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SNI Digital, Innovations and Learning, a new video journal which is interactive with discussion, now offering all of its programs including this program on podcasts on Apple Amazon and Spotify,
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in association with SNI Surgical Neurology International, an internet journal with Nancy Epstein as the editor-in-chief, are pleased to present another of the SNI Digital series of discussions with
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clinical neuroscience experts.
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In this series, we'll be talking with Asif Bashir and his brother Qasim Bashir and Gausmallik, a mentor, who is from Pakistan also, on how we developed a major neuroscience center in Pakistan.
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My Seth Beshear, who is one of the three presenters today, is a diplomat of the American Board of Neurosurgery, and now professor and chair of neurosurgery and the executive director and dean of
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the Punjab Institute of Neurosciences in Lahore, Pakistan.
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An institute he and his family have founded. He was formerly a professor at the JFK Neurosciences Institute in New Jersey and the reconstructive and spine neurosurgery section, neurosurgeon and the
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JFK Neurosciences Institute in New Jersey. His email is listed below his picture.
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Khasim Ashir, the
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brother of Asif, is now head of the Department of Neurology and the Services Institute of the Medical Sciences in Lahore, Pakistan.
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He's director of the neuroendovascular surgery section of the Punjab Institute of Medical Sciences in Lahore.
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He's the focal principal person in the development of the Stroke Management Center for the region of Punjab, Pakistan, which has 160 million people. He's a fellow of the Royal College of Physicians
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in Edinburgh, and he's certified as a neurocritical care specialist by the United Council of Neurological Specialties in the USA. He's certified as a vascular neurologist by the American Board of
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Medical Specialists. He's had a fellowship in neuroendovascular surgery at the University of Illinois at Chicago. He is certified in neuroendovascular surgery by the Committee on Advanced
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Subspecialty Training, cast under the Council of the Society of Neurologic Surgeons in the USA.
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His e-mail is listed there.
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Osmalek is the Executive Vice Chair and the John R. Davis Endowed Chair in the Department of Neurologic Surgery and Henry Ford Health in Detroit, Michigan. He is originally from Pakistan and has
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spent a great deal of his life helping build neurosurgery and neurosciences in Pakistan.
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Oh, first of all, thank you so much, Dr. Asman is such a player to actually talk to you after a long gap. So,
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and again, and Dr. Wasmailik and Dr. Asabashir being in the audience also, thank you so much for your time. So I made a presentation like about what I want to say is like, it's more of like a
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journey. And I thought like maybe I'll just like do the topic of mitigating the barriers to hyper acute stroke care in low bit in countries. And since you already mentioned that we are based in the
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horror in Pakistan and Pakistan is in that category. So I have no conflict with interest here.
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So I'm just going to start off like by quoting George Skola, who actually is now a fellow at World Stroke Organization. He came to know about stroke and then later became a very active member of the
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WS. So after only after suffering the stroke himself. And if you look at his statements, surviving stroke is the easy part. You either do or you don't. And while you're in the hospital, you're
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looked after and receive all the care you need. But the day you're discharged, it changes. That's when our lives as stroke survivor begins. But what I wanted to point out over here is that
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fortunately George lived in a European country and was able to get the best of the stroke care that exists in the developed world. But if you are living in a low-medium country, the things are not
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going to be the same as what George experienced. So it's not going to be easy even to survive, let alone facing the major morbidity associated with some majority of the strokes. And when you
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discharge, yes, that's the common thing, because when you're discharged in a low-medium country, your life definitely changes. But I would say that it's even worse than when you're discharged in
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a developed country. So when I was in US. like a startup under your mentorship
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in 1998 to 2000, when I was also working with you and Dr. Gerard de Bruin. In 1996, the first IV thrombolytic drug was approved. And just to give you a baseline in Pakistan, this drug was
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approved in 2021. And in
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February of 2025, the second IV thrombolytic drug connective plays was approved by FDA. And you can see how far we are from the developed world. For anything that you want to do, and you have far
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more experience than anyone amongst us here, Dr. Vassmelek has been very instrumental like
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in developing the neuroscience program in Detroit. But for me and myself, like here, like for any objective, for me, it was more of us developing a stroke infrastructure. you need a champion,
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you need funding, social mobilization, and you need a lot of technical support. But when you are in working in a low-median country, I think the
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most important part is actually the funding and the social mobilization, and I'll tell you why. So when we're talking about the barriers, let me quickly go through some of the barriers that
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actually affect which are coming from the developed world into the low-median countries So this is the 2014 framework for controlling a non-chemical diseases, and Pakistan became the signatory outfit
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in
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2014. And at that time, when the Pakistan became the signatory, I think the timeline given to Pakistan and the other countries was 10 years, that they need to make major progress in cardiovascular
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diseases, such as like non-chemical one in cancer, and then the cardiovascular and respiratory disease. But the problem that you see over here is Hylatoris cardiovascular. So when you are in a low
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middle country, the word cardiovascular is going to be construed in a different manner as compared to what is perceived or used in developed countries like stroke or heart disease.
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So keeping in that context, the other problem, the thing here is that I'm not going to go straight into how we did it. In
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Punjab, we have two health departments. One is specialized health and the other one is primary and secondary. Now in a country with 250 million population, this is the largest province by
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population and contributes more than half of
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the population of the country.
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And this is the only province where you have two health departments unlike the other three major provinces where you have one health department. So when you are working for the health department here,
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you have to deal with two departments separately. So now coming back, to that terminology. So if you have several vascular and you do not differentiate between stroke and heart disease, that
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becomes a major problem for us in the low medical country. And the reason is that there are so many barriers over here which I've highlighted, there are even more. And I'm not going to go into each
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and everything that I've listed over here, but these are some of the major ones that we get affected for developing neurosciences or anything which has acute emergency care. When I came back in 2012,
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end of 2012, it took me
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one or two years only to realize that you cannot copy and paste exactly what you see in
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the developed world because our demographic, our problems, our infrastructure is totally different So if you have a guideline, It's not very easy to follow that guidelines strictly to the core.
