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Rural patients left for hours with undiagnosed stroke, promoting calls for national telestroke service

Edson Aigbe

Sept. 12, 2019

Before his stroke Bill Vernon rode his bike 50 kilometres to and from work each day.
He used to work as a mechanic at a mine near Collie in Western Australia, but now struggles to speak and spends most days picking up sticks at his farm.
One night in December 2013, the then 53-year-old woke up to go to the bathroom, but collapsed before he got there.
The next 24 hours changed the course of his and his family's lives.
Mr Vernon got to the hospital in less than half an hour but, despite presenting with signs of a stroke, Mr Vernon's wife Denny Vernon said he only underwent ECG (heart) and blood pressure tests.
Ms Vernon said without a CT (Computerised Tomography) scan machine the doctor was unsure of a diagnosis and left him in a dark room overnight.
Data from the Australian Institute for Health and Welfare showed hospitalisation for cardiovascular disease is 35 per cent higher in remote and very remote areas than major cities.
The Stroke Foundation, the peak advocacy body, said if you have a stroke in the regions, you will be far worse off.
Rural stroke outcomes are far worse than their metropolitan counterparts due to a knowledge gap, according to the Foundation, which has been pushing for the national funding and roll out of a telestroke program.
Now, it is calling on the Federal Government to take action.
Delayed diagnosis leads to life-long disability
Ms Vernon said the man sitting next to her was not the man she married.
"I want my Bill back — I want to travel with Bill but we can't do things like that now," she said.
He had the stroke at 1:00am on December 5, 2013 and was in hospital within 30 minutes.
But on arrival, the rural doctor could not determine whether it was a clot or bleed.
Bill was left overnight waiting for a transfer scheduled for 8:30am the next day.
He was taken to the larger Bunbury Hospital early at 6:30am, but by then it was too late to have a clot-dissolving thrombolysis injection administered.
The delay in his diagnoses meant Mr Vernon became severely disabled, initially bedridden and unable to talk.
For almost a year he and Ms Vernon moved to Perth, two hours from home, to undergo rehabilitation.
"We didn't come back to Collie in that time — I was not coming back without him," Ms Vernon said.
During his rehabilitation Mr Vernon's goal was to get back to work, but his inability to speak proved too difficult a barrier.
"This is where you'll see how the stroke has really affected him," Ms Vernon said.
"He finds it hard to find a word for something."
Now he has been spending time tinkering with cars and pottering around his farm.
Photo Bill Vernon, 59, was a mechanic at a mine before he had a stroke, but now he spends most days on his farm limited by his ability to speak.
"Each day I feel like I'm getting a little bit better … it's a long road," Mr Vernon said.
WA Country Health said in a statement that it was unable to comment on individual cases, but said it had made significant progress to improve stroke care equity across the state since 2014.
In 2014 the WA Department of Health appointed a stroke director and in 2015 implemented a fully-funded state-wide telestroke service, which covers sites including Collie and Bunbury.
It said the implementation of that service meant the number of south-west WA patients accessing time-critical mechanical thrombectomies to remove brain clots had jumped 400 per cent between 2015–16 and 2017–18.
Fourteen hours in hospital without treatment
Photo Ken Blackwell had a stroke in 2017, but was only treated for migraine and dehydration at a remote hospital in central Queensland.
While WA had implemented a specialised telestroke system, Queensland and the Northern Territory have not.
In October 2017, Ken Blackwell was swimming after work when he had a sudden and intense headache.
Mr Blackwell lives in Middlemount, Queensland, a remote mining town about 800km north-west of Brisbane.
He got to the nearest hospital at Dysart by ambulance in about 45 minutes.
Mr Blackwell said when he arrived, the paramedic told the doctor he suspected Mr Blackwell was having a subarachnoid haemorrhage — a bleed in the brain.
"They put me straight into one of the rooms," he said.
"The doctor came and had a look and at that point as far as I knew the doctor said they were treating me for dehydration and a migraine."
The next morning, about 14 hours later, Mr Blackwell was discharged without treatment or a diagnosis.
He caught a lift with a friend to Emerald, around an hour-and-a-half drive, to where the doctor had ordered another brain scan at 2:00pm the day after his stroke.
It was inconclusive.
'She was surprised I survived the flight'
At the time Mr Blackwell's family was living in Brisbane and he needed to get to them.
