Piers: So this morning I'm joined by Sally who's introduced to me via a mutual friend who is a paramedic. And Sally, it's so great to have you with us. Could you give me a really quick introduction to your, your medical background? Sally: Yes. So I currently work as an intensive care paramedic in New South Wales. I've been a paramedic for 12 years now. And very much love it. It's my dream job. I'm very passionate about it and still enjoy going to work every day Piers: That's, that's not something everyone can say. And it's an incredibly I guess such a esteemed job in the community. And, and I think particularly over the last few years, there's been increased Awareness and gratitude for the work that you've always been doing. But I think just during COVID, it came that much more clearly into into perspective. As I said to you, one of the pieces of my own stroke experience is the very, very start of it. You know, I had gone to bed on Friday night with a. A skin full of wine and sort of. Kind of collapsed into bed as normal at around 1 a. m. And I had my beautiful six year old daughter come and very kindly jump on me at about six, six 30 in the morning. And I, I became fairly clear quite quickly that I was in the midst of a stroke. I collapsed when I tried to get outta bed. My, my face was hanging down. I thought I was speaking, but my, my daughter kindly informed me that I sounded like a walrus. And yeah. My partner, my fiance, Jane sort of tried to shake me and thought it was all a bit of fun. But it kind of dawned pretty quickly that this was not a joke. I was not fooling around. And she very, very quickly called an ambulance and I guess that was the beginning, beginning of things. And I have some memory of it. You know, I can, I can remember trying to pull a pair of shorts on. I can remember. Trying to sit on the toilet and sliding off. I can remember walking down the stairs to the ambulance and seeing my 12 year old son looking horrified and terrified. But there's, I don't, I certainly don't have the, the picture. I remember two paramedics being in my bedroom, but how they got there, I don't What I would love is for you, if you can, to give me. What happened from, from your point of view from when my, my fiance, Jane contacted triple zero, and spoke to them, what, what, what process was put in, in, in chain. Sally: So with calling OOO, it's answered usually in the first instance at a local call center. who you speak to a call taker who's trained and is using assistive programs to triage or sort the nature of the call and the priority of the call. So there's a standard set of questions that they ask whoever's calling. And usually the first one is where are you? So they can start generating an address to dispatch an ambulance. And I guess people often don't realise that even as they ask further questions, they're already mobilising resources to you. So they're not wasting, wasting time with asking questions, delaying a response. It's just a case of getting the best information so they can send the most appropriate resource. So we have primary response ambulances, which are qualified paramedics. We also have intensive care paramedics who can be dispatched as the first resource or an additional resource, depending on the severity of the call. And we also have medical teams that can bring doctors to the roadside. So part of gleaning the information from the caller is to make, an appropriate categorization of the job in terms of being an urgent. Lights and sirens job or something not so urgent. So your fiancé in this case would have answered questions about whether you were awake, whether you were conscious, if you were breathing normally, if you were talking, and then the symptoms that you were suffering from. And given the way you've described it, it does sound a classic stroke presentation. You mentioned your face being dropped. That's one of the ones that the public are quite good at recognizing. If half of the face is uneven or if one side of the body is weak it fits quite neatly into that stroke category. And the call taker is able to prompt the caller to perform assessment tools to work out if they believe the person is having a stroke. And that's a fast assessment that you might hear about. So the facial droop. The arm drift, if you can hold your arms up evenly if one falls down, and the speech, if you have speech changes, unable to speech, slurring, unable to find words, all of those. And then the timing, so when you were last seen well, because all of the stroke treatment is based on timeframes of how quickly we can reverse what's going on in the brain. So once the address is given and the call is categorized, it's dispatched to the closest ambulance resource. Who heads lights and sirens to your house. And the paramedic sitting in the front of the car on the way would have received details about your age, your gender, and the presentation, and what your fiancé has said on the phone. Which, Hopefully the call taker's sorted through that panic because as you can imagine, it's often scarier for the people watching their loved ones than the person in it because your awareness of it is, as you know, a little clouded probably a mix of the adrenaline of having a medical emergency and the fact that you've got altered oxygenation to your brain because of the stroke itself. Yeah. Piers: Right. So that's what was, I don't understand how I can sort of be with it and sort of not be with it. Is it part of the brain remains functional and another bit it's being deprived of oxygen and so you wind up with a half functional brain? Sally: Yeah, I can't claim to be a, an expert in brain function. It's such a complicated area. But I can speak from my own experience as well. When you have, , some sort of medical emergency or something that stimulates a stress response. I think that also does cloud our ability to make memory and to recall things as well. Often, you can be, conscious enough to maintain basic reflexes. And