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And since we're talking about the stroke, so I'm going to stick to it.
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So
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in 2013, I joined CMH Medical College, which is Combined Military Hospital College. For a person like me who came back with the best of the education, three fellowships, it was not an easy thing
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to get into the public sector, first of all. So this was the only place where I could join But the program that I wanted to start actually should have started in 2013, but it took me seven to eight
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years to make my way to the public sector. So in 2020, I was able to join the public sector only after they actually were the ones who realized what I was doing in the city and the things. So they
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offered the position and I'm joined the public sector. And that's where now this program comes in. So these are the big concerns. that I've listed, you need to identify the problems. We have a
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major problem, the human resource, career infrastructure, career growth, planning, which obviously the regulatory authorities and the health department has a major role to play infrastructure,
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communications, population, is one of the major problems because it's, the population's growing at such a rapid rate that whatever you come out with, it becomes like a major problem within a short
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time So you have to think again how to deal with the new problems. And then the other thing is standardization, the corporate industry, and the health insurance system. Brief note on the human
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resource. Again, 250 plus million population as of 2025, there are only like 440 neurologists. And I would say like maybe close to 500 or maybe less than 500 are able to tell more neurosurgeons
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for this population, which is too short to deal with the whole population.
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The other problem here is that the whole mantra actually revolves around providing treatment. And in this era of social media and those kinds of things where everyone who has a problem with the
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health care in a lower income country, they instantly go to the social media, put complaints and large complaints at those times, it becomes a major problem. So the focus has been on providing the
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treatment, but not on the prevention. So that's another major thing that has to change, a shift, how to prevent these problems. So this is a stroke chain, which is globally recognized and
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advocated by American Stroke Association, American
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Academy of Neurosurgery, American Capital Neurology. So I'm gonna just sum it up, they have five blocks, but I summed up all of them into four, and I'm gonna go each one of them as we developed
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the
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infrastructure here in the province So starting with the - the community, dispatcher, hospital, and then the rehabilitation.
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So in 2020, March, I was offered to join the public sector, which I did. Immediately, I already had kind of a blueprint for number of years when I moved back. So I reached out to the health
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department to give me the funding just to start IV thrombolytics, because at that time, the service hospital where I'm working still right now, and I also work at Punjab in
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St. Louis, where Assif is. We don't have the cath lab over there, but we didn't have the TPA in 2020. And TPA was not even registered with our drug regulatory authority of Pakistan, which is
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counterpart of
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FDA. So I reached out to a patient's family who had seen me in 2019 and offered that whenever I joined the public sector, I have something for the public they were willing to to offer. So they were
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kind enough. since the government didn't provide me the fund. So they were kind enough to give me 100, 000 brands. And then I reached out to the Alpac San Association of North America to act as a
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medium for moving the funds from APNA to Borhanger, Engleheim, Germany, which is the main company that manufactures TPA for the world. Now the world is divided by the Borhanger into two regions.
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One is USA, the other is the rest of the world outside the USA. For the USA, the TPA drug is made by the company Genetic because they got the license from Borhanger to manufacture TPA by themselves
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for the US population. The rest of the world, it was Borhanger. So
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Borhanger, Engleheim didn't have any presence in Pakistan at that time. So the only way I could get the drug into the country was A, arrange funding and then have a medium the funding could be
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transferred to them and then the drugs could be shipped to Pakistan. And that's what we did. And we got an institution based permit that allowed us to import till the drug was approved. So I made
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that program, started running the program and then using the social media, the WhatsApp and those sort of things started educating and highlighting to the health department, what we were doing,
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showing them the outcomes. And then short enough in 2023, a break came in and then again, at that time, the career government wanted me to reached out and they said, why don't you replicate the
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same local project of yours for the whole province. And in October 2023, the provision stroke management center was created. So these are the five things that we laid our foundation on that we're
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going to follow the same principles laid out by World Stock Organization. We're going to work on hyper acute inpatient prevention, stroke rehabilitation and community reintegration
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So I'll miss you more. Can I interrupt you a minute? Sure. So what you've, I mean, it's incredible what you've done, what you and your whole family have done there. It's incredible, but so
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basically, they didn't even recognize your talent and ability to begin with, it took you a great deal of time and patience to get into the system, which is the success sector, which you were going
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to benefit And then you got the TPA, or you
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got a drug that would be thrombolytic, and you would get that going. And then you had to - you'd develop this set of guidelines that you were going to use, and
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you were able then to get some help from the strong mob people who were private donors, I assume, and that was helpful. But you said one thing that was really important, And that is, I think the
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people listening to this want to know this. is you said, well, we use social media. How did you communicate your message to the people? I've been to Pakistan. I mean, the streets are filled
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with people. I'm not sure how many of them read with the literacy rate is. So you have to communicate with them somehow. I mean, this is not just a one sentence summary. I mean, this has got
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to be a major hurdle to get over to educate people to say, don't stay at home, go to the doctor, come to the hospital, the things you can do for stroke. And the other thing is I'm sure you are
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arguing against old habits and old traditions, which where they have a stroke, there's nothing you can do for. So I mean, in a couple of sentences, you
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cover a lot of territory that's very complicated. Do you wanna expand on that a little bit before you go on, or are you gonna do it later? No, no, I can do it right now. So Dr. Asman, I'd like
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to add one couple of lines before that. So what Kasim went through
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was this is an incredible journey, what he said, not that he's my brother. I say this to the top people in this country who interact with us and I had a different start and I'll tell you when we
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get to my side, but what he has achieved, just to tell you, comparing with US, US is not even 400 million We are like 370 million maybe in US. Punjab, where Kasim is leading the Punjab Stroke
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Initiative, he's covering 160 million people right now, with 18 centers and maybe more 27, I think the target is. But till he came to the public sector, where our father had started in 1960s,
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1966, he was working through the army institution, which was CMX, which was a single institution at the end. It was in their favor, not for it to, they wanted him. They didn't even allow him to
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do intervention there. So he scaled it up to a level which nobody in the world can do it, in my opinion, as regards stroke and intervention, what he's doing. And I'll show you some of those many.
