SHORTLY after 7 pm on Wednesday 5 July 2023, Maria Atienza posted the following message in a WhatsApp group of Angels consultants:
Hello team!! I just want to share with all of you that yesterday I was a neurologist for a whole day in Hospital de Alicante 👩🏽⚕️. During my meeting with the stroke unit TWO stroke codes were activated and they asked me if I wanted to be with them in both. One was an interhospital thrombectomy (they even showed me the clot when they took it out, it was a MASSIVE M1 occlusion) and the other one was a trombolysis administered in CT ✅ (also very successful). I was amazed at how they perfomed, and felt so lucky to have this experience. 🤍 I’m so proud of the work we have achieved together.
In a picture she shared, Maria wore pale blue scrubs instead of her navy blue Angels blazer. Here she tells the story.
We have stroke code
“I am the Angels consultant for Comunidad Valenciana, which consists of the provinces Valencia, Alicante and Castellón. It is a difficult region because a shortage of resources generates a degree of resistance to change. There are however bright spots like Dr Nicolás López at the General University Hospital of Alicante who has developed an app used by five hospitals in the region to register their stroke codes.
Coming from Barcelona, I’d spent the previous night in Valencia where I had an appointment at Doctor Peset University Hospital at 9 am on Tuesday morning. From there it’s about 90 minutes to Alicante, where Nico and I were going to discuss how the app data could automatically be transferred to the stroke registry, RES-Q. Then I would grab something to eat and head back to Barcelona.
Nico was on duty that morning and during our meeting his cellphone rang. “We have stroke code,” he said.
This hospital is the main one in Alicante and the only one that does thrombectomy. The patient for whom the code was activated was coming from another hospital. He was 87 and had survived a previous stroke.
Another call came in at the same time. This patient, a 55-year-old previously healthy male, had had a stroke while hiking with a friend. With only one thrombectomy room, there was a decision to be made.
I’d never observed a big hospital having to make a decision as difficult as this. It made sense that the hospital has to optimise its resources, but if the 87-year-old had been my grandfather I would have found it very hard.
We were losing time
When Nico asked if I wanted to change my clothes and see a stroke code, of course I said yes! I changed into the scrubs they gave me and joined them in the emergency department to wait for the ambulance.
The patient when he arrived was frustrated and crying. A visitor from the Netherlands, not only did he not understand Spanish, but he had massive aphasia and couldn’t speak at all. Nico performed the NIHSS in English and gently explained that they would be taking him to the CT room to confirm his diagnosis and treat him.
The patient’s symptoms had started at 10 am. It was now around 11.45 am, so he was still within the treatment window. The pharmacy had already been notified to prepare the thrombolytic drug. However, the diagnosis wasn’t clear. Although his clinicals suggested a massive stroke, they couldn’t see the occlusion. And we were losing time.
The patient had high blood pressure, which is a contraindication for thrombolysis. Once they’d lowered the pressure, they commenced treatment at CT, then removed him to the stroke unit.
It was now about 12.30.
Twenty minutes later the patient was asking for his phone. He was still aphasic but able to speak a bit, and he was typing with both hands. It had turned out to be a small occlusion and he wouldn’t need thrombectomy after all.
It took a single pass
On the same afternoon the team was notified of 73-year-old stroke patient being transferred from Hospital de Torrevieja an hour away. The woman was on anticoagulants and therefore ineligible for fibrinolysis. She would go to thrombectomy as soon as she arrived.
It was now 3 pm and Nico’s shift was over, but I stayed with the others as they waited in the street outside the hospital for the patient to arrive.
This patient’s condition seemed less severe than that of the earlier one. She could speak a bit but was confused. She was a visitor from Germany and knew no Spanish, but one of the neurologists, who had spent a year in Germany, spoke to her in German.
It is one of the challenges in Alicante, that resources are allocated based on the resident population. The region is very popular with tourists some of whom engage in risky behaviour while on holiday. During summer they see as many as five strokes per day and there are people on the staff who speak German, Russian and of course English.
I joined the neurologists watching on a big screen as the catheter went in from the groin to the brain. The CT had shown a massive M1 occlusion, but full recanalisation was achieved after a single pass. It took maybe 30 minutes. I was so excited!
I’d arrived in Alicante around 11 am and it was now 5 pm. In all the excitement I’d forgotten to eat, but I wasn’t hungry. With Barcelona five hours away, I wouldn’t get home until 10 pm. I didn’t care, I was so happy.
When I got home, I called my mom and told her, I have to go study medicine now! I had always wanted to be a doctor, but life happens. I only just missed being admitted to medical school and studied pharmacy instead. For a moment I wondered if I should’ve repeated the test.
This is what we fight for
As a consultant, this experience affected me in so many ways. I was able to see the real impact of our work. I had grown used to seeing the Angels stroke bag in simulations and thinking maybe it is only because we’re here. When I saw them grab the bag and say, come on, let’s run, it was almost a shock.
While we were waiting in the street for the ambulance, the neurologist asked every ambulance that arrived, is this my stroke code? This mindset is what we fight for. It was so rewarding to see.
The stroke team at this hospital does more with less. Despite limited resources, they implement an almost perfect pathway. They treat at CT, do point-of-care testing and they’re always prenotified by the ambulance or referring hospital. The patient is preadmitted and the nurses in triage also know the code is coming. Once they open their new ER, the patient will go directly to CT.
The doctors in Alicante made me feel part of the team. They didn’t leave me standing in the back, they asked questions and involved me in the conversation. Afterwards one of the neurologists said, I have only ever worked in Alicante, I do not have a vision of different hospitals like you do. Tell us how do you see us, give us feedback, how can we improve? It made me feel valuable.
My relationship with the team has changed completely. I feel that I can count on them, that they will do what they can to help. I’m already thinking of using them as an example for the region.
Go with the flow
So far, the hard part of my job has been dealing with people. That may still be true but this experience has empowered me.
The first time I visited this hospital last December I had been a consultant for little over a month. I thought, what can I say that they don’t already know? But I kept reading and learning, and on this occasion I discovered that I knew what to ask, I knew what to answer.
I’ve also learnt that it’s sometimes okay to just let go. As consultants we work hard to organise our entire days – when to travel, when to meet, when to sleep. Usually I am very structured, I write everything down, I struggle with improvisation. But this time I didn’t care about what I’d been planning to do that afternoon.
Spending time with doctors is important because otherwise an experience like this couldn’t happen. And when the opportunity comes, you should take it. Don’t even think about it because a chance like this may only come along once.”
