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The the stroke pathway. So we um started to then encourage our senior nurses are banned, six nurses which are junior sisters too. Um, start to do some in house training and online training with the N I H S S scale. In order for up the stroke nurses too assess strokes in A and E as they came through the doors to decide whether they were original candidates for um from dialysis. So the N I H S S CAL Vesely is the National Institute of Health uh stroke Statistics. And then it's kind of an objective rate for set of severity of strokes. But obviously, it does give you a baseline and uh the severity of somebody's a stroke. Um So originally when we started, we were just um going down to a any to assess people that obviously were originally they thought would have strokes. We and we'll try to coordinate beds for the ward. However, this role has evolved over the last nine, 10, 12 years that we've been doing this. Um And obviously now as a trust we offer thrombolysis, so we offer patient's that have a onset time of 4.5 hours um, the thrombolysis outer plays drug if they meet the very, you know, quite strict criteria for thrombolysis. So, my day to day role at the moment is, um, anybody that comes into East Surrey Hospital with any stroke like symptoms, be it clinically looking like the advert or with any kind of dizziness or double vision loss or, um, we can see a lot of nausea and dizziness a and, er, now encouraged to activate a stroke or so to, to, to, to stroke call, activates. Um and we go, we come as a team, although there's a small team, it's just the three of us which is a stroke registrar and two stroke nurses come down to A and E come down to where and even in the hospital as well, we see patient's that are in the hospital that have already been as in patient's, but then develop stroke symptoms whilst they're in patient's on the walled, we assess the patient's, we do the N I H S S score. We have timings, we have to achieve now where we have to be within the CT scan, er for any kind of stroke, within um that the first hour, obviously time is brain. So within um we can usually do CT scan with sort of immediately to be fair now. So we get the patient into the scan er to see if there is any evolving infarct or see if there's any bleeding. Um Obviously the pathway of 90% of our patient's we see is that they, their scans are usually normal, but we go clinically. So how the patient is um score ing on the N I H S s and how visually they look for stroke call, you know, for having a stroke like symptoms. Um We also have started recently because of from beck to me offering a C T A at that moment as well. But obviously, it's difficult as a stroke nurse when you're trying to see somebody assess somebody do bloods on somebody, get a little bit of history and an aunt set time. Then it's a medical dot job to order CT scan and order CT A. So as a stroke nurse, it's very nice. If we have a doctor with us that listens to quickly of the handover, then orders the scans that are necessary, which is usually a CT and a CT, a obviously dependent on renal function. Um So the CT and the CT are undertaken and we usually head back to recess, which is where most of the stroke calls go out. And we then make a decision of whether if the patient meets the criteria for thrombolysis, um which is an onset time. Um no stroke within all set time of 4.5 hours, no previous stroke, you know, bleeding tendencies, platelet count is good premorbidly there M R S is if anything are usually above three and four, we don't usually thrombolysis due to, you know, severity of strokes or what previous past medical history people have. Um if they're on a blood thinner anyway, like a Rivaroxaban or it Apixaban um or any kind of warfarin. Um Obviously, it takes them out of the criteria for thrombolysis. However, we if there is a um occlusion or vessel occlusion seen on C T A, we can offer from vasectomy. So then they don't need to be thrombolysis in order to be obtained to consideration for thrombectomy. And that's where you guys as um doctors come in because the stroke consultants are on call for thrombolysis out of um 9 to 5, their in house, our own stroke consultants see our patient's after five o'clock, it's a stroke consultant from the network. Um is then on call at home for thrombolysis and consideration for thrombectomy. So, um unfortunately, the stroke consultants on call, they do get to see the scans, they're able to access the scans at home as well. But obviously they prefer if it's a, a medical medical staff that speak to them because of the questions that they need to ask. However, usually the stroke nurses there to say, oh no, the N I H S S is this or they're premorbidly. They were this because a lot of the time we get that information before you guys do. Um So for consideration for from back to me, um it's, they don't, we don't do the thrombectomy. He's in the trust thrombectomy is are done that either at Saint George's Hospital or um ST uh