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So Kasima, let you continue.
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So thank you, Asif. So Dr. Asif, like, so social media. So my target on the social media was the health department So all the contacts that I was making in the process, like I kept their
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numbers and then the doctors. And my, when I talked about the physicians, I was concentrating more on the Lahore area only, because obviously the center that I was working and trying to do the IV
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thrombolysis program was in Lahore. And that was a first and the only center at that time doing IV thrombolysis in the country in public sector. So I'm not talking about the private in the public
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sector So whenever we had a case, either a good outcome or a bad outcome, a majority of the things were good outcomes because we were very selective initially. The first 20 cases that we did with
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the TPA, we were very selective. We wanted to have good patient. We wanted to build up the conference of the neurology residents. We wanted to build up the conference of my other colleagues in the
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neurology and obviously the referring physicians. So we would make small videos like one or two minute videos and send them through the WhatsApp to the contacts and that's how we were propagating. I
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tried to reach out to the media outlets but unfortunately if they were kind of from my patient or I had some kind of that link, they invited me maybe very few times for a few minutes talking those
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times but it wasn't working that way because at the end of the day they always wanted some form of like the
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money. There was a fee associated with it if you want to do highlight, even though this was. a life-saving program and a community-related program, but it wasn't selling in the media. So we
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relied on the most cheapest one that was the WhatsApp. And that's how we started doing it. And it took us two years for the government to actually reach out again and then saying in 2023 that, you
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know, let's replicate and we'll give you the initial seed money And that's how we converted a philanthropy into the public funding. So I hope this answer is like what you were trying to - It's
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terrific. Also, do you have any comments? 'Cause you saw this develop from the very time they came back and the time they were building this. I think people
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can underestimate. I'm glad I said for me it is, and I'm glad that the committee's talking about 160 million people with nothing to begin with. And within a few years, he was able to get this
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going. Any comments you had about what went into this story? It just reminds me
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what Professor Bichiram went through,
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as he turned back from UK to start neurosurgeon in Pakistan. There was only one other neurosurgeon who wasn't very active in education. He was
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trying to provide care to, he was in Karachi. Lahore, which was, at that time, combined
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province West Pakistan,
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they told him that there was no position available in Lahore or him to practice neurosurgeon So he was given a position in Molton, and he had to struggle through finding the operating facilities,
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trying to educate people. You know, he had interest in addition to general neurosurgery in stereotactic neurosurgery and Parkinson's disease. So,
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I remember that
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he was the first one to get a CT scanner
22:32
In 1978 and a few times, I accompanied him to go to the government offices. And they would not approve it, even though it was through a grant from Sweden was not even the money that the government
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was spending So, those are the challenges and, you know, I have been encouraging both caution and asset is to. stay steady and keep working and ultimately you become successful if you are sincere
23:10
and working for the public and they're doing just a tremendous job. I understand. And Dr Asman, let me, let me add a few. So when I moved in, Gasm had been, he moved in 2012. I moved in end of
23:25
17. So like Dr. Malik mentioned, neurosurgery had, they were like 250, 300 neurosurgeons, but then already, but there was no neurology, stroke, intervention, forget about intervention. Well,
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when I came in also, I joined the public sector and Dr. Gasmalik, I'm thankful to him because I, I discussed with him so many things. Even to a point that when I joined the dominant sector, it
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was such a pathetic I would be operating in the same condition where my father had left in 1990s. That I said, I'm going to leave. I'm going to resign because this is not hard. And what do we do
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with two acoustics, five centimeter, with a great five CP angles, and a couple of hundred aneurysms, which are being
24:17
taken to nobody's taken care of them. So he said, you do your job, just stay in there. He and my wife, Marwan, and you know, they said, just give it a week, maybe a month. And I think
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eventually, I think that's the best thing that happened. I did not resign. And my staying inside, if I had not stayed, Carson would not have survived or gotten in, to be honest, right? Because
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we made context to a point that from the lower person to the top of this country, everybody eventually gets to us. And by the way, I just messaged my wife, Marwan, to come and see you on video,
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Today, Kasim wasn't there, but I was with our time with you because we all owe it to you to be getting to where we are. Of course,
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you pick different people as you go and you learn. But you learn to swim. But somebody has got to give you a platform to get in But today, I was fortunate to
25:20
be involved
25:22
in a blind school auditorium opening, which was, in fact, opened by the same person who was going to be inaugurating our father's book on the 20th. Say it, Barbaralee. He's 99 years old and
25:38
eight months old. So you are
25:41
a spring chicken in Dr. Aspen in front of the way he is And he's the founder of all these large business
25:51
as well as the Lam's Law or University of Medical Sciences. What are truly
25:58
gifted? He's been gifted recently a couple of times by Harvard and all that. So I think if you keep on it, and now, by looking at you and Gauss pilot today, we have been revived also. And so
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we'll continue this journey and then tell you our side
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It's terrific. I think there are a couple of points that I want you to go out and consume. But one is there's always a silent person in the room. He's always been that way. That's Gauss.
