (Photo: Corine Tiah)

72-year-old Tan Mong Huat was luckier than Mr Chew.

Last year, the former Grab driver was ferrying a passenger from Jurong to Labrador Park when his vehicle crashed into a lamp post.

"At first I thought my car tyre was punctured," said Mr Tan. "But luckily my customer was alert and saw that I might have (had) a stroke. He asked me not to move and immediately called the ambulance."

SCDF paramedics arrived within 10 minutes and he was sent to National University Hospital where he was given the clot-busting medication.

As a result of that timely intervention, he suffers no side-effects or disability from the stroke. 

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Tan Mong Huat (Photo: Himself)

When asked what he would have done if he were alone, Mr Tan replied: "I would not know, that was the first time I suffered a stroke and I don't know the symptoms."

"I want to express my heartfelt gratitude towards the passenger who called 995, the SCDF paramedics and the hospital’s acute stroke team. Their actions had contributed to a better outcome for me and my condition would have been more serious without their prompt response."

"TIME IS BRAIN"

​​A stroke occurs when a part of the brain gets damaged due to an interruption in its blood supply. When brain cells die because they do not receive oxygen from blood, it is irreversible.

Stroke remains the fourth leading cause of death in Singapore and one of the top contributors of adult disability.

In the treatment of acute stroke, the team’s priority is to save the brain tissue that hasn’t died, which in turn saves body function and the patient's quality of life in the long run.

“If you ask me, the better term is time is brain," said Dr De Silva. 

The more time we lose, the more brain we're losing.

For the team, the clock starts ticking not when the patients passed through the doors of the hospital, but when they first experienced the symptoms.

The most common signs of a stroke are sudden drooping of one side of the face, weakness of one side of the body and difficulty speaking or understanding speech.

There's a bit of “detective work” involved in pinpointing when the symptoms first appeared, said NNI Advance Practice Nurse Il Fan.

“The patient’s history is the most important thing that we want to find out when they arrive," said Il Fan. "Sometimes if patients come in unable to talk, we go to the extent of checking their phone to trace their last conversations and find out (the last time) they were well.”

"If the SCDF (paramedics) can actually give us a lot of information then it will be helpful, because sometimes even though passers-by witness it, they don’t come together with the patient to the emergency department.”

When CNA observed the Tan Tock Seng Hospital’s acute stroke team in action on a Tuesday, an alert came in at 7.48am, just 18 minutes after II Fan started her shift.

“When we receive a notification that there is a stroke case (inbound), we will go down to the emergency department,” said Il Fan as she quickened her pace to the basement where the resuscitation area is located.

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Il Fan and another nurse rushes to the resuscitation area when an alert came in. (Photo: Corine Tiah)

The notification comes in the form of a text, with the patient's name, gender, NRIC number and the estimated time of arrival at the hospital. For Il Fan and her team, this information is key to minimising the debilitating effects of stroke.

“We want to try to utilise the time as much as we can, so usually we will screen through the patient's medical history while we will wait for patients to arrive. Very specifically if the patient is on any blood-thinning medicine, and if there is any history of stroke before.”

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The acute stroke team assessing the patient's eligibility for time-sensitive treatments. (Photo: Corine Tiah)

Before the ambulance arrives, the stroke team would already be on stand-by fully prepared to assess the patient once he or she is transferred from the ambulance.

The patient wasn't accompanied by a family member and had difficulty speaking due to facial droop, which made it trickier to pinpoint the time of onset of stroke.

In such cases, a brain scan will be done. 

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Patient undergoing a CT scan. (Photo: Corine Tiah)

In this case, the patient was not given any acute treatment due to risk of complications following an assessment and sent to the stroke unit for further monitoring.

In another case a few hours later, the patient who came in by ambulance, was given clot-busting medication within 45 minutes.

A DISEASE THAT CAN BE TREATED

The treatment window is now wider as research on stroke advances. For example, since the introduction of the clot-busting medication in 1996, the window has widened from three hours to six hours.

While this means more people are eligible for acute stroke treatments, Dr De Silva is concerned that this would lull patients into thinking they have ample time to get treated.

"I don't use timeframes. We don't want the concept to go that, let's say it's x number of hours and there I have that amount of time to come in," she explained.

We just want people to recognise stroke and come in as soon as possible. It should just be as soon as you detect the symptoms, you need to act fast and call 995. 

​​​​​​​

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Mr Chew receiving physical therapy as part of his stroke rehabilitation journey. (Photo: Corine Tiah)

Mr Chew goes to Ren Ci @ Bukit Batok St. 52 for rehabilitation twice a week to regain some function in his limbs. At the rehabilitation centre, he shared the reason why he agreed to this interview. He hoped to help more people understand the urgency of treatment for stroke, and not end up in his shoes.

"Maybe one day, I can look for my remaining golf clubs, and then go and hit some balls in the driving range," he said wistfully. "That's my goal."

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Source: CNA/co

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