One in six people will suffer a stroke in their lifetime. With changing lifestyles, stroke has become more prevalent in developing countries like the Philippines and around the world, with stroke as the second leading cause of death. It is the leading cause of chronic disability in adults and the second leading cause of dementia.
Lower national income has been associated with higher relative mortality and burden of disease from stroke. One third of stroke survivors are left permanently disabled for life and three quarters are vocationally impaired. Such is the burden of stroke.
Dedication of the Brain Attack AGPAS Team with Dr. Ramon Moreno (photo courtesy of Dr. Art Surdilla)
Last August 8, 2014, the Northern Mindanao Medical Center (NMMC) launched a three-pronged counter attack on stroke with the inauguration of its 11-bed Neuro Intensive-Acute Stroke Unit and 10-bed Stroke Ward, dedication of the “AGPAS” (Active Group of People Against Stroke) Team , and the launching of the “I-DALI Mo” early stroke recognition advocacy campaign.
“I-DALI Mo” aims to ramp up public awareness about stroke and make Northern Mindanao a stroke-smart region, with the capability to effectively prevent, treat and rehabilitate stroke patients,” said Dr. Arturo F Surdilla, MD, president of the Stroke Society of the Philippines (SSP) Northern Mindanao Chapter as he launched the Stroke Public Awareness Campaign.
“Every stroke patient deserves the best functional outcome,” he noted. “Thus, our “I-DALI Mo” (A Bisayan acronym for “I-dali mo ang pag-atiman ug pagtambal sa pasyente na na-stroke”) campaign will focus on four important messages: Prevention, Early Recognition, Effective Treatment, and Rehabilitation.
Figures from the DOH-CHD, NM (FHSIS) show while there was a 5-year average of 15,868 cases in Region X (1999-2003) or 528.42 cases per 100,000 population, the leading cause of deaths for the same period was “Diseases of the Circulatory System” with 2,945 cases or an incidence of 98.07 per 1,000 population. Even more ominous, the number of cases had climbed to 3,842 by 2004 with a higher rate of 101.63 cases per 100,000 population.
DALI-A (photo courtesy of Dr. Art Surdilla)
Risk factors of stroke are often related to lifestyle changes: dietary changes leading to hypertension, obesity, hypercholesterolenenia, and diabetes; physical inactivity, cigarette smoking and alcoholism. A rise in the systolic and/or diastolic blood pressure (hypertension) increases the risk of developing heart disease, kidney disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and brain damage following a stroke.
Dr. Surdilla, who is also the Director of Stroke Services and founder of AKBAY Stroke Care and Neurological Rehabilitation Center, said stroke is preventable through identification and modification of risk factors (Prevention); it is a brain attack emergency where early recognition and timely intervention is absolutely imperative (Early Recognition); it is treatable with specific and proven means (Effective Treatment) and not the least, the best functional outcome after stroke is achievable with optimal rehabilitation (Rehabilitation).
Dr Ma. Cristina Z. San Jose, in her first official function as national president of SSP, acknowledged in her keynote address that despite these significant advances, gaps exist between what we know about and what is done for stroke.
“Lack of knowledge of stroke signs and symptoms and the urgency of seeking medical attention by patient account for a major cause of delay in hospital presentation,” she noted. “Our mantra that Stroke is Brain Attack, Stroke is an Emergency, Stroke is Treatable and Stroke is Preventable has yet to be reach far flung areas. We need more stroke champions in the Philippines.”
Dr. Surdilla said even in advanced countries like the US, stroke statistics indicate that adults for 50 years old and above, 38 percent do not know where a stroke occurs, 50 percent do not know when a stroke occurs, 40 percent did not know the warning signs of stroke, 12 percent did not know of any risk factors, only 40 percent will call an emergency number when they experience stroke-like symptoms; and only one percent is aware of stroke as a leading cause of death. (source: www.stroke.org/Stroke_Facts.
Stroke statistics are even more depressing for developing countries where the incidence of stroke is on the rise due to decreased physical activity and dietary changes arising from a more affluent lifestyle and 60 percent of all strokes occur in low and middle income communities.
“The prognosis is poor,” Dr. Surdilla admits. “Some 30-35% of all stroke victims die, 35-40% will suffer a major disability and 10-18% will have another stroke within one year.”