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And he was a real rock and a really important person. Henry Ford, we drive together to work in the morning. We talk about all kinds of things. He's just got a wonderful soul. And he's continued
26:49
on, and I'm sure his help has been very invaluable. And people like that don't get enough credit. And the other thing is you guys have all overcome what are incredible obstacles. This, we do a
27:05
grand rounds with Sub-Saharan Africa. In Sub-Saharan Africa, there are one billion people, one billion people in 50 countries And they have different levels of accomplishment because the same
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problems you have. And now we've had our, we're gonna have our 16th meeting, tomorrow, grand rounds, it's been going on for over a year. And I've gotten a lot of participation in it, but it
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isn't an easy job, isn't that's the point I wanted to come out from what you were saying? 'Cause then it is not easy. And it takes a lot of persistence, a lot of. a lot of. help getting to the
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goals and that's why I wanted you to bring it out a little bit so that this doesn't fly past people and say, well, I'll just go out there and in a year from now I'm gonna have a stroke center. It
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doesn't work that way. And so I'm sorry to interrupt you for this, but why don't you go ahead and really appreciate that, okay?
28:10
So this is how then we decided to replicate the initial program So since I already come across the major problems and what I was facing when I was making the first center. So the couple of things I
28:25
wanted to highlight was that I wanted something where I could bypass our local hospital administration, especially the finance department and the administration because what happens is that when
28:37
you're working in a public sector, if you're the head of department, you have a particular plan, you will reach out to the administration, They will first approve it. Then all the paperwork will
28:48
go to the health department and then the communication will go in fourth. And you can, if you don't follow on both the sides, the project will not fly. So I had already learned my message, my
28:59
thing like in the first two years, so that's why I went straight. I restarted the health department, they refused. I didn't stop, I just restarted with the donor and thought, you know, why
29:08
don't I produce results? And that's what actually my late father kept on telling me when I came back in 2012, because I was getting frustrated because near intervention was not at all developed the
29:22
way neurosurgery was. And I was, no one was giving me the access to the cath labs in the private sector. Didn't, wasn't in the public sector either. So there were no distributors, no companies
29:35
like Metronic or Microvention and none of those resources were existent even in the private sector at that time. But he kept on telling me one thing that Kasim just produced results, show good
29:45
patient outcome, just like Dr. Wasser just wanted to highlight it. And that's exactly what he was telling me, that Kasim just see patients, produce results, and people will just follow and then
29:56
they will know. So this cost center was created in services hospital court. The cost center was the idea that all the funds for this project will come to this cost center directly The hospital
30:09
administration will have no saying over it. And the end user, that is the physician, will decide what they want to purchase. And in our case, we wanted to purchase thromboletics. And this cost
30:21
center will just be the distributed center as well for the rest of the province. Wherever we go and open primary stroke centers, the cost center will be the point of communication for that
30:30
particular primary stroke center and it will not be their local administration or the health department So I was the bridge. between the primary stroke centers that we have now created and the health
30:42
department, all the problems HR, money, whatever it's needed, actually come through me, and I'm the one actually now trying to streamline, like, you know, how to help each center and how to
30:55
grow the process. On the left side, you will see the primary stroke centers. So our first emphasis was to replicate as many primary stroke centers as we can across the province because the major
31:05
hurdle that we were facing, even at our center in Lahore, was that people were coming so late. We started with the hyper acute therapy. We tried to do the awareness through the social media, but
31:17
it was not hitting the projected target. So now you have a drug, you have people trained, but people are coming late. And we were getting patients six hours or 10 hours away from the cities, from
31:30
Lahore. And even by the time they would land over here, they went out of the window for the IVTPA as you know the windows up to four and a half hours. So the first thing was to open centers in the
31:40
smaller cities, take the drug over there so that they can be administered over there, and only the large vessel occlusion patients eventually start coming into the urban areas. So
31:53
now creating the primary stroke center brings along the first part that you need to have in a awareness. There is no point, it's a struggling to ask that you bring in the hyperitude therapies or you
32:04
train the infrastructure staff, but then the people don't know what you are offering over there. So what we did was we kept with the global stroke awareness sign. So this is the fast acronym. So
32:16
we translated that into Urdu. We kept on, we made a Facebook page which is calledProvision Stroke Management Center. We started posting all of these things there, started circulating and our
32:27
biggest social media platform right now is either the Facebook or the WhatsApp
32:34
So
32:36
a couple of things about the awareness. So in the developed world, you will see that you will come across so much literature on the fast knowledge, stroke of wellness knowledge, children, stroke
32:46
definition. So you will search any of these categories and you'll come across papers after papers. So but what happens in the low-median countries? You do not get any funding for awareness. When I
32:57
went to the public for this program and I said, you know, I need an X amount of money for the awareness, they said, oh, doctor, like I would, we would suggest like, you know, stick to the
33:06
medications Maybe the next day we'll give you some money for the awareness. So again, a roadblock over here. So the other thing is that Pakistan is a country where there's a two-tier system and
33:19
I'll explain to you quickly what the two-tier system is. When you are in high school, we have O levels, which is a British education degree coming from the Cambridge or the local degree called
33:36
metric.