things that are very known to you, like trying to get dressed, toileting yourself, knowing who people are all the way around your own house. That's so inbuilt to us. We do it every day. It's those higher functions, you know, if we're asking you to do something new or explaining something that your brain sort of stops and says, no, I can only maintain these basic functions. I'm at my limit. Yeah. Piers: I remember my fiance saying that the paramedics were firstly incredibly fast in getting, Like it was only a matter of minutes until my team was on the, the ground. Are these high priority, responses? Sally: Yes. So if it's identified as a stroke, we have a certain timeframe to work within and you become an urgent case. sO the next step from the call taker, once the job's categorized, it gets passed over to a dispatcher who maintains a number of resources over an area. And I guess it's a little bit like Tetris working out who goes where, who's closest to what and managing, a huge number of calls and outstanding jobs and a limited number of resources. So it's their job to sort through who needs an ambulance first based on the category and who's closest to the jobs. So they do a very difficult job maintaining lots of different elements that are sort of competing against each other. So often they'll have a look at their board, they'll see an outstanding urgent job, and they'll dispatch the closest resource to manage that. So that means they could be at the closest ED, or they could be down the road, just finishing up with another patient that happens to be close by. There's no way to predict, because we're so mobile, I guess, and fluid. Piers: I think I also benefited from living about 300 meters from the Alexandria ambulance say station. So I think that may have also been Working on my side, which was handy. Although, as you said, it could have come from anywhere. When the paramedics got to the house they very quickly came up to the bedroom. Can you tell me what you would be doing in that situation to assess or treat or how that process goes? Sally: So Our assessment of a job starts on the way to the job as we're reading the information that we're given and trying to sort out a rough plan. We don't always get accurate information to pre plan for jobs, but it's worth discussing with your partner, especially if they're junior or you haven't worked with them before, just an approach for how you're going to manage the scene and the patient, depending on what you find. The driver is in charge of Not only driving the vehicle, but radio communications and extrication. So working out how to access and get the patient out. And that's a very, very important job because we're dealing with patients in every location you can imagine. A movie theater, the beach, a shopping center, on a train. The, the scene is never the same. And so, our job starts as soon as we sort of pull up. We're thinking, how many stories, where are the stairs, how do we get out? Are we going to need more resources to help us do that? And the paramedic sitting in the treat seat is obviously in charge of the treating of the patient and the assessment. Although once you're on scene, you sort of work together to sort that out. As soon as you approach the patient, you're doing a global assessment, trying to work out what position they're in, if they're awake, if they're looking at you, if they look a good color, if they're speaking with you, and we're also taking on board a lot of the, I guess, energy in the room, how are the relatives themselves. Friends, bystanders responding to what's happening. Do we need to manage them and their panic? Are they giving us a good indication that the way the patient is presenting is a very long way from their baseline and how they would normally be? Because we've never met people. It's the first time we're meeting them and we're trying to work out what's their everyday nature and what's happening today. So we do a bit of listening to what the relatives have to say and why they've called triple O. And then we assess the patient working through a systematic approach, looking at their airway. Because it's obviously the most life threatening thing. Can they maintain? Are they speaking themselves? They're breathing. Are they working hard to breathe? Are they a good color? Are they breathing very quickly? Do they have pulses? Are they weak pulses? Strong pulses? And then we can go into a more specific assessment for stroke. Piers: Right. Very interesting. I, you hear a lot about stroke busters. And I certainly didn't get one of those, but are there treatments that you deliver the person's home or is it all about getting them into that car and getting them to ED as fast as you can? Sally: At the moment in metro areas in New South Wales, it's all about transporting quickly so that we can get the patient to a scan to differentiate between a bleed and a clot, because they're two different types of stroke that are managed very differently. And at the moment yes, we don't have any capability to be. Diagnosing which type of stroke it is, and therefore our best line of action is to transport rapidly. Because if we deliver a clot buster as such to someone having a bleed stroke the results will be catastrophic. Piers: Right. Okay. So it's, it's just stabilize, make sure they're breathing, they're, they're. Okay. And then just hit the siren and go like hell, Sally: Yes. Normally, if the patient has a altered level of consciousness, if they're drowsy or unconscious we play an important role in maintaining an airway for them. We can also monitor observations like sugar levels, temperatures, heart rate, oxygen, blood pressure, all those important factors. But the other role we play is in alerting the incoming hospital that we're coming so that they can start their processes before we're even through the doors. So we have systems where we pass information, where we've summarized the patient's presentation, their current observations, the