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Monday, January 4, 2016

My Story

By Dr. Channa Ratnatunga Most of us have met Channa (Chester) Ratnatunga who was in the first Peradeniya batch. Although I had heard about the stroke that he suffered, I didn't know the details. In today's Sunday Times newspaper, he has recounted the story in detail and it should be read by all viewers who visit the blog. I am sure the reader will clearly see the message embedded in it - that of the need to establish more and more stroke units throughout the country. It is our duty to do what we can to spread the word. Please click on the link "My Story" below to access the article. My story

18 comments:

  1. It was inspiring to read this. Channa Ratnatunga is a very loyal son of Sri Lanka who chose to remain in Sri Lanka and serve its people in an honest and humble way. He is one person I really admire and respect. He is an example of a person who will have a good outcome whatever Religion or Belief system proves to be the "right one". Yes, most certainly "A good human being". I hope his plea will result in the establishment of Stroke Units in Sri Lanka

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  2. The healthcare in SL got a great deal of bad press recently. Well, this is a good news story. I am greatly impressed by the rapid access to treatment and the ability to work together for a good clinical outcome. So pleased CR has recovered well after such a nasty event. May his plea for more stroke units be heard in the right places and will become reality soon. I greatly admire his courage and humility to bring this story to the attention of the public making them aware of what can be achieved.

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  3. I am publishing this e-mail from Sanath as a comment under this post.

    Dear friends,

    Channa was with me in school from the age of 5 years. We parted company when he entered the Peradeniya Faculty and I entered Colombo. We were in London at the same time during PG study leave. Later his wife Neelakanthi was a house officer in Ward 1 LRH. During his illness I visited him regularly until he went home to Kandy. His recovery was slow but a medical miracle. He wishes that other such units be established elsewhere by the Ministry of Health, but the question is whether an average patient without medical connections would get the same treatment that Channa received. The "window period" (i.e. the interval between the stroke and intervention) is the vital factor.

    Kind regards,

    Sanath

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  4. At the height of the crisis Channa's daughter Champa was in Australia on PG study leave. She was informed that in Australia ,they would not intervene. The same feed back was received from the UK. Nevertheless the family decided to go ahead and the Sri Lankan specialists agreed to do so.That is the reason why I would call it a medical miracle
    Sanath

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  5. Being a non-clinician, I am a bit confused. It is hoped that Sanath and our neurologist colleague Speedy will shed more light on this matter in this forum itself so that others of my ilk too would benefit.

    If I understand correctly, the time elapsed between the onset of the event (appearance of first symptoms) and admission to an emergency care unit is crucial. Sooner the patient gets there, better will be the prognosis. What do foreign experts mean by "non-intervention"? Aren't life support systems needed? What do they really do in so called "Stroke Units"?
    I fully understand the importance of physiotherapy. But is that the only intervention needed"?

    I am sure if I ask my Senior local neurologist friend J.B. Pieris, he might have his own views!

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  6. They advised conservative management i.e. No attempt at removal of thrombus. If it was left behind the area of infarction in the pons probably would have increased and worsened the prognosis further
    Sanath

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  7. Okay, I think I understand. What you really meant by "miracle" is that Channa recovered because of the intervention. Had he been abroad at the time and treated by "foreign experts", the outcome may have been different.

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  9. Yes, that would have been the logical sequence of events unfortunately.

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  10. Yes, that would have been the logical sequence of events unfortunately.

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  11. The therapeutic window was determined by a series of trials and is not about absolutes but all about risk Vs benefit. The later the intervention, the lesser the chances of a good outcome. This does not mean that a late intervention NEVER works, it just means the chances are less. If you take a group of patients offered late intervention, the number of people with a good outcome are less,BUT there are patients who show benefit. There is no way of predicting this in individual patients at a particular stage in time apart froma % of success(have not looked at studies looking at horoscopes!) and you will know only retrospectively. So why not intervene anyway? For one thing, there is a significant risk attached to it (worsening of stroke and increased mortality) and secondly, we must always consider the best use of resources. Clot removal surgically has significant risks of causing bleeding in the infarct ed area but it could also enhance regeneration and earlier recovery. The later you do it, the higher the risk of worsening the clinical state. If CR became worse (thank goodness he didn't), the judgement of those who decided to intervene could have been questioned.

