AT Services Hospital, Lahore the stroke team carry a knapsack with everything they need to treat a patient with acute ischaemic stroke – from IV cannulas, glucometer and syringes to test tubes, cotton swabs and tape. Also in the bag is a smartphone capable of transmitting high-resolution CT images via WhatsApp. The smartphone is a gift from a donor. It is the little things that count.
The knapsack, like the phone, is a workaround – a piece of ingenuity to overcome resource limitations. It solves at least some of the problems you encounter when treating stroke in an emergency department that receives over a thousand patients a day. The competition for beds is intense and,
as is the case in much of Pakistan’s public healthcare system, the hospital is understaffed. For this reason, residents remain in the ER to monitor and care for stroke patients receiving thrombolysis. And when they are done playing nurse, the same young doctors become porters, wheeling their patients to the neurology ward housed on the fourth floor of a different building.
This is a smart hack: the dedication of a new generation of neurology residents who model their conduct on the example set by a doctor whose one- man campaign to change stroke care in Lahore is finally bearing fruit.
DR QASIM Bashir was raised on neurosurgery the way the children of sporting heroes grow up beside the pitch. His late father, Professor Bashir Ahmed, was a pioneer in neurosurgery in Pakistan and in 1964 founded the neurosurgery department at Lahore General Hospital that later became the acclaimed Punjab Institute of Neurosciences (PINS).
All the Bashir siblings followed their legendary father into medicine, attending Lahore’s King Edward Medical College before continuing their studies abroad. Dr. Qasim describes his fellowship in neuroendovascular surgery at the University of Illinois as “a turning point”.
“Up until 1998 I had seen only neurosurgery; then I became aware of the potential of minimally invasive treatments for neurological diseases including stroke.”
In 2012 Dr Qasim Bashir returned to Pakistan, which at the time was one of a handful of countries yet to approve rTPA for treating acute ischaemic stroke. Even before the drug was approved by the official Drug Regulatory Authority Pakistan [DRAP], he obtained a special institutional waiver from DRAP to start offering rTPA at the Services Institute
of Medical Sciences affiliated hospital in 2021.
Aware that seeking funding from the government would be a long and tedious process, Dr Qasim reached out to an American philanthropist of Pakistani origin, Mr Asher Aziz, who gave a $100,000 grant in honour of his late mother, Mrs Nisar Aziz, who had been a stroke victim. The grant facilitated a dedicated and standalone acute stroke programme in the public sector in Lahore city. In fact, says Dr Qasim, “this funding laid the very ground of acute stroke care within the public sector nationally.”
THE grant provided free access to thrombolysis for poor patients presenting with acute ischaemic stroke at the 1,650-bed tertiary care Services Hospital. Help came from multiple other sources, Dr Qasim says. “The Association of Physicians of Pakistani Descent of North America (APPNA), Punjab Health Department, DRAP, the Pakistan customs authority and Boehringer Ingelheim, as well as the administrations of both Services Hospital and the Services Institute of Medical Sciences, were among those who chipped in their services for the noble cause.”
Within 20 months the Services Hospital stroke team treated more than 60 acute stroke patients with thrombolysis, encountered no drug-related complications, and saw positive outcomes at three months. Their door-to-needle time isn’t far off the international benchmark, and their department research work by neurology residents has been recognised with honours at the annual conferences of the Pakistan Society of Neurology and the Pakistan Stroke Society.
All of it matters, but especially this: Having the power to treat a poor patient for free and witness their recovery is “amazing”, Dr Qasim says. “It brings tears to your eyes.” It is also the driving force for expanding the stroke services available to Lahore’s 13 million population.
Philanthropy can get you started, but it cannot sustain you, Dr Qasim says. Once you can show that your programme is successful, you must get the public sector involved for its long-term continuity.
Dr Qasim’s expansion plan includes a hub and spoke model that revolves around Pakistan’s biggest neurosurgical centre – the one established by his father. He has been busy for several months overhauling the neuroendovascular programme at PINS and developing a neurovascular service so that patients with large vessel occlusion or those ineligible for thrombolysis can be referred for thrombectomy.
AT Services Hospital, too, there is progress. There is, finally, a dedicated stroke bay with four beds at the entrance of the newly renovated emergency department. There are dedicated doctors and nurses who have taken advantage of online training in the Angels Academy and use its online resources exclusively.
There is a burgeoning culture of quality monitoring; the team submit their cases to RES-Q and have reason to look forward to their first WSO Angels Award. They can also look ahead to reinforcements down the line thanks to a donor-funded fellowship programme in which one stroke neurologist, one neurosurgeon and one stroke nurse will be trained at PINS every year.
If anything is more urgent than training neurologists, it is teaching the public about stroke symptoms and stroke-ready hospitals, Dr Qasim believes. Not only for the obvious reason that more patients will access treatment in time, but because he trusts an educated public to put much-needed pressure on the healthcare system by demanding the best treatment. Much, much further down the list is joining the drive towards stroke centre certification currently underway in the region with the aim of standardising stroke treatment.
“Our priority is enforcing and implementing institutional protocols at our hospitals and turning them into role models in Lahore where we have a huge population to look after,” he says.
“If we dedicate ourselves to this goal, we will not fall short.”