33:38
I would say that you go into the high school and then you do either the FSC or what we call as A levels. I would say that the people who can afford the private schools, they are able to do all
33:50
levels in the A level. So there is again now a dichotomy and the two tier system starts right from your basic education. When you want to come into the medicine, you come into the medical school
34:02
Now you have, and then you go into the post-graduation, then you have another two tier system, one is called University of Health Sciences, the other one is called College of Physicians and
34:09
Surgeons of Pakistan. Now two different standards of training, again a dichotomy, you cannot standardize. And then the other problem, which started like again, probably 15, 15 some years ago,
34:24
was that the cardiology started to create their own institutes across the country And then it became like a standard
34:33
that every city or every province started to follow that platform platform. Over the years happened was now we have two emergency systems, one for cardiology, because they have separate institutes
34:43
where they are just doing cardiology and they have allied positions, but there's nothing allied there, meaning no medicine, no surgery, no neurosurgery, and you know that all of these patients
34:55
can also have complications. So in a separate ER, and they blossomed over the years, and then the rest of the body has general hospitals and that's where the emergency systems get created. Now
35:08
when you have a country where you have a literacy rate of around 60, how do you go in a community and educate them about stroke awareness and which emergency system to use? Because every time they
35:20
have a problem, they think it's a heart attack. Even when you have a stroke, full-fledged stroke, they walk straight into the cardiac institute, which is right next door. And a couple of hours
35:29
later, the cardinals would say, Oh, you don't have anything cardiac they're not even trained to identify stroke as well. And they will say, go to the next door. You need to see a neurologist.
35:40
And by the time they will land to the hospital, they're out of the window. So
35:45
this is what I was saying, that if you look at the literature, of all the people who come with acute chest pain, it's only at 10 with
35:54
the non-injured visits. And of those people who are admitted, only 25 will have a diagnosis of acute converse syndrome. But then in Pakistan, you have these huge cardiac institutes with
36:04
emergencies and all the resources going in and infrastructure, HR, and then the rest of the hospitals are totally separate. So this brings in the territorial games. This is where the
36:16
multinationals also, I would say, that played a little bit of a dirty role in our part of the world. Because what they did was that when I am in US and I want to do neuro-intervention, I will have
36:28
to do neurology, neuro-critical care, basket neurology, boards, fellowship, and then two ways of new intervention. So it's a eight years standard training program, whether you're coming from
36:38
neurosurgery, neurology, or radiology, but what started happening here was that these multinationals through their distributors will fund for a two-week course or for a month on simulator, send
36:50
them to you somewhere in Europe or lately I'm also hitting places in the US. So just to see how they're doing the stroke, they don't have any hands-on experience and then come back and start open
37:02
the shop in your own cardiac institute And this started to create more problems because when you have worse outcomes or bad outcomes because people are not properly trained, the public awareness and
37:13
the public conference starts dropping and so does the referrals. So again, another challenge that stems in. So this is something that I now am very vocal about these things when I go to the
37:25
conference and I have these battles with the cardiology that instead of having a combined multidisciplinary institute, This is a problem that we are now facing. in our part of the world. So unlike
37:38
the developed world, the ratio is 80, 20, 80 is skimmick and hemorrhagic. We actually are 70 and 30, and some of the literature now it's coming actually that is skimmick stroke is 65 and the
37:48
hemorrhagic is now exceeding to 35. And the reason is we have more diabetes, we have more hypertension, we have now more drugs problem because of the brand war and subsequently the years that have
38:01
been following. So, and the lifestyle has changed A lot of westernized diet and those type of things fast food. So, and then hepatitis and those type of things. So, all of these things
38:14
contribute directly or indirectly to this stroke prevalence. So, like I told you before, how do you educate the people when you're going and creating these centers which emergency system to use A?
38:26
Now, we have for the first time like a dedicated public, Similar to 911, we have 1122 in Pakistan, which has now expanded to
38:36
all of the country, but then because the population, the resources, there is a lot of philanthropic support coming into the healthcare as well. But even though that is helpful, but
38:50
when you're trying to standardize something, it doesn't become like a
38:56
very helpful, because again, how do you train that philanthropic EMS system, which is, you know, there are so many in a city. How do you bring them into one standardize umbrella? So that
39:07
becomes a very challenging task as well, how to educate the people which ambulance to use and where to come. So this is how I've been adopting right now, like, you know, take the guidelines from
39:20
abroad, but deal with the problems locally So we came up with our first version in 2025 where we published all the standards for stroke care ESMC. The second was published in September 2025 and
39:34
being co-operated, both skimmick and hemorrhagic strokes. Ivy thrombolysis, neuro-divastler, primary stroke centers, comprehensive, everything is contained in this book. And as part of our
39:46
manifest goal that you know, we're going to standardize wherever we go to different cities, we're going to try to standardize even the order sets are the same. You know, if you are hemorrhagic
39:55
stroke, you can just take the order sets from this booklet, put in your hospital logo and then you follow the same so that the care is the same even if you have a hemorrhagic stroke in Lahore and
40:06
you have a stroke, let's say in Cial Court,
40:10
and they're using the same booklet. It's going to be the same standardize protocol and also helps in the training of those physicians in those hospitals. So the first, we are still in the first
40:24
blocks of stroke awareness We were not getting any money from the government, so I reached out to another giant pharmaceutical company in Pakistan. And I said, you know, why don't you fund me for
40:37
the video? Because we don't have anything in our language. We, you know, just copy what's being posted in American Stroke Association. We need something in the local language. So we brainstormed
40:51
and then since we use the acronym FAST and for the Pakistan, the most favorite game is cricket and we have fast ballers. So we came across like a scheme, you know, where we will link the cricket
41:05
match, a fast baller playing bowling and then link it with the stroke symptoms. And I'm going to quickly show you the video as well.
