Saddling up at the Calgary Stroke Program

CSPSarah Blayney is a Clinical Fellow in the Calgary Stroke Program at Foothills Hospital, University of Calgary. She received a BGS SpR Travel Grant to help fund her fellowship.

As the branch flicked back and caught me full in the face, I saw another coming from the side just in time to throw my weight left and precariously low over the horse’s neck. We had left the trail some time ago after encountering more fallen trees after last week’s snowstorm; the temperatures had soared to the high twenties again but this far out into the mountains there was no one around to clear the trail. Narrowly avoiding my leg being crushed against a tree as we forged our own path through the undergrowth, I wondered quite what I’d let myself in for this weekend. The initial natural obstacles encountered on the lower level trails were nothing in comparison to those up here, and the gradient was punishing for both us and the horses.

Eventually we broke the tree line and took in a spectacular view of the valley below. Any breath left was soon gone after struggling up the last section: so steep here that we were out of the saddles and down onto our feet. After three hours of hard riding my legs were
in no shape to clamber up a rocky outcrop while trying to persuade several hundred pounds of horseflesh behind me to wait his turn, but a few minutes later I sank gratefully onto the coarse grass at the top. Once up there our horizon broadened further, taking
in the mountain ranges to the north and west. Far in the distance, a hunter’s rifle fired periodically and the echo bounced around the mountains for several seconds each time. It was the hardest and most exhilarating riding I’d ever done, and the view from the
top was outstanding.

There are many parallels to draw between my experiences of the Calgary Stroke Fellowship and that ride through Ghost River Canyon in the fall. Relocating my life halfway round the world seemed a minor task when compared to the daunting prospect of going to work for a team of world class stroke neurologists. This was to require a shift in attitude that I had entirely underestimated, with an emphasis on neuroanatomy and detailed neuroimaging that is several steps removed from the ‘anterior versus posterior’ localisation that I had previously relied upon. Then there is the speed with which everything happens in Calgary: at a spring conference in Montreal, I was amused to hear a Toronto stroke neurologist remark dryly that anyone sitting still too long at a bus stop in Calgary was liable to be thrombolysed. But time is brain, and in the hyperacute setting this is no joke(1).

I quickly became conscious of the weaknesses in my ability to read CT angiograms, debate anatomical variants and reel off evidence (or the lack thereof) for a given intervention in any number of circumstances. The roughly half academic component to my variable work pattern has allowed time to fill in the gaps, as well as become involved in various projects. Writing up a chapter on leptomeningeal collateral imaging has
deepened my understanding of the anatomy involved. Taking a look at secondary outcomes of stroke in a recent cardiovascular surgical trial is teaching me many useful lessons about trial design and analysis. Review of triage measures and outcomes in Stroke Prevention Clinic has given me ideas to bring home. Referral and triage processes are forever evolving, and since conception the clinic has grown almost beyond recognition.

This has brought new problems as urgent slots reserved to see patients within 24 hours become overwhelmed, but the poor quality of information accompanying referrals from peripheral hospitals often undermines appropriate use of a valuable resource. At least this is not an unfamiliar problem, that anything vaguely neurological in nature is labelled ‘possible TIA’. One of my Calgary steals however will be to bring back the name for these urgent slots: TIARA clinic sounds so much slicker than rapid access TIA. My respect has deepened for colleagues trained outside of the UK who are working in a language that is not their first, after my experiences of making myself understood here. My ‘very strong’ accent (in fact a neutral Warwickshire pronunciation) has caused sufficient problem at times to hinder the easy rapport with patients that I usually take for granted. The resultingly fragmented conversation has been highly frustrating, particularly when a Canadian medical student repeats my words verbatim and is instantly understood. Medical jargon and drug names continue to catch me out in dialogue with nursing staff, further accentuating the cultural differences in styles of working.

Absence does indeed make the heart grow fonder, for an unexpected benefit of this year was to find how much I miss general medicine when it is distilled out of my everyday job. I left the UK as a seasoned medical registrar, weary of the politics and barely contained chaos of the acute medical take, and always keen to get back to my chosen specialty. Here, I am only allowed to manage a stroke patient’s impending DKA for as long as it takes the endocrine resident to arrive. As I greet another 8am TIA patient, knowing a whole day of similar referrals lies ahead, I am beginning to yearn for the mixed bag of problems presenting to a general medical clinic. Our program director laughingly reminds me from time to time that here, I must think like a stroke neurologist, not a geriatrician.

The latter job title produces raised eyebrows since Canadian geriatricians function very differently compared to the UK; I have learnt to introduce myself instead as an internist. Between the ‘ologies, the internists and the hospitalists, there is little left over for the geriatricians and so they appear (in Calgary at least) to be left with the patients that no one else wants, generally those requiring non-specialist rehab or long term care. I find it hard to reconcile the shift in attitude that this specialty-specific focus brings to the overall coordination of care of an individual patient.

There will always be a balance to achieve between specialism and generalism, but it has reinforced my belief in our current method of parallel training and practise in general internal medicine. Of course the chance to immerse myself in stroke neurology is providing a quality and intensity of training that is far removed from what was on offer back home, diluted by the ever present service demands of a medical oncall rota. A twenty four hour Calgary stroke oncall usually involves a few hours sleep, but always involves several more hours of consultant-led learning. Here, there is time to think properly on the hoof and apply myself to the experiential learning, rather than dashing off to do more medical reg firefighting.

Thursday morning rounds is when the whole department gathers to review neuroimaging of a dozen selected cases from the week, and it not infrequently develops into heated debate about the best option in the context of recent or active clinical trials. The intensity with which results are scrutinized and ideas pursued is reflected in the breadth of work ongoing in a number of areas that push the boundaries of established stroke practice, including the recently presented TEMPO-1 trial looking at use of alteplase in minor stroke
or TIA with proven occlusion(2). This is a part of the fellowship that is harder to put onto paper: it is about attitude as well as acquired skills.

The best example of this, and a suitably exciting finale to my fellowship, has been to watch the results of the ESCAPE trial unfold(3). It was thrilling to be in Nashville for this year’s International Stroke Conference when those results were presented alongside three other major endovascular trials. A dramatic number needed to treat of 4 to achieve an outcome of modified Rankin score of 0-2 (living independently at home) at 90 days truly heralds “a new era of stroke therapy for major ischaemic stroke” (4). Experiencing the tenacity
and leadership that was fundamental to the success of ESCAPE, and playing my own small part in recruiting and caring for the patients who were enrolled at our site has left a lasting impression on my attitude to clinical trials.

Just as that day in Ghost River Canyon introduced me to another level of intensity and pace in the saddle, so too has this fellowship in Calgary opened my eyes to how much more is possible in stroke. As I enter the homeward stretch now, I am looking forward
to getting back to the NHS and more familiar terrain. I will be bringing my cowboy boots home with me however, as a reminder of all that I have learnt this year: go faster, climb higher and always keep looking for a better horizon ahead.

  1. Hill MD, Coutts SB. Alteplase in acute ischaemic stroke: the need for speed. Lancet.
    2014;384(9958):1904-6
  2. Coutts SB, Dubuc V, Mandzia J, Kenney C, Demchuk AM, Smith EE, et al. Tenecteplase-tissuetype plasminogen activator evaluation for minor ischemic stroke with proven occlusion. Stroke; a journal of cerebral circulation. 2015;46(3):769-74
  3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. The New England journal of medicine. 2015;372(11):1019-30
  4. Hill MD, Goyal M, Demchuk AM. Endovascular stroke therapy – a new era. International journal of stroke : official journal of the International Stroke Society. 2015;10(3):278-9

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