King's College Hospital and they're on a roll in row to and then we're informed that if the heart's receiving hospital has accepted, then the stroke consultant on call will let us know what um hospital has accepted the patient and then they're blue lighted with the stroke nurse to the hospital for thrombectomy. Um We don't send a lot of people off the throne back to me. I have to say we kind of do fits and starts with it. Um It's very dependent on the patient, it's very dependent on the frailty of the patient as well. Um And also then if they've been thrombolysis test, sometimes it's typically bill more difficult to try to, to uh get the patient there as soon as we possibly can cause they're also undergoing a thrombolysis at the same time as well as going off to a receiving hospital. Um A lot of our um job is trying to coordinate, we've to be fair. We we thrombolysis, very few people. A lot of our job is um sort of query stroke could be, stroke has stroke like symptoms that obviously score on the N I H S S score but not necessarily a stroke. So a lot of our patient's and a lot of of our stroke calls we see is trying to actually tease out as a timeline medically what's brought the patient NG Um And we find a lot of the patient's will score on the N I H S s and clinically look like stroke. However, when they're then admitted and we undergo MRI scan or, or they're full bloods come back, we realize that it's not a stroke at all. It's, you know, low sodium or their thyroid or um something vestibular. Um once MRI has been done, um so a lot of our patient's, we, we see we tend to rule out stroke rather than pinpoint it. Um And obviously, as the role has evolved over, over the years, um we've kind of got to realize that perhaps the gold standard would be to MRI people sooner on admission rather than CT that because a lot of the time the CT scans um and the C T A S, they give us a bit of knowledge, but obviously, not the knowledge we'd require, which would be the gold standard of getting an MRI um sort of on admission to hospital. Um We um had started to do CT perfusion scans to see obviously, then the perfusion scan would um ascertain how much of penumbra we could start save with listhesis or thrombectomy knees and, or both. However, we've, they, we've kind of found that they were just kind of not wasting time, but it was a little bit of time. We had to go into CT then come out of CT, then go back in for a profusion scan and actually, I think we've found that they're not, um we were always, not always, um uh you know, they're not really conducive to what we can then offer at East Surrey Hospital. So from a, you know, um we try to obviously treat people at the front door and then try to bring them to the walls as soon as we possibly can, even the patient's that aren't really stroke or that we think aren't stroke, but we bring them to the world anyway to rule it out rather than pinpoint in order to the continuity as well. Because obviously, we build up a rapport when we're in a and E with the, with the relatives and the and the patient, especially if we're thinking it definitely, you know, it's, it might be stroke but it might not be. But we need an MRI just to confirm either way. Um ideally, we would like what's called a ring fenced bed on the ward. So as soon as we get a stroke call, and if we thrombolysis, we can use that ring fence bed straight away so that we can bring our patient's to the ward within four hours. Obviously, it's quite challenging at present. So we haven't been able to um achieved that in, in quite a while. I can't remember the last time we had a ring fence bed, but we are a 40 old bedded ward. I think it's 38 beds we have on the stroke ward. At the moment. And obviously, they're always, always, always full. Um Our pathway for stroke is once they come through A and E and they meet, come to the ward. Um depending on the severity of stroke, they have physio therapy, occupational therapy, and speech and language therapy if it's needed on the ward. Um And then we have an M D T meeting every week to make a decision of whether the patient needs um would require further rehabilitation. And this trust uses Piper ward at the hospital for rehabilitation. And it also uses Q E F which Leatherhead um for rehabilitation as as well. If you're a sorry patient, you go to Q E F. If you're a sussex patient, you go to Piper. Um So from a nurses, stroke nurse's point of view, we do like it that we especially out of hours. So after five o'clock, if the stroke four goes off, that the attending doctor kind of stays with us because then there's continuity. Sometimes the doctoral say, oh, I've ordered the CT scan and the CT A and then they don't come back or they don't come with you to see the patient. They can kind of just do it from afar. But actually, it's quite nice and the continuity that the stroke nurse does work with a doctor as well because there are things that obviously from a medical perspective, you guys pick up on that we may not pick up on and sometimes