In Q3 of 2023, after treating 67,7 percent of strokes in under 60 minutes and having increased its recanalisation rate to 26,8 percent, UMHAT Prof Dr Stoyan Kirkovich, a university hospital located in Stara Zagora, won its first ESO Angels Gold Award. Here to tell their story are:
Dr Teodora Manolova-Mancheva, head of the neurology department.
Dr Hristo Dimitrov, a medical doctor at the Centre for Emergency Medicine & Accidents.
Prof Yovcho Yovchev, the hospital director.
Dr Bozhidar Petrov, chief of neurosurgery.
Drs Yordanka Argirova, Georgi Georgiev and Kristiyan Naydenov, neurology residents.
I Changing and relying on each other
Dr Teodora Manolova-Mancheva: The first thrombolysis I did was during a very emotional period for me. The head of our department [Professor Ivan Manchev] had just died after having a stroke himself. I had just come back after bereavement when we admitted an elderly woman who was having a stroke. Her family, who were in the medical profession, recognised the symptoms and brought her to the hospital a mere 12 minutes after onset. I was on duty together with my trainee Dr Georgi Georgiev. We pushed her to the CT scanner ourselves without waiting for porters; we prepared the rtPA ourselves and administered the treatment. It had been a heavy stroke, but thankfully she recovered.
We started treating acute stroke with thrombolysis in 2019. There had been earlier attempts but due to organisational changes and hospital mergers things didn’t take off. In 2019, after an Angels training, we started our proper but cautious attempts.
After our work with Angels resumed in July 2023, we evaluated all the elements and departments involved in the process. We came up with priority actions, did simulations and trainings, and improved our patient care in the postacute phase. We also held meetings to analyse cases that hadn’t gone well, and we discussed our national protocols. These are more limiting than newer international guidelines in terms of contraindications, so in reality we have more indicated patients than the national protocols suppose.
Our goal was to support every doctor by giving real-time assistance while they were actively treating a patient with stroke. Our target was to reduce the times as much as possible.
One significant step was to work on our mindset and treat stroke patients as a priority. We adopted the approach that we should look for reasons to treat, rather than reasons not to. Bit by bit this mentality is taking hold.
Our biggest priority action was to implement a phone number for prenotification so that the neurologist can go directly to the emergency department (ED) when a stroke patient is on the way. We’ve had a case where a patient completely bypassed the ED. Thanks to this phone number we went from the hospital door straight to the CT and were able to start treatment within 10 minutes.
Dr Hristo Dimitrov: I can’t say that before July 2023 stroke patients were neglected by EMS teams, but after collective trainings with the hospital staff, patients with symptoms suggesting stroke are definitely treated faster. This is the result of training and the ensuing discussions about practice, logistics, and sharing the results from our collective efforts. There is no doubt that collaboration with our colleagues from the ED and neurology clinic results in medical care that is timelier and therefore of better quality. This of course helps reduce the patient’s odds of disability.
The pathway now starts with a phone call from the EMS team on site to the neurologist on duty. During this phone call we report the symptoms, time of onset, vital signs, any other information about the patient, and the approximate time we’ll arrive at the ED. We have established a good channel of communication between EMS and the hospital, which is the important aspect of the relationship.
Dr Manolova: Establishing this relationship wasn’t easy and the process is still underway. It is important to actively seek collaboration and to communicate how important it is to transport the patient within the therapeutic window, and how a concise medical history together with a phone call improves the clinical outcome of the patient. Regarding prenotification and identifying patients suitable for treatment, we are seeing an increase in the engagement of EMS personnel. We are relying on them more and more and because of this we have improved our results.
Prof Yovcho Yovchev: The collaboration between the subregional divisions of EMS and the hospitals is critical for the timely and adequate treatment of emergency cases. According to the national standard for emergency medicine, every patient in critical condition must be transported to the closest hospital, depending on the hospital’s competency level. Our hospital has the highest competency level and number of staff in the region. Despite this, we have witnessed the transportation of patients in the so-called “golden hour”, with diagnoses that presuppose emergency resuscitation and therapeutic methods, to hospitals that do not have the necessary diagnostic capabilities to precisely assess the level of emergency. This problem has existed for years, and it leads to loss of time that is critical for the patient.
However, in the last few months we have observed a tendency for better synchronicity between the EMS team and our ED. I hope that ensuring an adequate and timely diagnosis for improved treatment perspectives will continue to be the main motivating factor for the work of EMS staff.
Dr Dimitrov: Providing regular feedback to EMS staff, especially if the patient outcome has been positive, will further stimulate them to do a good job. We would definitely benefit from regular meetings with the hospital staff so we can further remove obstacles and mistakes.
Dr Bozhidar Petrov: Some of the most impactful changes we observed after July 2023 were the improvement in competency, motivation and communication between teams, and the unification of many departments to work in synchrony for the benefit of the patient. Without doubt this improved cooperation between hospital and EMS will benefit other patients too.
II Of family, first patients and neurology as art
Dr Dimitrov: I chose this profession because of the feeling it gives you when you see the result of having helped a patient. I remember the first patient after we started our dedicated work with stroke patients. It was a woman around 80 years of age with motor aphasia, after which she also developed hemiparesis. I did the medical exam as quickly as possible, then prenotified the neurologist who was waiting for the patient at the ED. The patient was then immediately scanned and treated. The result is that today this patient does not have any disability and has completely recovered from her symptoms.
Dr Georgi Georgiev: The first patient I had to diagnose with stroke and take responsibility for, was my grandfather – he’d had ischaemic stroke. I was still a medical student then, in year four.