43:16
So this video is a very powerful message, how to recognize a stroke, what to do, which emergency system to use, and the timely treatment intervention and then the outcomes. And as of this month,
43:33
this was released in August on August 18 of this month It took us a little around six to eight months to
43:42
make this video, get all the paperwork done and everything so now from this month onwards we have now signed MOUs with the leading airline, local airline It's a cineplex theaters. So they're going
43:56
to be displaying all of these videos, a few banks. So it is going to expand our network of awareness. And we allowed them at the last four at the end of the video you can put your own logos and
44:10
whatever, and we have no legal binding on it. So this is going to be how the latest part is going to come. Now quickly moving it to the dispatcher, what we did was in the same booklet, we signed
44:21
an MOU with our 112 main ambulance and we have been going there. I started going to the main headquarters which are based in Lahore. A very nice training ground for the
44:31
EMS, the EMTs and all of those people involved. So we created these spectral booklets for them and the order sets so that they can also be aware and how to recognize the stroke, standardize the
44:47
recognition and then use a triad system when they're transporting the patients and which hospitals they're going to bring the patients. They're not going to go to every hospital which doesn't have a
44:57
stroke center. And as part of the pre-notification system which we still don't have, so we also started training them and they were already doing this thing that we said that you are going to draw
45:11
the blood samples because we have shortage of nurses. in majority of the public sectors in the ER because the ERs are so heavily busy. So, if you draw the samples when you're bringing the patient
45:23
in and you pre-notify us, it will save a lot of our important time, probably around 10 to 15 minutes.
45:32
So, and this is again, learning from the pre-order, you know, when you're going to the traveling, you can pre-order on the airports, your food is ready. And this pre-notification system in the
45:42
hospitals, it's pretty much the same thing. And that's what we have been now doing, and using the pre-notification awareness things with the 11 to 2. And this started taking place as of March of
45:53
this year. So, how to integrate now 11 to 2 with our stroke centers? We don't have the pages anymore. We don't have the high tech, you know, the software that the Western countries have linking
46:07
the ambulances of service with the hospitals. So we decided to have WhatsApp dedicated, WhatsApp stroke numbers for all of these primary stroke centers. And we entered those numbers into the cold
46:18
centers of the one round two to in every major city where the stroke centers were being created. So they called the WhatsApp number directly from their own cell phones and said, Tell us that we have
46:30
a patient coming inand give us a brief history. And this is a work in the progress. A lot of work needs to go, but obviously this whole program started was conceptualized in October 2023,
46:43
but actually it became functional in April or May of 2024. So a little over a year now.
46:50
So the pre-notification and this is how we do it. We have these WhatsApp numbers and we don't share the number with the public. Only the institutional physicians know about it and the local
47:01
emergency 1122 call center knows about that number And that's our way of communication to win. in a low middle country, any political crisis brews, and they shut down the telecom sector so that
47:16
they can't spread the information, they don't want the public to know anything. All this, what we are doing at the health on our end gets really affected. So this is another major obstacle in our
47:29
part of the world because any political crisis or anything, the instant knee-jerk reaction is that shut down the towers and then the communication barriers starts coming in. So quickly moving to the
47:41
hospital site. So
47:44
Dr. Osman, I didn't care about to have these fancy ER stroke-based things. So based on wherever the city was, based on the local resources, we gave them a genetic that you can build from anywhere
47:58
from one bed to four beds of stroke beds in your ER That was also part of our technique. to improve the awareness in the emergency systems, emergency rooms so that you have a dedicated stroke base
48:12
listed over there so every time patients are coming in, they are seeing that there is something called stroke there also and then have a stroke unit. Anyone who gets a thrombolysis goes to a stroke
48:22
unit for the follow up. So quick word again on the cost center. What does a cost center do? The cost center procures the thrombolytics for all the centers, distributes, maintains a quality So
48:35
Borhanger and the World Stroke Organization were kind enough, and they gave us this rescue online platform. It's a very nice data collection. We don't have any national data or a promotional one in
48:52
Pakistan. So this is our way of trying to build up a stroke data, at least from the public sector. So rescue is a pre-made software cloud-based Every patient who comes to these primary stroke
49:06
centers is getting the IV thrombolysis, is listed. Their outcomes are listed up to three months, and we can do research, whatever, and we can monitor the quality and all these things. And I told
49:18
you about working with other associates. So as of today, we have 14 centers. The one listed in the two listed in the yellow, actually there's only now the two listed in the yellow, actually are
49:32
what put on hold a month ago because their human resource got a little bit disturbed. But the rest of the 14 centers are working. There is four, these are 14 primary stroke centers and one
49:44
comprehensive, which is a Punjab and neuroscience, which are simple, so heads. So this is an important slide. You can see that the population of the country is 250, 51 million, Punjab is around
49:56
130 million So as of these 14 centers are only covering 305 million. and we still have more centers to build. But at least it's a good start. First time anyone in the province is doing it, at
50:13
least in Punjab, and it's not being done in any of the province in the country at the moment.
50:19
So, just to give you an example, this is a data that was shared by BI and Martindong. In 2023, you can see in Punjab, in the red in public sector, only 18 patients got TPA out of the total 205
50:34
and out of those 205 majority were in the private sector. They were getting the TPA's, but in the public sector, only 18 patients got TPA in 2023 when we did not have this program. When we started
50:45
the program, this is what happened. So, we delivered around 570
50:53
miles of TPA. Out of those 511 were used, we treated 600 patients and
51:01
instantly within a year, This result came out and our. we went from 39 percent utilization in three months to almost 90 percent of TPA, which is far higher than reported in any developed country at
51:14
this point even. So this is an effect that just came out within a year. But the another important thing that came out was this thing, that out of the 600 patients that we treated, 463 were those
51:28
patients who were treated outside the Lahore. Previously, all of these patients would be coming to Lahore to seek care for their loved ones. But these 463 saved a lot of money trying to arrange for
51:40
the transport to Pakistan and saved a lot of major morbidity and mortality by just giving them the drug in their area of residence. So this was a very dramatic shift that we started noticing. So the
51:54
health department last year invested 135 million into this program. I did
52:01
thrombolysis and you can see the utilization rate.
