After the stroke…

Health care specialists on the front line of stroke care include therapists, dietitians, social workers, nurses, pharmacists, physicians, speech language pathologists and client patient access services.  Photograph by: Gord Waldner , The StarPhoenix

BY JONATHAN CHARLTON

Two million neurons die each minute when someone has a stroke — and they don’t come back. While early medication and surgery can help limit the damage, it takes months, even years before many patients can relearn basic skills. For two decades, health care providers in Saskatoon have dreamt of having a specific unit dedicated to helping patients recover. Now, it’s finally becoming a reality. Here’s an introduction to the new team on the front line of stroke care.

It’s a few seconds past 9:30 a.m. as 14 health care staff start their meeting in a corner office on the sixth floor of Royal University Hospital.

Jodi Copeland, the acting clinical coordinator, frowns while discussing a 68-year-old woman whose lab work appears to be a mess.

“I think we’re going about this the wrong way,” she tells the team, and suggests fixing her sodium levels might help.

The team consists of physiotherapists, occupational therapists, clinical dietitians, social workers, nurses, pharmacists, physicians, speech language pathologists and client patient access services. They briefly check off the rest of the patients in Unit 4, then move to another room to see the patients in Unit 5.

The entire meeting has taken just four minutes — “bullet rounds” are called that for a reason.

These rounds used to happen only every Tuesday and Thursday, but are now held seven days a week. This lets the team catch missed tests, or recommendations from physiotherapists and nutritionists, days earlier than before.

The efficient, informative planning session seems unremarkable, but it’s part of a health care innovation 20 years in the making.

Changing the system

“Stroke is a bad disease,” Ruth Whelan stresses over and over again in an interview at the RUH neurology unit.

Whelan, the clinical nurse specialist for stroke services, went to the University of Saskatchewan for bachelor and master’s degrees in nursing. During her studies, she was placed in the neuroscience unit, and it was an immediate fit.

“It just clicked with me. I love it,” she said.

She taught for a while, before getting hired in the Department of Medicine to help with stroke research. On the side, she sketched out plans for what a dedicated stroke unit would look like. Then the health region hired her as a part time specialist. In her new gig she’s been able to delve into the research and learn more about best practices.

“I’ve been given time, which is all we really needed, was someone dedicated with time, who could start writing out a little bit more specific plans.”

Stroke patients have always come to this floor, but they weren’t concentrated in the same area, instead scattered among the 45 beds, said Dalene Newton, the health region’s director of adult medicine and complex care.

In the past, a therapist on the unit might count people with strokes, spinal cord injuries, multiple sclerosis or Parkinson’s disease as patients.

The best practice, however, is to keep stroke patients in one place and build a team around them, Newton said. This allows them to build up expertise and eventually decrease the length of patients’ hospital stays.

RUH is one of the last comprehensive hospitals in Canada to get a dedicated stroke unit, Newton said. Even five years ago, it was obvious the hospital needed to make the change, but it didn’t have the ability to gather and create a team.

One spark to making changes was the province’s acute stroke pathway, which aims to cut the waits — just minutes long — that can add up to critical delays in patients receiving emergency care. The unit became a priority during the 14- and 90-day challenges spearheaded by CEO Dan Florizone earlier this year. The SHR leadership and staff were ready for change, with years of grassroots preparation to draw on, Newton said.

The new 16-bed stroke unit opened June 1. The long term goal is for every stroke patient to stay there, but the unit doesn’t yet have an observation room. At the moment, it remains just down the hall.

How to treat a stroke

When a person has a stroke, one of two things are happening.

One kind of stroke involves a blood clot in an artery which blocks the flow of blood to an area of the brain, causing it to die.

Two treatments are then available. A clot-buster drug has been the standard of care for the past two decades, as long as it’s given within four and a half hours of the last time the patient felt well.

More recently, surgeons have been able send guide wires up through an artery in the groin to the brain and physically pull out the clot.

“It’s like a plumber with their snake going up, really,” Whelan said.

If the stroke involves a hemorrhage rather than a blockage, however, there’s not much doctors can do, other than to try to prevent further strokes by controlling blood pressure.

Whelan stresses, however, the most important factor in a patient’s outcome is rehabilitating and rewiring the brain to make up for the dead tissue.

“It’s so important for our patients to know that — ‘You know what, you don’t have a lot of great movement in that side,’ or ‘Yeah, you have some drooping,’ or ‘Yeah, your swallow isn’t working that great.’ But we have all these excellent therapists and excellent nurses, and that’s the key to getting better.”

The day after a stroke, therapists examine how the stroke has affected a patient, whether that means balance issues, dexterity or motor control. They can then teach ways to work around those deficits, such as using the tongue to feel for food if a person’s cheek has lost sensation.

Treatment means exercise, proper diet and medication, and talking through a patient’s anger.

“Stroke is interesting because not only is it physically debilitating, but it really is a huge time of grieving what you’ve lost,” Whelan said.