Even in the US where advanced medical and health care is more prevalent, stroke statistics show that of those patients who suffer a stroke, 71% are vocationally impaired after 7 years; 35% are unemployable below 65 years; 31% require assistance with care; 20% need help with walking and 16% are institutionalized. (source: Framingham Study Cohort, 1991).
“SSP has taken steps to raise public awareness through advocacy and provision of health care services nationwide through the establishment of various chapters,” Dr. San Jose said.”While there are victories, much remains to be done.”
As a start, SSP is pushing the imperative to “Think Globally, Act Locally” in implementing the following principles: acknowledging that Stroke is a “BRAIN ATTACK” needing emergency management, including specific treatment and secondary and tertiary prevention; Stroke is an EMERGENCY where virtually no allowances for worsening is tolerated; Stroke is TREATABLE optimally, through proven, affordable, culturally acceptable and ethical means; and most important perhaps, Stroke is PREVENTABLE in a manner that can be implemented across all levels of society (First Stroke Congress, 1999).
“The setting of care is important, hence the guidelines for establishment of stroke and critical care units,” Dr. San Jose noted. “Many hospitals are ill – equipped or unprepared to handle hyper acute stroke. We cannot undermine economics and lack or limited resources as major barriers to access and provision of standard of care in a country such as ours.”
Thus, the NMMC sought to address this crying need with its 11-bed Neuro Intensive-Acute Stroke Unit and 10-bed Stroke Ward, ably staffed by the “AGPAS” (Active Group of People Against Stroke) Team.
“We aim to provide the best possible outcome for every stroke patient with our Stroke Services in NMMC,” said Dr. Surdilla. “Our mission is to decrease the incidence and morbidity from stroke in the region through clinical excellence, research and education with the establishment of the Stroke Unit & Stroke Ward.”
The Stroke Ward was established by simply designating some beds in a ward, where stroke patients go straight from the Emergency Room (ER) to avert any delayed stay in the ER which predisposes them to secondary complications like pneumonia and bedsores.
At present, stroke patients face a dismal 10:1 patient to nurse ratio and very often, nurses have no expertise in dealing with stroke, have no knowledge of routines, standardized tools or protocols, and have no facilities or equipment such as monitors.
The AGPAS team takes up the pledge to serve stroke patients. (photo courtesy of Dr. Art Surdilla)
Thus, the dedicated AGPAS Team was organized to fill the gaps in stroke care: meeting the patient and family upon arrival at the ER; assist with the ER assessment; coordinate and communicate with the team; screen inclusion/exclusion criteria for possible intravenous recombinant tissue plasminogen activator (rtPA)* ; update and educate the family; ensure stroke nursing for the patient from the ER to the Acute Stroke Unit/Stroke Ward; respond to in- hospital stroke alerts; and audit and communicate outcomes of the stroke services.
“The task to reduce the burden of stroke in the Philippines is formidable. With an aging population and increasing urbanization, we foresee a rise in the number of cases in the coming years,” Dr. San Jose stressed. “The burden of stroke does not only translate to a socio-economic burden on society as actual health care costs and productivity losses but also disability and impact on the quality of life (QOL) of the survivor and caregiver.”
She cited the “Life After Stroke” program of St. Luke’s Medical Center in Quezon City where patients and caregivers are re-educated about stroke, taught of the importance of compliances and adherence, and coping mechanisms.
“Change and commitment should begin from within as expressed in the theme for the 2009 World Stroke Day “What I can Do,” Dr. San Jose said. “As an individual, as a health care provider, as member of a team or a community, as a voter fighting for legislative change, there is no limit to the many roles as your imagination, time, and resources allow.”
“Aside from individual efforts, partnership and concerted efforts of both private and governments agencies and sectors, and institutions is needed if we truly want to achieve a stroke free Philippines. A perfect example of partnership and teamwork is what we are witnessing in NMMC,” she added.
(*Recombinant tissue plasminogen activator (rtPA), a specific clot-busting drug now available in Cagayan de Oro City, is used to treat ischemic stroke within the crucial first 3 hours (in some eligible patients, up to 4.5 hours) from onset of acute stroke symptoms).
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