52:04
And this year, our target is to expand from 14 to 24 centers. We are going to be adding on top of two pediatric centers based in Lahore, because in those two pediatric centers, at least one to two
52:19
pediatric children are coming with strokes, which are potential candidates for thrombolytic therapies. And if we are able to achieve the 24 centers by the end of this year, which are in calendar
52:32
year ends June 12th, 2026,
52:35
we'll be covering close to half the population of Punjab at that time within two years.
52:42
We are going to be switching to Teneti Place. The US has already switched, I think, somewhere around 2020, 2021. Park Sun is now the second country in the region after UAE this year to be given
52:56
Teneti Place and the company's Boringa is going to graduate a place at TPA And the reason the Pakistan was chosen was because of this program. And that's a fact, because that's what they said, that
53:08
they looked at the performance in the public sector, how we were doing, and they decided to choose Pakistan, which actually on the list was five years down the line, but they decided to bring
53:16
Pakistan after UAE, because of the stroke incidents and the requirement for the thrombolytics. A quick word on the comprehensive stroke center, this is where I signed the MOU with the ourselves
53:29
institute because they had the biplane and geography, they didn't have an operator, it was installed
53:36
in 2023. I'm based in another medical facility which by driving time is close to 20 minutes, one way depending on the traffic. So started the program in 2023 at the Punjab and St-Neuro science,
53:49
which previously was called the Heart General Hospital, which was as you know, our late father had the foundation stone to lay out over there and Dr. Wasmolek was also there And I'm just going to
54:02
be sharing these numbers that.
54:05
In 2024, we did 511 diagnostic and 223 therapeutic. And this institute actually is kind of the mucka for hemorrhagic strokes, aneurysms, ABMs, fistulas, trauma, you name it, and it's there,
54:21
adults and pediatrics. And it's so much volume that you just cannot handle it. But all of these patients have been treated without any charge, everything was funded by the government and a lot of
54:35
credit goes to ASEF also for getting the funds in timely fashion. And for next year, our funds have increased. So this is another part of the PSMC Association with them to build a competent stroke
54:47
center and we didn't end stop over here. So in July 2025, the Punjab Institute of Neuroscience became the first center in the country to have the first accredited stroke near intervention fellowship.
55:03
funded by the government. And we had started doing the fellowship on honoree basis a year, two years ago, since 2023. And it was funded by the same person which Arsep initially mentioned, say
55:15
Barbara Lilly, his organization, I really give him a lot of credit and thanks because they were the ones who initially gave us a seat money to start the fellowship. But after two years of showing
55:25
them, showing the government the outcomes, they decided to approve the fellowship. And we are taking one neurology, one-year neurology resident every six months. And it's a two-year training
55:38
program accredited so that they can work anywhere in the country. It's not going to be just like an experience certificate.
55:46
So the things that we were learning from the Comprehensive Stroke Center was the value of the time and the infrastructure. One of the things that we really lack in this part of the world are the
55:58
engineers, are the architectures who design hospitals. especially in the public sector. And because the infectious control things, how to move the patient between the departments, especially the
56:10
emergency OR, that those are the things that are not taken into account for. And this, the medical architecture field really needs a lot of investment as well. So just to give you an idea, since
56:25
we were short of the trained neurologist, so I wanted to have more people 247 in the emergency room So we took this institute, the Punjab Institute of Neuroscience as our pilot project area. And we,
56:36
just like in US, and I learned so many things from US, I continue to do so. So we developed this program called Snap, Stroke Nurse Advanced Practitioner. We trained them for three months,
56:47
trained them how to recognize a stroke, how to read a basic CT, how to administer IV thrombolytics, everything a neurology senior resident is supposed to know, we trained them and we put them on
56:59
three shifts. 247 in the stroke emergency rooms, in the emergency rooms in the stroke base, so that we have a dedicated face in the stroke base and patients can be recognized very quickly because
57:11
Pakistan still is following the old path of the emergency system. We don't have our own emergency emergency program. So historically anything medicine or medicine allied will go to the medicine
57:22
emergency and then anything surgical will go to the surgical and then they will be filtered into orthopedics and neurosurgery and that actually creates a lot of delays for the patients. So we wanted
57:33
to overcome this thing. So this is now a team of these nurses who have been trained, the two new fellows who have joined us for the fellowship.
57:44
And just to give you an idea, in February 2024 to March 2025 that's almost a year, the same emergency room, same stroke bay, they were only able to
57:59
filter Thank you. large vocal occlusion out of the 20 patients, nine cases. For last one year, we only were able to do thromvectomies in nine cases, but we were doing left and right oilings,
58:10
tendings, like I said, the hemorrhagic stroke volume is far higher than the skimmick in pungemants and neurosciences. But in
58:17
just five months, when we've stationed these nurses, you can see that they were able to identify 27 large vessel occlusions out of those 20 benefited. So this is how the change came about just by
58:29
training these nurses into the basic stroke large vessel occlusion training pathways. And you can see the difference, even for the IV thrombolytics in nine months, they were able to filter in 56
58:44
patients for IV. And in five months, we were able to do 50. So again, the major change, but just training these nurses instead of relying on the neurology HR
58:57
So, this year. We decided to just last month we are going to be launching our diploma. It's going to be funded by the practice foundation, the same SEGA Baba relief that Asa mentioned. His
59:10
foundation has been kind enough that they are giving us the initial funding for two years. We are training, we are designed to diploma for one year. We're gonna be training 30 nurses now, which
59:23
are going to be a hybrid type of nurses working in the stroke base as neuro-angiography nurses after 2pm and managing the patient in the
59:35
ICO. So these are going to be the nurses which are going to be working in three different domains and be trained and certified.
59:45
So a quick word on this year, initially we started with the target of 60 minutes, door to needle time. Now this year our whole whole campaign is now focused on to reduce the door to nearly time.