treatment we've given, and we're speaking to the doctors on the radio before we even arrive. So that they've got the bed, the doctors and they've got their specialists at the bedside for when we walk through the door. Piers: right. And in terms of patients that you've seen, I mean, how, how wide can the presentation be between sort of a, a mild stroke and a really, um, intense? I don't, I don't even know if that's the right language, but. You kind of know what I'm getting at, I think. Sally: I do, I do. It's the, the spectrum is huge. It's enormous. And as humans, we present so differently as well within that spectrum. I guess on the worst case. You're looking at someone who's profoundly unconscious. They have an altered pattern of breathing. And that can often give away that something massive cerebral is happening. Often a stroke. So you can find those patients. You've got no sense of history, when these symptoms came on, how long they've been in this state. state of altered consciousness, which obviously comes with other complications like aspiration or breathing in your own secretions and those sorts of things. And that's on the worst case end. And then you can get some people having quite atypical presentations of stroke. So they might not have any deficits on a side or weakness, but they might feel dizzy or off balance. And that may be the only symptom that they're having a stroke. Piers: This is just a really sort of, uh, curious question, really. I mean, I think of heart attacks and strokes as being these, um, bolts that come out of the sky and zap you. And you think of like a heart attack and, you know, a guy falling over while Jogging and, and, and never getting up. Does that happen with strokes or do, do people generally make it to hospital and get treated or can it be a kind of a bolt from, from the heavens knocks you over? Sally: It can be depending on the type and the size of the stroke. I guess there's a cohort of patients that we're attending who have already passed away and there's a chance that it could have been a stroke. I'm unable to tell at that point. It's not my job to, to determine. But obviously there are quite significant medical events that can take you out on the spot. And there's nothing, you know, that we can do no matter how quickly we're there that's going to undo the damage that's already been done. Piers: The stroke survival rates seem to be just getting better and better. What do you think has, um, materially led to that improvement? Sally: Good pre hospital care in terms of getting resources to people, um, wherever they may be. We've also seen advancements in the technology for treating, especially the clot types. Of strokes in terms of the medication that we can give. But we can also see, um, advancements with doing clot retrieval, which specialist hospitals across Sydney, , are equipped to do. And because of the, I guess, effectiveness of these treatments, we've also seen an extension in the window in which doctors are prepared to do these interventions and hope for good outcomes. So it used to be a very tight window of about four and a half hours. And at the moment, in certain areas, we're now allowing patients 24 hours to receive these interventions with the hope that they can. You know, reverse what's happening. There's a point at which we can't reverse dead brain tissue. But the brain can rewire itself to a certain degree. So even with areas that are infarcted or dead, um, the brain around it does a pretty good job of trying to, to create new pathways, I guess. So there's been a lot of advancement in the last 5 to 10 years. In the way that we do manage and treat strokes. Piers: it seems to be an incredibly smoothly put together, process. Now, when Alex put us in touch, uh, I think the reason that he thought, uh, you would be such a terrific person to speak to, um, and there's no way on earth our audience will have, uh, gleaned this from the conversation, but I understand you're about 11 months, uh, after having your own stroke, Sally: Yes, that's correct. I had a stroke, um, 11 months ago. Piers: and you do not look like somebody who, uh, Either would have a stroke or has had a stroke. There doesn't appear to be any deficit, but I mean, this must have been quite the shock to you as it is for everyone, but healthy, uh, young woman working in the profession, you think you'd be as eyes wide open to this sort of thing as anyone could be. But how did it, how did it sneak up on you? Sally: So, I was home, uh, just folding the washing as you do, and I had a sudden onset of my left hand was completely numb, um, and sort of there had no power to it. And I also felt this, um, sort of impending sense of doom, like I was about to Pass out or have a seizure like I was on the edge of something bad And I also for the life of me couldn't coordinate sitting myself down So I didn't feel safe standing and all I wanted to do was to lie down Because I felt like I would fall down But my husband was working from home that day and I called out to him. I'm not sure if I was In my head, I was yelling out, but he found me, um, half crouched down, trying to lie myself down. But because I'm a paramedic, I'm a terrible patient. And so , I didn't want an ambulance called. I didn't. I don't want to do anything about it, but I ended up calling some colleagues of mine who were off duty who insisted that I go to the emergency department. But yes, we don't make good patients. We don't like being on the other side. And, yes, I can admit to that. Piers: That's fascinating that, um, you of all people would appreciate that time is brain, as they say, and, uh, you're like, no, don't, don't, don't get me exactly what you, I'm sure would recommend the other eight and a half billion people on the planet should do in that exact situation, like, but not you. Sally: That's it. And maybe it comes down to that sort of altered cognition. You know, if I was well, I'd be a very good advocate for that person