With a 'game changer' stroke treatment in doctors' hands comes a new challenge — shaving off the minutes

It's about saving a minute here, a minute there, which is why the stroke patient isn't even transferred to a bed or changed into a johnny shirt, and is instead rolled to their CT scan on the same ambulance stretcher that rushed them to hospital.

It all happens so quickly — the process has been compared to a car-racing pit crew — that sometimes the patient is even hooked to an intravenous line with a blood clot-busting drug before they leave the scanning room.

And there is a chance — one that didn't exist just a few years ago — that little more than an hour after being brought by paramedics to Valley Regional Hospital in Kentville, N.S., they could be on the road to Halifax for what's been dubbed a "game changer" treatment for stroke victims.

"It can be life-changing for them," said Lesley Austin-Smith, a registered nurse and cardiovascular co-ordinator at Valley Regional.

"It can take what would have been a devastating stroke and leaves them with possibly mild deficits, if any at all."

Health care in Nova Scotia has come under enormous criticism in recent years, for long emergency department wait times, doctor and nurse shortages, and ambulance delays. But changes in how strokes are treated at hospitals in the province is a bright spot, one that shows improvement is possible, even in a system under strain.

About 85 per cent of strokes are ischemic, in which a blood clot plugs an artery in the brain like a cork in a bottle. With no blood flow, that part of the brain begins to die.

A major breakthrough in treatment has been endovascular thrombectomy, also known as EVT, which involves inserting a catheter into an artery in the groin and slipping it up all the way to the brain, where it then pulls out the clot.

EVTs are now deployed at major hospitals in Canada, including the QEII Health Sciences Centre in Halifax, which began using the treatment in earnest in 2018.

It is only appropriate for about 10 per cent of stroke victims. Crucially, time is an enormous factor. In Nova Scotia, standards dictate it should be performed within 11 or 12 hours of the onset of stroke symptoms.

Time is also critical for another treatment, thrombolytic drugs, which are available at 11 hospitals in Nova Scotia and can "bust" smaller clots. That time frame is even narrower — 4½ hours, according to Halifax stroke neurologist Gord Gubitz.

Factor in that a person may suffer a stroke while sleeping, or may not seek medical help right away, and the window gets even smaller.

So attention has turned to another question: how to get the best in stroke treatment to patients outside Nova Scotia's largest city.

Enter Noreen Kamal, an industrial engineer at Dalhousie University, who has led an Atlantic Canadian team that aims to reduce treatment times for strokes.

Part of the work has involved analyzing every step from the moment a paramedic gets to a patient to find small efficiencies which, added together, can save enough time to get inside the tight thrombolytic drug and EVT treatment windows.

That can mean reviewing a patient's medical history while they are still en route to hospital, making sure the CT scan is free before they arrive, and putting the LifeFlight air ambulance on notice that a quick transfer to Halifax might be coming.

Any step that is not useful is jettisoned. 

It follows similar work Kamal did in Alberta, where "door-to-needle" times between when a patient arrives and when they get a shot of thrombolytic medication were reduced from an average of 70 minutes to 39 minutes.

The results were significant: the proportion of patients who were able to return home after a stroke, instead of going to long-term care, rose from 46 per cent to nearly 60 per cent.

Finding the time

Kamal has been on a campaign to quicken stroke treatment. She acknowledges there can be push back from health-care workers who say they're too strapped for time. But she has pitch.

"What my response to them is we're actually talking about spending less time with a patient," Kamal said. "We're actually allowing you then to free up time for other patients, and I actually think that's what we should be doing across the health system."

The Halifax Infirmary is the only hospital in Nova Scotia with an EVT suite. Even so, more than 30 per cent of the 67 stroke victims treated with EVT last year arrived from hospitals in other parts of the province and from Prince Edward Island, according to Gubitz.

If a blood clot to the major vessel leading to the brain is not relieved, Gubitz said, the chance of walking out of hospital is zero. There's a 95 per cent chance the person will die or will be so disabled they will depend on other people for every aspect of their lives.

The difference thrombolytics and EVTs have made is dramatic. One out of two patients treated with EVT have a "good outcome," he said. 

"The game changer is if you can restore the blood supply and the damage is reversed entirely, or if their stroke is much smaller, they're much more likely to walk out of hospital alive, they're much more likely to be independent going forward," he said.

'Seconds count'

Scott Theriault, a Halifax forensic psychiatrist who had a stroke in 2016, was treated with EVT. He was home within five days, he said, a "spectacular turnaround for that kind of event."

He said he recognizes he was lucky. The ambulance arrived in minutes, and he lived just five blocks from the QEII Health Sciences Centre. Others with his kind of stroke, but without access to the "full-on treatment," often die, he said.

"We could always say, 'Well, we could use more EVT suites throughout the province and that,' but it's more a question of organizational efficiency," he said. 

"Seconds count, so finding ways to meaningfully shave off those seconds means that even with the resources that we have that we can improve outcomes."