vice versa. Um And then also it's just making sure that the patient is handed over correctly. If it's, the decision is made, actually, the, the event isn't anything stroke like because unfortunately, once a stroke call goes out, um sometimes the a any team think that the patient is then under the stroke team, but out of hours, they're actually, they still have to go through the normal um process of being seen by E D and then referring onto medic medics and then clerking that way, if necessary, which obviously if the stroke nurse doesn't always have somebody with her, sometimes it can get lost in translation. So the stroke nurses, somebody thinks actually, I don't think the symptoms our stroke like or it doesn't fit the symptoms don't fit with the history or it doesn't seem that it's anything stroke. But obviously, then if stroke halls gone out, um you don't want the patient being left in limbo with a and a thinking that the stroke team are seeing when actually, then they haven't been referred correctly. Um So um kind of that's where we are at the moment. So thank you. Oh, that was, that was really good. Let's see if anybody have any questions. Thank you so much, Debra. Thank you. You look good. I have a question. Mhm Yeah. So you say you trained at is sorry, what was the training like to become a stroke nurse? Oh, so the training I did was that obviously I trained in event in 1992. So my original stroke nurse, most original training was very much old school training. Little hat, little belt as a student nurse, you were on the walled, counted in the numbers for my stroke nurse training. It was just obviously the wall had changed into stroke and evolved into stroke. So it was just gaining knowledge, working on the walled up in stroke, doing a lot of the ward rounds for stroke nursing with the trust didn't have a stroke nurse. So it's a kind of originally, all we had to complete was our online NIHS S training and that was all we'd had two to um complete in order for the band Sixes, which we were the sisters to start going down. And it literally was a bit like I've seen a consultant do the N I H S s to the next one I'll do. And it literally has just become like that and evolved. A lot of us now have completed the physical assessment course through the unique for the university in order for us to then um you know, listen to lungs and do a general assessment and, and percuss and stuff like that if we never feel it's necessary. Um We've also all of us have done in house training to assess swallow within the first four hours, which is one of the criterias that has to be met as one of the gold standards for stroke, the stroke strategy that every patient that comes in query, stroke or stroke like symptoms has a swallow screen obtained or done by the stroke nurse. So we've all done in house training for that, which we, we uh we have to update every year. Um So that is mainly just all in house training. Apart from, I think there is a lot, some um stroke specific training that is done through universities, but a lot of it is fund based. And as you know, it's difficult to then do that. A lot of our trainees just what we see on the wall and carry forward that way. And because um, our main audiences either like really junior doctors who haven't gotten to the NHS yet or like doctors who might be coming or even like nurses who might be stroke nurses. So, um, I just wanted to ask what are some things that you think we can do better with our side to help facilitate your roles when you assess these stroke patient's um, query, stroke patient's. Yeah, I think from, from, I think so, staying with the stroke nurse, sometimes a stroke call will go off, the doctor will turn up, see the stroke nurse and then they'll go, oh, I'll go and book the scans and sometimes I'm like, no stay and listen to the history because I don't think this is stroke and then I'm like, we're going off for a CT scan and I'm like, do we really need a CT scan once you listen to the history? And you can kind of think actually, or they get into CT scan and CT, the radiographers will say A C T A has been ordered, but they need somebody as a doctor to say, yes, proceed with that. So sometimes it's a stroke nurse that says uh yeah, like I can look at the scan and go, but there's no bleeding on it. But you know, it's not actually my call and they'll be like, oh, well, it's all good. So sometimes it's better if the doctor comes just with us just to say, yeah, that's fine. Just, you know, carry on with the C T A and then obviously it's the follow through because sometimes, then you're left with the patient that you think. Actually, I don't think that is stroke or I think it is stroke, but where's everybody gone? So sometimes it's just having that somebody else there to go, right? I'll carry on getting some history or I'll speak to a family member if you don't mind taking the patient or accompanying the patient or um just just saying on call stroke consultant. Sometimes I'll just phone the uncle stroke consultant and