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08 May 2017

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

At our recent meeting, the AMA Council of Rural Doctors received with great interest a presentation on the Victorian Stroke Telemedicine program, which is successfully delivering equity of access to acute stroke care for people living in regional Victoria.

We all know the ugly face of Cerebrovascular accident (CVA) as we encounter it too often in regional and remote Australia. Of the 55,000 new strokes that occur each year in Australia, 23,000 occur in regional areas. However, in comparison to urban centres, we often deal with this devastating presentation with the knowledge we will not be able to image, diagnose and treat the stroke in time to salvage the cerebral damage.

This may be our Mum, but we will not be in time to start the tissue saving clot busters, endovascular clot retrieval (catheter removal of a clot) is a dream away. Why? It is the reality of living in the bush, the mobile cellular ability to call 000, the distance to the hospital, the flooded out roads, and the limitations of the ambulance services.

If we are fortunate enough to have a CT scanner in our town, we do not have the fortune to have an in-house radiographer to work the CT scanner 24/7. We are GPs out here, we are not neurologists, obvious CVAs are easy to diagnose but out of 100 stroke-like presentations only 50 will be strokes. Once diagnosed, we can be five hours to the nearest tertiary centre by RFDS, Careflight, or chopper.

Luckily here in Australia we find groups of stubborn people who will not take such scenarios as insurmountable. Five years ago, no-one outside of the urban areas received stroke thrombolysis. Now, with the guidance of Professor Chris Bladin, a Melbourne neurologist, and the Victorian Stroke Telemedicine (VST) program, the state of Victoria is able to say the following:

  • 94 per cent of Victoria is within 1 hour from state of the art stroke care. 16 regional centres in all;
  • More than 1400 telehealth consults for stroke evaluation have been performed;
  • Of those, 1 in 5 calls result in stroke thrombolysis - some regional hospitals are now thrombolysing patients for the first time with the assistance of VST consultants;
  • 70 patients of the 1400 have been referred for endovascular clot retrieval;
  • Treatment is safer when delivered with the help of a consultant neurologist, with a 60 per cent decrease in post thrombolysis complications;
  • There has been a 130 per cent increase in patients with acute stroke treated under 60 mins of hospital arrival; and
  • There has been a 30 per cent decrease in treatment time – e.g. door to CT, door to stroke thrombolysis times.

How do they do it? The answer is stubbornness, good ol’ Australian stubbornness. This involved a trip to Germany to see how they do it over there. With 16 made-for-purpose telehealth gizmos the stroke specialist can remotely examine patients at the bedside, view PACs, make clinical notes, and speak to distressed families, all in one machine.

It involved gathering a cohort of neurologists from Perth to Christchurch to man the on call phones 24/7. It meant interrupted meals out and gym work outs to be ‘Triple A’, Affable, Available and Able. It meant surmounting suspicion that early thrombolysis was ineffectual. It meant quelling the initial objections from local ED doctors that they did not need a hotshot urban neurologist to diagnose a stroke. It was an attitude of ‘we can do this’ and ‘we can do this together’.

The Victorian Stroke Telemedicine people have a dream for us. They want to roll this out to become Australia wide. The future Australian Telestroke Network (ATN), with the goal of ‘No Stroke Untreated’.

The AMA Council of Rural Doctors was really impressed with the VST program presentation and the results being delivered to patients. However, it clearly needs more support if it is to become a truly national initiative. It needs the backing of governments, and it will require State and hospital support for the on-call neurologist and other staff needed to man this program.

That means recognition by the funding system, the hospital administration to allow for State wide privileging of the on call neurologist. We need to put their 1-300 number on the wall and we need to call them. It requires our support so that we can thank them later for looking after our Mum who just had a stroke.


Published: 08 May 2017