“Sometimes stroke has warning signs, those mini strokes. Lots of times patients come in and they were fine at home. They went to bed just fine and now today (their) life is totally different.”

Patients are not necessarily bound to spending their lives in a long term care home — Whelan encourages them to have hope for their recovery, even as she helps bathe and feed them.

It’s also just as important to her to offer compassionate, pain-free deaths, when the time comes.

The results

It’s early days, but neurologist Dr. Gary Hunter says patients in the stroke unit are staying half as long in hospital as they used to.

“It’s been one of the most important developments in stroke care in the province in the last 10 years,” he said.

“We can see it’s made a huge difference for how we treat and manage these patients. We’re seeing they’re staying in hospital for a shorter period of time, they’re getting to the appropriate discharge destinations quicker, we’re seeing reduction in any sort of misses or near misses as far as how we’re delivering care.”

Meanwhile, Whelan says she has noticed an improvement in staff morale and communication. Nurses are also better informed and better able to keep patients and families up to date on their care plans; it’s exhausting for patients to keep repeating their stories to different care providers, she said.

On a patient’s third day in the unit, the team is already starting to plan future treatment, such as long term care or rehab, and figuring out how to prevent another stroke.

The team members have plans to further improve the unit. They want to be able to better transition patients to their next step, such as providing home care services every time they’re needed.

The health region aims to copy the stroke unit model for other conditions, such as spinal cord injuries, and make RUH the first hospital in Canada to implement a palliative care plan specifically for stroke patients.

“A stroke is a long journey,” Whelan said.

Every Mile for Mom and Dad

 

BY JON CASWELL

Christine Duval lived through both her parents’ strokes and has been her father’s caregiver for more than a decade, but has found support from Tedy’s Team. In 1997, when she was a junior in high school, Christine’s father Joseph had a cerebral hemorrhage at age 50. It left him with aphasia and right-side weakness. Christine’s mother Beverly quit her job and stayed home to be his caregiver for five years. Then without warning, an aneurysm ruptured in Beverly’s brain in November 2003 while she was visiting Christine at college in Denver.

Through Tedy’s Team, Christine has learned about the warning signs acronym F.A.S.T. — Face drooping, Arm weakness, Speech difficulty, Time to call 9-1-1, but her mother had no warning signs. “We were shopping in Home Depot and she just collapsed,” Christine recalled. “She was laughing and giving one of the employees a hard time just moments before. Obviously, F.A.S.T. is very important for people, but it didn’t work out in my situation. We had no time to act because we didn’t know what was happening.”

Christine Duval (center) with Tedy and Heidi Bruschi

Beverly never returned to her home and lives in a care facility in Boston. She cannot walk, and has aphasia and limb spasticity. For many years she could not feed herself.

At 23, Christine left her nursing degree unfinished and moved home to take care of her father and oversee the care of her mother. That was 11 years ago.

She’s grateful to be able to care for her parents, but she also grieves for them. “The thing that’s most difficult is they’re both physically here, but I’ve lost them,” she said. “The stroke took my mother’s humor and silliness and my dad’s smart wits about everything around the house. I miss them. I miss them a ton.”

Soon after moving home, Christine began working at her family’s business, Andy’s Sports Shop, which sells ski equipment and scuba gear in the Boston area. After buying the business seven years ago her life got busy. Although she has always been active, for someone with such a dramatic family history of stroke, she didn’t pay much attention to her health. “I definitely didn’t watch what I ate, and I wasn’t a daily exerciser,” she said.

That would change after joining Tedy’s Team in October 2013, originally to raise money and awareness for stroke. “After the surgery to clamp my mother’s aneurysm, the surgeon said she would be running a marathon in a couple of months,” Christine recalled. “Of course, that didn’t happen, so every day that I can run, I’m trying to live for her and my father. So everything that’s happened with my parents and their struggles and getting to the point where they are now, which is the best they’re going to be, motivates me to be a runner, to be healthy, and to raise awareness and money for stroke.” Her parents are her stroke heroes, and to honor them she started the hashtag — ‘em4mad,’ which is ‘every mile for mom and dad.’

She will run her fourth marathon with Tedy’s Team in April. Christine has run four half-marathons and two Falmouth Road Races. As much as she enjoys running, the camaraderie and support of her teammates has touched her most. “Not only do we run together and raise money and awareness, but we’re a support group,” she said. “When one of us is going through something with our stroke heroes, we are able to support each other.”

The team has supported her as a caregiver, which she didn’t have after her mother’s stroke. “One of my biggest regrets is that I didn’t reach out and look for support,” Christine said. “I didn’t know where to look, and besides I was young and thought I was invincible. But I’m a much better person, a happier person now that I have a support group around me. Being a caregiver is tough. It’s a full-time job. You can’t do it alone.”

Editor’s Note: If you’re a family caregiver hoping to connect with others for support, visit the AHA/ASA’s Support Network, an online community for survivors and caregivers.