Around 45 hours after having a stroke, still untreated, he got on a plane — an extremely dangerous move for a patient with a brain bleed.
Soon after landing he was taken to hospital in Brisbane and this time was told he had had a stroke.
"When I spoke to the neurosurgeon at RBH [Royal Brisbane Hospital] she was actually surprised I had survived the flight down," Mr Blackwell said.
"Normally they say once you've had a brain bleed it [flying] would just make it worse."
Mr Blackwell's fitness and memory suffered and he was not able to work for several months.
"You go from being that fit to not even being able to walk 50m without having to sit down.
Mr Blackwell said his case could have been a lot worse and that the system needed to improve.
"I'm more annoyed than anything. I did survive and it could happen to somebody else and they might not survive," he said.
Photo Ken Blackwell used to run, cycle and swim every day before he had a stroke 22 months ago, and he's only just getting back into running.
Mr Blackwell made a formal complaint after the incident.
In a statement the Mackay Hospital and Health Service said Mr Blackwell did not appear to be having a stroke when he presented at hospital.
It said Dysart Hospital had processes in place to refer patients requiring specialist imaging to larger centres.
The statement said Dysart Hospital did not have a CT scan machine and that rural doctors had access to general telehealth connections with specialists.
The hospital still does not a CT scan machine.
Foundation push for co-ordinated telestroke system
The Stroke Foundation, an Australian charity which advocates for prevention and treatment of the condition, said the answer to improving rural stroke outcomes was implementing a national telehealth service.
Victoria, South Australia and Western Australia now have ongoing telestroke services funded by their state governments, and Tasmania soon will too.
The Federal Government has put $9.4 million towards a centralised stroke telehealth service for New South Wales, which is jointly funded with the State Government.
Queensland and the Northern Territory do not have specialised telestroke services.
But there is no federal or state agreement on funding for a national roll out.
Bruce Campbell, who works as a consultant for the Victorian stroke telemedicine, is the Head of Stroke at the Royal Melbourne Hospital and is the Clinical Council Chair at the Stroke Foundation, said access to information and equipment was driving the gap between metro and rural healthcare.
"In many parts of Australia if you go to a local hospital, the reality is you're not going to get access to the kinds of urgent treatments that stroke patients need to minimise the disability after stroke.
"It's access to the specialist knowledge and partly the brain imaging that people need to make an accurate diagnosis of stroke and then to deliver these time-critical treatments.
"They have really good data from the Victorian telestroke system, which has been running with a telestroke network now for years. It provides the kind of expert access to therapy and improves outcomes for patients.
In a statement, a spokesperson for the Federal Health Minister said the Government was supporting community hospital projects in every state and territory as well as providing $4 million to the National Strategic Action Plan for heart disease and stroke.
It said further rollout of telestroke systems would be considered as part of the budget consultation process with the state and territory governments.
Telehealth needs equipment: rural doctors
Photo Dr Adam Coltzau, President of the Rural Doctors Association of Australia, says some rural hospitals are not properly equipped to deal with stroke cases quickly.
President of the Rural Doctors Association of Australia Adam Coltzau said a telestroke system would be beneficial for regional hospitals that had diagnostic equipment, but that not all did.
"The biggest barrier to stroke care in rural Australia is the access to the modern diagnostic equipment that is needed to make a clear diagnosis and that's CT scans," Dr Coltzau said.
Neither Collie nor Dysart hospitals have CT scan machines.
Dr Coltzau works in the south-west Queensland town of St George, which has 3,000 residents.
For his patients presenting with stroke, it is 200 kilometres to the nearest CT scan machine in Roma or Goondiwindi.
"The ability to diagnose a stroke is reasonably straightforward but it's very difficult to make that clear diagnosis of where that clot is without a CT scanner.
He said a national telestroke network would be of benefit to rural doctors and their patients.
"It would be great to be able to get some advice on a patient who has had a stroke over telehealth, especially if those people can also look at the CT scan results in formulating a treatment plan," he said.
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