say, I don't think this is going to be for anything but kind of do you agree? Just so you've got that second person just to go actually, no, that's the right call or I'll look at the scans for you or, you know, you know, so it's from a nurse's point of view. It's just the fact that somebody else is sometimes there because the stroke nurse and then sometimes be left on their own. And we're like, where's everybody gone? And then nobody takes responsibility for the patient. And that's, that's the ultimate thing that somebody then is going to carry on. Obviously the clerk in and the drug chart and, and, uh, making the decisions about BP and BP control and aspirins and things like that. So, and even sometimes from the severity, if people have got very severe strokes, just talking to the relatives, as had there been any discussion's prior to, if this was to happen. Are we going to nasogastric Lee feed or, you know, just kind of those kind of conversations as well? Sorry. Yeah, that's really helpful because obviously I've probably in that position where possibly I've walked away or possibly of stage. Yeah. What do you think is, um, something that really, um, like a struggle of your day to day job? I know, obviously when you see these patient's that might be stroke, query stroke and sometimes a lot of times they're not to be honest. Yeah. Oh, no, that doesn't bother me. I'd rather go to somebody and it not be some of the thing than, than the main struggle is when you see somebody and they desperately need a bed on the wall. And you can't get them to love them money, getting them to the ward because, you know, then you've just got to walk away. Either they'll go to M U or they'll go to an outlying warden. I think that's my main struggle. Especially when I've seen somebody in a and E it would be fantastic just to go. Actually, I've got a bed, let's go. And even if they come to the ward and then not being stroke, I think it calms somebody when they come in because, you know, I think it's really frightening, isn't it? And then you have a whole team of people going. What's what timing? When were you were, when were you this? When you that and then you go. Okay. I might see you later or I might see it and it's just that continuity. So I think that's my main struggle. It would be fantastic if everybody we saw, we could get to the ward, even if we down two or three that are days down the line, it turned out they weren't stroke because I think their experience is better and it's for continuity. I really, really do. And obviously it's very, I think it's really frightening and it's such a big, a big thing stroke that obviously a lot of the people don't look like the advert there a lot severe or they're very confused or they're very agitated and people aren't aware of that in the community, but that's actually how stroke can also present rather than a bit like the advert, which is, you know, as, you know, it's not always, it was like that. Yeah, I can imagine that it's, it's good to, you know, it's, it's very difficult now with the best situation, especially in the times of, you know, bad pressures now. But, yeah, I agree that it would be quite a deal. But then, yeah, and they're on a different word. It's, it's a bit, were like, yeah, what do we do know? And also sort of stroke, stroke has never been sexy as it, it's never been, you know, my husband have an I T U background when you say, what do you do? And he goes, oh, I worked in I T U. Everyone's like, man, they say to me, what do you do? I'm a stroke nurse. Oh, that's, that's heavy. And you're like, actually, no, it's really rewarding and it's very medical and it's very interesting and it's, the brain is amazing and everyone's up, you know, it's, it's, it's, I think because it's like a stroke, heavy, heavy stroke. But it isn't, it's very rewarding. It's very, it's, it's a very, I find obviously done it for so long, still passionate about it. But I find it really rewarding. I find it really interesting. I learn something new every single day about stroke and brain and, you know how people act and the same stroke can be different with you know, the same two different people can have exactly the same stroke but their symptoms can be completely different. So, it's very, very, and it's very, very medical as well, which, which I personally enjoy. So it's really nice to hear somebody speak so passionately. Both stroke. I don't think. I hear that enough for sure. I definitely don't hear that now. So it's really good. Yeah. Does anybody have any questions you can type in the chat balls or you can turn on your mic to ask Deborah questions before her bleeps go off? Which hopefully doesn't happen. I'm sorry. That's okay. Well, if anybody have questions after event, would you be happy for me to pass your email to them? If they have any specific questions to that, then that way I can release you to your responsibility. Thank you so much for joining while you're very much. Thank you very much. Thank you. See you soon in the hospital by