59:59
30 minutes, especially since now we have connective plays and you just have to give a bowl of struct for connective plays. And we now introduce the hemorrhagic stroke also because the easiest thing
1:00:08
to do for hemorrhagic stroke is to give them timely anti-hypertensive, which is ignored so easily everywhere. And this is going to be another focus for us now as part of the PSMC initiative that
1:00:21
we're going to be going and doing trainings with the neurosurgeons as well, and the emergency rooms and train them that you see a hemorrhagic stroke, how to manage and give them these very cheap IV
1:00:29
antihabitensives and target the blood pressures to reduce the morbidity. Coming to the
1:00:36
patient timeline thing, one of the things that we learned in the conference of stroke center was just to move that patient that we recognize for the large vessel occlusion, the emergency room is
1:00:47
located around 150 meters away from our cath lab. But in order to come to the cath lab, you have to wheel the patient on a stretcher, which in an open airway. The family usually pushes the
1:00:59
patients, brings them to the basement. You have to wait for the lift, which is heavily crowded, busy 247, and then come to the basement. So we were losing 45 to 60 minutes, even after we had
1:01:10
identified the patient, there was a large vessel occlusion. How do you overcome this thing? You cannot build a new building within 24 hours. So again, came up with an idea to convert, come up
1:01:25
with these E-stroke ambulance for the local hospital thing. So we, again, reached out to two or three donors, imported this golf cart from China. It took us four months to import it. A local
1:01:40
company that actually
1:01:43
makes the ambulances for the governments across the country was kind enough and they refurbished this golf cart into an ambulance So, we take the patient from the emergency room,
1:01:58
The fellow who is in training fellow, a doctor actually is a driver, our nurse and the driver when they get a call that we have a large resolution, they open the cath lab, they take the card out
1:02:08
while the other staff is setting the cath lab up. They go and bring the patient in safety and in with respect from the
1:02:16
ER, and then under the monitoring condition they bring the patient to the cath lab straight We have reduced the 45 to 60 minutes to 15 to 20 minutes, a simple initiative required money and just a
1:02:28
little bit of how to do and bring the other stakeholders on the same page. I'm going to quickly go into the last part. This is right now the service hospital order is probably right now
1:02:45
the only I'm stationed as a professor of neurology. So we converted our major ward into a rehab center. Again, the got some seed money from the government and from the philanthropy to build an
1:02:57
inpatient rehab. So this, you can see the stroke patient numbers from 8 am. to 2 pm. which are the offshore working hours. Each patient gets 15 minutes of physical therapy twice from 8 to 2 pm.
1:03:13
Even on Sundays, which is a local holiday here also. So seven days a week, they get two sessions when they are admitted to our unit. And this is another thing which now I'm advocating to the
1:03:23
government that we need to replicate to all the primary stroke centers so that they have their own in-patient rehab because as part of the initiative for the global stroke recovery, the world stroke
1:03:34
organization this year and last year added to their agenda that the stroke rehabilitation and the community reintegration has to be part and parcel of the stroke programs. And this is the rescue,
1:03:47
which I was talking to you about, the cloud-based software that each center now has, they quickly enter the data and each one of us can see the progress Every center has a number. They don't, we
1:03:59
don't see only I know which center has which number, but the rest of the centers don't know that which everyone is given a definite number.
1:04:12
So this is a summary that I wanted to share you that we, the health department and philanthropy, a total 820 million rupees invested into Punjab stroke program, both the primary and the
1:04:27
comprehensive. We were able to create primary stroke centers, comprehensive stroke centers. In first year, treated our expectation was 300, but we ended up treating 600 patients more than 1, 000
1:04:38
gut neurodivascular treatments, created a predator fellowship training for neuro intervention and the awareness campaign, the video, the first one that came out and I told you that now it's going
1:04:48
to be
1:04:51
posted in major businesses and we're just signing MOUs with them it's far more cheaper than trying to get the money and trying to do the media and pay them the media houses, the money, which I think
1:05:04
if you can just reach the public through these banks and the cinema theaters and those type of things, it is far more effective that way also.
1:05:14
So I'm just going to, this is, I don't know if you're talking to us when you like movies, but this one just came out this year, had very strong some dialogues and one of the things that I really
1:05:27
like was it's not absolutely about the money. And the same passion here that, you know, it's absolutely not about the money, it's just pure stroke, wanted to do what you, Dr. Ross, and
1:05:39
everyone has been instilling in my mind that when you go back, you need to serve the community and, you know, get the care up and going for the people. And I think that's the motivation that I
1:05:52
inherited from my parents, my father. and from all of you, and that's what is a driving force. Thank you so much. And this is now the first slide that I showed you that now we have the manager or
1:06:04
the champion as a BSMC dealing with the funding part, the social mobilization and the technical support that we have now created on the same grid that I showed you in the beginning. Thank you so
1:06:16
much. That's an outstanding job that you've all done there And what I'm gonna do, I have a whole bunch of questions here for you, but what I'd like to do is say, well, we'll come back to that
1:06:30
afterward if you have time. But I think what you're presenting us consume is
1:06:38
an extremely well conceived and developed plan that can be utilized across the world in many countries. And I'll talk to you about it at the end, but I'm sure people want to hear your presentation.
1:06:55
probably come there, they want to have some way to become educated to do this. Obviously, you're saving lives, and so we'll get into that and so forth. So what I'd like to do is to go to Gauss,
1:07:08
do you have anything you want to say at this point before we go on to, I said? No, I think we should go ahead. Okay. It's possible. You did such a tremendous job in pointing out all the
1:07:22
intricacies and challenges that he has come through. So. I think I totally agree. So is it? Disclaimer, the views and opinions expressed in this program are those are the author interviewees and
1:07:38
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