    About what would have happened in the UK, again it depends on where you are and how quickly you can be brought for treatment. If recognised early, most Districts are geared up for quick action and would have acute stroke units to deal with the cases. The problem is the early recognition of stroke and acting accordingly. The Stroke Association here has been carrying out a big campaign for several years to educate the public in early recognition of Stroke. http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_308528_SubHomePage.jsp
    It is quite possible that if CR was in UK when this happened, the outcome would have been good, but we will never know! What matters is that he is doing well

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  12. Sorry! The link I gave was from the Americam Stroke Association Here is the one from UK, which is essentially the same.
    https://www.stroke.org.uk/take-action/recognise-signs-stroke

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  13. Being in Radiology I know there is a rapid response service for stroke in all Teaching and many District General hospitals in the UK. They select their cases for the reasons mentioned by Mahen. The results are good and are getting better.

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  14. My earlier question may have sounded a bit silly or foolish to a clinician who makes the assumption that any "Intervention" is necessarily surgical. In my own specialty (Public Health and Health Education), we talk of "educational interventions", "Nutritional Interventions" etc. To us, such interventions are important in prevention and treatment of many communicable and non-communicable diseases. However, I concede that "surgical intervention" sounds more dramatic, and even more "glamorous" (for want of a better word) as they yield quick results.

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  15. Thanks, everyone!
    I have learned such a lot. Reading 'my story' was instructive and interesting.
    Zita

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  16. So nice to see you back Zita. I always enjoy reading your comments.

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  17. Senior Consultant Neurologist Dr. J.B. Peiris has sent in this at my request. I am publishing his piece as a comment under Channa's "My Story".

    LOCKED –IN –SYNDROME
    Locked in syndrome is one of the most dreadful neurological conditions - the patient is compared to a person buried in the sand up to the nostrils and sometimes require long term ventilation and assisted feeding. It is not dissimilar to a severe motor neuron disease with bulbar affection. Until recently there was no treatment for an ischaemic ventral pontine lesion causing locked In syndrome.
    When I saw Prof Channa(Chester) Ratnatunga in the Central ICU, as a friend and colleague, he was ‘locked in’ and it was going to be long battle but timely intervention of the highest order saved him from a terrible prolonged disability .I have seen another doctor suffer 12 years in the locked in state as there was no intervention available anywhere in the world at that time(1970-80s).
    What saved Channa from such a fate? –it was not a stroke unit or intensive care but clot buster treatment with rtPA and direct thrombus retrieval in the Central hospital . Correct choice of doctors by family and friends and prompt action seems to have changed the prognosis. Though intensive care is needed for survival in the acute phase and intensive rehabilitation in the recovery phase, the prognosis and disability is more dependent on re-establishing the circulation as early as possible.
    Basilar artery thrombosis is not common and it is difficult to prevent a fatal out come in most. Intraveous thrombolysis is available in a few hospitals – state and private – but angiographic facilities and the expertise to do intra-arterial fibrinolysis and direct intrarterial removal of the clot requires expertise which at present is the preserve of two interventional radiologists – Dr Lakmali and Dr Wijewardena. The Central hospital Angiographic suite seems to be the best equipped at present.
    Recanalization of the basilar artery is key to the successful treatment of basilar artery thrombosis and to improving its prognosis viz: Intra-arterial thrombolysis, mechanical thrombolysis or clot removal , or a combination . The time window for the treatment for thrombotic stroke is given as a maximum of 4.5-6 hours. In patients who do not recanalize within 1 to 2 hours of intravenous thrombolysis, further intervention with intra-arterial or mechanical clot removal should be considered. Prof Channa Ratnatunga had his thrombolytic and interventional procedures much after this period but yet made a good recovery once the circulation was re-established.- clot lysis and clot retrieval re-establishing the circulation made all the difference.


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  18. Thank you very much JB for that detailed analysis. I learnt a lot.
    Sanath

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