Two exceptional teachers helped me find myself and my path in life. The first was my chemistry teacher thanks to whom I understood the subject and fell in love with it, and who also taught me to believe in myself. The other was Prof Manchev, at the time the director of the neurology clinic and my neurology professor at university. I remember his lectures to this day.
After I completed my exams he invited me to participate in his hospital rounds. I was captivated by his air, his medical examinations, his discussions of the patient cases, and his general behaviour. Through him, I saw medicine, and particularly neurology, as an art.
Dr Manolova: Neurology is for me one of the most interesting medical disciplines – it’s far-reaching, colourful, intensive, logical, it requires detailed study of the patient’s problem but paradoxically it can also require rapid intervention.
Over 50 percent of patients in neurology are never actually cured of their ailments, but thrombolysis by contrast is one of the few treatments that definitively make the patient better.
Prof Manchev, Acad Ivan Milanov, and Prof Rossen Kalpachki have all influenced my career. Prof Manchev was my mentor and taught me everything. There is in my view no-one in Bulgaria who knows the fine details of every aspect of neurology like Acad Milanov. And Prof Kalpachki showed me exactly how to treat my patients effectively, and I know he will never refuse to help me.
Dr Bozhidar Petrov: A leader needs to set a personal example, they are competent, responsible, hard-working, responsive, and put their whole heart in their work. Dr Manolova is this kind of person.
Dr Manolova: It has never been a goal of mine to be the head of a department. I don’t like conflict, nor do I like to be the centre of attention and responsibility. But things change and after I accepted stroke treatment as a personal mission and priority, I came to value this position. I fight for my patients every day. The fact that one of my mentors left this world because of stroke motivates me. I remember it happening right before my eyes and being powerless to help him. I could only watch as he got the stroke and then slipped into a coma. Now I’m developing myself and make every effort to give others the opportunity for treatment.
Dr Yordanka Argirova: My grandmother had Alzheimer’s, the other had a brain haemorrhage, and my father had a stroke. So I know what it is like to care for patients with serious neurological conditions. Even if you can’t do anything for the patient, an important part of the doctor’s role is empathy. In Bulgaria, this is still not much discussed, but from my perspective if you cannot empathise with a patient you shouldn’t be a medic. I’ve always wanted to go into this profession and am very pleased that I have fulfilled my dream.
III Proud moments and a perfect world
Dr Manolova: The mission of every medic is to help their patient. We are all emergency neurologists and as such we know what the outcomes are, both short and long-term. There is a treatment for stroke, it was established more than 20 years ago. We cannot allow anything to stop us, not even our own hesitation, because the patient simply will not get better on their own. The outcome will affect the patient and their family throughout their lifetime. When the patient is on the gurney in front of you, totally helpless, this is the only thing that you have to be thinking about.
It is incredibly important to educate and support younger doctors for their own growth and the future of the discipline. We have to invest in young people, share our valuable experience with them, in order to put them on the path to self-development and so they’ll have the confidence to embrace innovation in contemporary neurology.
They also have to accept that mistakes are part of the game. Only he who doesn’t work makes no mistakes. You just have to learn from your actions and move ahead. This is what I teach to my residents.
Dr Georgiev: My work in this clinic is certainly having an impact on my professional development, but it has also helped me to gain a greater appreciation of life itself – of what is truly important.
Dr Argirova: Professionally I have gained a lot of experience. I make decisions quickly and confidently; I know that there is no other option and I must do my utmost for the patients. I feel the same effects on my personal life.
Dr Manolova: Receiving the ESO Angels Award was a proud moment, of course. It was a surprise, actually, we hadn’t expected it. But proud moments occur almost every day when I see how my colleagues treat patients with stroke. I’m actively involved in their work and every day they make me proud. I was proud of Dr Argirova when she saved the life of a young man of 36 years. I was proud of Dr Naydenov who managed to administer rtPA to a patient within 10 minutes of their arrival.
Dr Kristiyan Naydenov: It was thanks to Prof Manchev that I arrived at this clinic. He paid attention to me as a student, kindled my interest and encouraged me.
I chose to study medicine because I was looking for a pure, intellectual profession. Neurology was a love at first sight and still is. We are in the 10th year of our romance, which is a critical year in a long-term relationship.
Professionally, the experience in this clinic jumpstarted my development. I build on my knowledge and experience every day. However, it has taken a toll on my personal life – the work is very stressful, and we bring this home with us. The heavy responsibility that we carry always weighs on my mind.
I have also learned that the general health knowledge of the population is too low, the priorities of patients are incorrectly arranged, and their general level of education has a direct correlation with what they do to preserve their health. I learned that you have to have many sound personal qualities to be a successful neurologist and to perform the volume of work required to the necessary high standard.
Dr Dimitrov: From an EMS perspective, our remaining challenges are twofold. First is the general public and the pressing need for awareness campaigns like FAST Heroes in schools, but also for adults to learn how to recognise stroke symptoms and immediately call 112. Second is to increase the awareness and qualifications of our EMS colleagues through joint theoretical and practical trainings with our hospital colleagues.
Dr Manolova: In a perfect world, I would change the motivation that neurologists have for treating stroke. I would rearrange their priorities so that they are more engaged in the timely intervention in stroke.
Dr Kristiyan Naydenov: I dream of a reality where for every doctor there are two nurses and four porters, as is laid down in the national legal standard. But we have realised that we must rely on ourselves. Our entire team is working to address all the problems we can through education of new cadres and through public outreach. Our motivation is the team that we’re in.