suffering from those symptoms. But because it was me, and maybe my brain wasn't working at its best, um, as brain cells were dying off because of the clot, um, Yeah, I didn't. I, I wanted to maintain some power, I guess, and I didn't want to be a patient and I didn't want to get dragged off and I didn't want to be in the bed being asked the questions. That's not my position of comfort. Piers: I, I completely agree. I mean, I found loss of agency, one of the biggest issues, you know, like your life is just taken out of your hands very, very suddenly. And it's even though, you know, you're not well, it's still a very, um, as I said, a terrible way to start a Saturday. So did your, uh, husband drive you to hospital or did you accede to an ambulance in the Sally: No, so I had a friend drive me up and I refused to go through the ambulance entry. I went through the main waiting room and I was seen by the doctors and by this point my deficits in my hand had resolved. And I was just left with, um, a mild headache on the right side and I felt, um, very vague. I felt, um, as if I was drugged, just a bit disconnected from what was, was happening. But I was able to answer all of the questions and do all the touch this and balance here and those sorts of things. And given that I didn't have any risk factors, they were not really even considering. That I was having a stroke. Piers: Right. Were you considering that you were having a stroke? Sally: No, I, because the numbness had resolved and I didn't have the classic, my face wasn't droopy, I didn't have any issues with my speech, I was able to hold my arms up, all those things, and the fact that a lot of it had resolved and I was just left with a lingering, cloudy feeling in my head. I'd I, no, despite all my training, I, for some reason, I knew something significant had happened and I knew that it had happened in my brain, but I wasn't confident enough in my unwell state to say, I've had a stroke or I've had this. It was just a, something's wrong. Can you, can you test for something? Piers: Hmm. So how did you get from a situation where, you know, the, the initial symptoms had sort of self solved and you, you hadn't been diagnosed as having a stroke and yet here we are 11 months later and you clearly did, how did, how did it unfold that, uh, the realization came to pass that you actually had a really serious medical problem? situation, Sally: I. I Got discharged from the hospital and I just didn't feel right for a couple of days. I didn't trust myself to do anything, to look after the kids, to drive, to go to work. And so I went back to the GP and as soon as my GP, who knows me quite well, saw I had a discharge summary from ED, she knew something significant had happened. for me to present to ED. She, cause she knows I'm a terrible patient. So she to get me into the neurologist, um, very quickly, which I'm very thankful for. And they ordered a series of tests, EEGs to look for things like seizure disorders and an MRI of the brain and the spine. And they were also looking for, um, MS, multiple sclerosis and atypical presentation, but they really didn't know what they were looking for. The neurologist with. more experienced than years I've been alive, um, sort of said it wasn't typical of anything the way I described it didn't sound classic of anything, but that they were going to perform these tests and hopefully just come back with clear results. And I could rest easy that everything was okay. But as you can guess, the results came back that I'd had a stroke. The clot luckily for me had broken in to at least two pieces and made it smaller. If the clot had remained it could have been catastrophic, I guess. Piers: it does always seem to be these tiny little things. I remember being told that if my clot was a centimeter deeper in the brain, it would have been a very, very different outcome. And these tiny little tweaks seem to make, know, you've already rolled bad dice, but then how land is, uh, so, so critical to the. You know, the rest of our lives. Have you, do you feel that you have made a full recovery or do you feel like there are deficits that we can't see, but that you kind of know, uh, are going on? Sally: I do have moments where something will happen, I'll struggle to recall something, or stumble over words and things like that and just think deep inside me, ooh, is that because of the stroke? Piers: Do you live with fear that it's going to happen again? Sally: guess at this point I just need to trust that I've been examined thoroughly and that this time around the diagnosis is correct and they've said that I'm now not at any higher risk of having a stroke than the next person and I guess there's It's an element of fear in everyone that something's going to happen at some stage, um, and maybe because I see the patients that things have just happened to out of the blue, um, it is in the back of your mind, but I, I try not to let it create fear , I it's, it's for me created a sense of gratitude at the quality of life that I do have. Piers: Hmm. No, I, I feel the very much the same. There is this, uh, bonus time that I feel I have been gifted in life , another time or another happenstance, uh, it would have ended very, very differently. Sally: Hmm , Piers: Sally, I'm very aware that you've actually got a full day in front of you. And You need to get going with it. But I want to thank you so much for joining me this morning, both from a clinical perspective and really shedding some great light on the experience for for stroke victims in those first instances and, and, and how I guess through the fog of the situation, there is an underlying infrastructure and a great team of paramedics that jump into action, but also for sharing your personal experience, because I think, um, seeing these things from both sides is a an extraordinary perspective that you bring. So thank you so much for your time, Sally. Sally: Thank you so much for having me on. I really appreciate it.