Forty-one-year-old Chedilal Gupta, an autorickshaw driver from Nallasopara, made around ₹600-₹800 a day. The sole breadwinner in a family of six, including his wife and four children, Mr. Gupta would work overtime to cover their monthly expenses. One day in December 2017, Mr. Gupta woke up at 6 a.m., disoriented. His speech was slurred. Unable to understand what was wrong, his wife advised him to rest. Two hours later, he woke up in the same condition, this time unable to utter a single word. A neighbour and a relative rushed him to a nearby hospital by 9.30 a.m., where he was admitted immediately.
“We completed all formalities after which they told us that an MRI was needed. Since the hospital was not equipped with an MRI facility, we were asked to take him to a nearby diagnostic centre. We got it done by 3 p.m.,” recalls Mr. Gupta’s wife, Kiran. Later that evening, a senior doctor saw the report and said that Mr. Gupta had developed paralysis and should be taken to KEM Hospital for further treatment, she said.
The next day, Mr. Gupta was shifted to KEM where doctors said that he had had a stroke due to a blood clot. However, the crucial time period of 4.5 hours in which a clot dissolving medication can be administered had passed, and Mr. Gupta would thus have to now depend on occupational therapy and anti-platelet medication. After observing him for nearly a year, the KEM Hospital doctors declared him 50% disabled and are in the process of issuing him a permanent disability certificate.
Tingling sensation
Worli resident Anant Anbhavane (58) is another example of how little awareness about symptoms of stroke leads to missing out on the golden window of treatment. In March, Mr. Anbhavane, a worker at Podar Mill, suddenly felt a strange tingling sensation in his right arm and leg. He described it as mungya (ants). As it became more severe, his colleagues called one of his three sons to take him home.
“[Mr. Anbhavane] came home at 11.30 p.m. We took him to a nearby family physician who said the sensation could be because of diabetes. After returning home, he ate a chapati, had water and went to sleep. He woke up at 2.30 a.m. to go to the bathroom and realised he could not feel the right side of his body at all,” said his wife Smita. The panic-stricken family took him to ESIS Hospital in Worli where they were told to rush him to KEM as they were not adequately equipped to handle his case. By 3.30 a.m., Mr. Anbhavane was in KEM’s casualty department. Formalities were completed and he was taken for a CT scan by 4.30 a.m. “Soon, the doctor told us that he had a stroke but nothing more could be done. He was put on medication to prevent blood clots and asked to do physiotherapy to improve movement on the paralysed side,” said Ms. Smita. The doctors said that he is 40% disabled.
Smita and Anant Anbhavane at KEM Hospital on Friday. | Photo Credit: Emmanual Yogini
Like Mr. Gupta and Mr. Anbhavane, hundreds of patients miss out on timely treatment for stroke every day. They either succumb to the stroke or are left disabled. “There are continuous trials going on worldwide to make the time period for treatment larger. A year-and-a-half ago, the window for thrombolysis, a procedure which involves administering a clot dissolving injection, was extended from three to 4.5 hours. In May, the DAWN trial said that thrombectomy, an interventional procedure to remove blood clots, could be offered up to 24 hours in select acute ischemic stroke patients, who have significantly surviving brain tissue. Earlier, this window was only six hours. While medical science is constantly evolving, awareness about stroke continues to be very limited,” said neurosurgeon Dr. Nitin Dange adding that nearly 60% patients reach hospitals beyond these time windows.
Alarming figure
In KEM, there have been over 3,500 stroke patients in the past two years. The hospital receives nearly 8 to 10 acute stroke patients every day. However, of the 3,500, only 54 could get the clot dissolving injection.
The Global Burden of Diseases (GBD) study in 1990 stated that stroke was the second leading cause of death worldwide. It reported 5.87 million stroke deaths globally in 2010 as compared to 4.66 million in 1990, indicating a 26% rise in two decades. A 2013 article in the Journal of Stroke stated that stroke unit implementation remains a big challenge in India. It recorded approximately 35 stroke units, predominantly in private sector hospitals in cities at the time. “Many private hospitals lack a CT scan facility and refer for incentives to other hospitals or centres. This results in crucial time being lost. On the other hand, public hospitals lack a dedicated team and place to manage stroke patients. Unavailability of CT scan facilities is also an issue in smaller public hospitals,” the article said.
After landing up at inadequately equipped hospitals and dodging traffic, when a patient eventually reaches a tertiary care public hospital, getting clear passage still remains difficult. In September, an NGO sent a dummy patient with stroke-like symptoms to KEM Hospital in order to gauge the points of delay at the hospital-level. The report by the NGO showed delays at various levels, including when a resident doctor asked for the money for a CT scan to be paid and a file to be made before treatment, and delays in putting the intravenous line.
“We have studied all these aspects and our team has drawn out a protocol for stroke patients. For example, a CT scan will be carried out on priority basis now,” said Dr. Sangeeta Ravat, head of neurology at KEM Hospital. “Brain attacks are more dangerous than heart attacks. While a patient manages to get back to his life to an extent after a heart attack, a majority of stroke patients cannot do that,” she said. In major strokes, complete recovery is not possible. “It all depends on which area of the brain is affected. If it’s the speech area, patients may have difficulty in speaking for months altogether, if it’s the motor area, limb movement may get affected,” she said. The level of disability in stroke patients can go up to 50%. The hospital waits for a year to gauge improvement in patients before issuing a permanent disability certificate.
Most tertiary care private hospitals have a well-defined stroke code. Dr. P.P. Ashok, head of neurology at P.D. Hinduja Hospital in Mahim, says that private hospitals with active neurology residency programmes are most efficient in handling strokes. “Having a residency programme means the availability of a neurology resident 24x7. The doctor springs into action immediately,” said Dr. Ashok, adding that the key to early treatment is awareness about symptoms. “We are living in the time of WhatsApp where a patient’s CT image can be sent to a senior doctor within minutes and the clot dissolving drip can be started before shifting the patient to a better facility. This communication needs to be defined well.”