This vehicle could save your life

THE EXPERTS are formal: four hours and 30 minutes is the critical timeframe if the life of a stroke patient is to be saved. Obviously, the sooner a stroke victim receives professional help, the better his or her chances of survival, as immediate treatment minimises the long-term effects of the stroke and helps reduce the risk of death. 
Hospitals in Thailand like elsewhere in the world are constantly improving the critical time for stroke victims by providing a fast-track system once when they arrive at the medical centre. Today, life-saving treatment is usually started with an hour of arrival or, in the case of a medical school hospital like Siriraj, just 40 minutes. 
But they can do better, which is why Siriraj Hospital has now introduced a mobile stroke unit –a specially designed ambulance that can provide immediate treatment to stroke victims before they even reach the hospital.
The mobile stroke unit is a custom-built vehicle modified from a six-wheeled truck and equipped with a computed tomography (CT) scanner, medical equipment, generator, standby battery for the scanner, water and a telecommunication system that allows the MSU team to receive instructions from a stroke specialist at the hospital. Staffed by a four-man team –specially trained doctor, nurse, radiologist and driver – it allow for rapid diagnosis and treatment of an ischemic stroke, thus reducing the time between the event and receiving appropriate help. 

“In a way, it’s like we are taking the emergency unit close to your home,” says Assoc Prof Dr Yongchai Nilanont, the director of Siriraj Stroke unit, who initiated the MSU project.
The Siriraj MSU service is the first to be launched by a public hospital though private facility Phyathai 1 Hospital also operates a unit. As a medical school and public hospital, the MSU will provide the service at a lower cost and free to patients who are part of the universal coverage scheme.
Strokes caused by blood clots (ischemic) or brain bleeds (haemorrhagic) deprive the brain of oxygen-rich blood. Ischemic is the most common stroke type and makes up about 80 per cent of all cases. The 4.5 hour-critical time refers to the period between the stroke and the administering of a clot-busting medication. 
The longer the brain goes without oxygen and other nutrients, the more likely it is that a stroke will result in permanent damage to the brain. When a person has an ischemic stroke, restoring blood flow as quickly as possible is key. Immediate treatment is needed to dissolve the clot and improve the blood flow and is given through a thrombolytic drug that helps recanalisation of the occluded artery and reperfusion. Without this, the salvageable brain tissue will stop working and lead to death. If reperfusion is begun early enough and blood supply is renewed to the brain, the salvaged tissue can be healed and the patient can recover, slowly getting back to normal. 
The prevalence of stroke in Thailand is estimated at 1.88 per cent among adults aged 45-80 years and most cases are found in central and southern region. The mortality rate for hyper-acute stroke is five per cent and 70 per cent of victims suffer some level of disability.
There are three important points in a stroke case, says Dr Yongchai –the onset, the hospital arrival time and administering the drug to open the artery. 

“The most serious delay is when the event occurs as this is not something hospitals can control. As there are many factors that cause delayed treatment, the mobile stroke unit is our way of reaching out to the patient –a progressive procedure that will significantly reduce the time wasted,” he says. 
And even through there is a fast track channel at the hospital, it is useless if people are not aware of the critical time period or if the patient is only found hours after the stroke manifests itself. Another obstacle to timely treatment is the city’s notorious traffic. 
“It’s not a symptom about which you can say ‘we’ll wait until morning and then go to the hospital’. Giving knowledge about stroke is important. If someone shows any of these symptoms, even if the symptoms go away, call 1669 and inform them of the symptoms and the Mobile Stroke Unit will be deployed,” says Prof Dr Prasit Watanapa, dean of Siriraj Medical School. 
In the USA, the acronym “FAST” is used to help people quickly recognise the warning signs and symptoms of stroke and the American Stroke Association has added a FAST app to help people remember these signs.
The F refers to drooping on one side of the face, which may also be numb. “A” means arm weakness, which can be checked by asking the person to raise both arms. If a stroke has occurred, one arm will drift downwards. “S” stands for speech difficulty and shows if the victim has trouble speaking, or is incomprehensible. And “T” means it’s time to make an emergency call, which in Thailand means dialling 1669. 
Siriraj’s mobile stroke unit isn’t working alone. The hospital has joined with emergency medical services, Ministry of Public Health and private companies to complete the process when the mobile unit goes out to help people.
The MSU service is now in a pilot phase and is operational in the general area of Siriraj on the Thon Buri side of the river from Borommaratchachonnani Road to the Buddha Monthon Sai 4 Road and to Phetchkasem Road and the Mahai Sawan intersection in Bukkhalo sub-district of Thon Buri district.
People in the MSU working zone can call 1669 and give details of the situation and the responders of the hotline will judge whether it fits the symptoms of stroke. The emergency service then calls Siriraj to release the MSU to the nearest meeting point while sending an ambulance from partner organisations such as Narenthorn hotline (1669), Erawan hotline, Por Tek Tung or Ruamkatanyu foundation to pick up patients and take them to the meeting point.
A “buddy” ambulance travels with the MSU to the meeting point and provides trained paramedic teams who will bridge the communication gap between medical specialists on the MSU and the foundation’s ambulance team, who are volunteers and sometimes have problems with technical communication. The buddy ambulance also has experience of the area so will clear they the way for the MSU to the meeting point.
When the three ambulances meet up, the patient will be loaded to the MSU for a CT scan. The MSU doctor then uses telemedicine to enable a specialist at Siriraj’s stroke centre to remotely assess and diagnose the patient, as well as recommend treatment, which includes the administration of thrombolytic drugs while on route to the hospital thus reducing the critical window for treatment.
“When they receive treatment in the mobile stroke unit while the vehicle is heading back to Siriraj, the follow-up medication can be given immediately on their arrival,” says Dr Yongchai.
But while this procedure applies to cases of ischemic stroke, victims of haemorrhagic stroke will receive a different treatment, one that focuses on controlling bleeding by reducing blood pressure in the brain. In these cases, the MSU will prescribe medication to reduce the pressure and then dispatch patients to the nearest hospital or the medical facility that holds their records.
“We need three months to see the outcome and evaluate the whole project. Our MSU will serve as a model for similar vehicles to be introduced in remote areas such as on islands and in the jungle,” Dr Yongchai says.