Wednesday, November 12, 2003
The following is an article that was posted in the Straits Times Forum. The background of the case is as follows : Lee Kuan Yew, the Senior Minister for Singapore, and ex Prime Minister, was on holiday in the United Kingdom with his wife when the latter had the misfortune to suffer a stroke.
All accounts make it out to be an ischaemic stroke, and the article that follows appears to corroborate this.
She was brought to the Royal London Hospital, where apparently SM Lee was "horrified" that she would not be seen ahead of three cardiac patients, and had to wait in a queue to be seen.
Subsequently, when she had been assessed by the on-call doctors, Mr Lee Kuan Yew was informed at 2 am that she would be admitted, and a CT scan performed at 8am the same morning. Outraged at the delay, Mr Lee's aides then proceeded to telephone 10 Downing Street, to attempt to "pull strings" and bring forwards her CT scan.
Her CT scan was then performed at 3.30 am, confirming an ischaemic stroke (Mr Lee said in a press release that the clot could be seen on the scan. It is probably more likely that he meant that the area of infarction could be seen on the scan) An official press release from Mr Lee went on to state that 10 Downing Street had assisted in obtaining the prompt CT, making it appear that the hospital in question had been ordered to do so. It later transpired that Downing Street had not, in fact intervened to pull strings, which it felt would have been "utterly inappropriate", and the on call doctors had apparently made special provisions to bring in a radiology consultant and organise the CT scan. SM Lee subsequently released an apology to 10 Downing Street, for essentially jumping to conclusions that his requests had been aceded to by the British government.
After 72 hours of treatment at the Royal London, Singapore then sensationalistically, and against medical advice, airlifted Mrs Lee home in a 747, with 2 ITU nurses, a consultant rheumatologist, and a constulant neurologist as an escort party, and, according to the Straits Times (the only main english-language newspaper in Singapore), a "drip", making this a "mobile ITU". No mention was made about ventilatory support equipment or provisions for artificial airways in this news article.
subsequently, in the aftermath of the event, a Straits Times reporter has taken it upon himself to carry implied accusations of negligence and incompetence on the part of the NHS still further, with the following article.
***********
From the Straits Times Commentary
"Why an early brain scan makes sense
By Andy Ho
WHEN Mrs Lee Kuan Yew suffered a stroke in London recently, she was taken to the Royal London Hospital at 12.30am. A brain scan was done at 3.30am, although it had supposedly been scheduled for 8am.
Four days later, accompanied by doctors and nurses, Mrs Lee flew home safely on a Singapore Airlines flight outfitted for the purpose.
Since then, there has been unhappy muttering on the ground about how high officials and members of their family enjoy special treatment. A doctor gave voice to some of these arguments in a posting on the Internet, albeit anonymously.
The imprimatur of his precise medical knowledge makes his arguments hard for the lay public to brush off.
But these guidelines need to be changed - not so that SM Lee may be proven correct, retroactively, but simply because research has now determined that the best time to treat a stroke is within the first three hours.
SM Lee probably did not look at the MOH guidelines but, more likely, would have got in touch with his daughter, Dr Lee Wei Ling, a noted neurologist, who would have apprised him of the golden three hour rule.[/b]
Since the early 1990s, American doctors have been advised to ward patients as quickly as possible if a stroke is suspected.
There are two varieties of strokes. Haemorrhagic strokes occur when a blood vessel within the brain bursts, pouring into the substance of the brain or spaces around brain cells.
Locally, however, 70 per cent of strokes are of the ischaemic variety. These are caused by clots that block blood flow to the brain, thus depriving it of oxygen.
For the ischemic stroke, a very important treatment option is thrombolysis - injecting an enzyme to dissolve the clot.
Here's the reason for the Golden Three Hour Rule: US studies show that damage in the zone surrounding the central area of a stroke is potentially reversible. If thrombolysis is started within three hours, the afflicted area of the brain can be limited.
A brain scan needs to be done within that time window to see if it is an ischaemic, not haemorrhagic, stroke, and thus amenable to thrombolytic therapy.
The drug used to dissolve clots is called tissue plasminogen activator (tPA). A National Institutes of Neurologic Disorders and Stroke trial in the US reported in 1995 that half of patients so treated achieved essentially full recovery.
[b]In Singapore, early scanning and thrombolysis therapy aren't practised widely enough simply because most stroke patients come in too late, 12 to 48 hours later.
In August last year, London clinicians at three medical schools reported in the British Medical Journal that their study of 400 female and 339 male stroke cases showed that UK hospitals should adopt the Golden Three Hour Rule already embraced in Western Europe and North America.
In the end, it wouldn't be right to say that Mrs Lee was granted special treatment: she simply received what everyone with a stroke - rich or poor, powerful or lowly - deserves.
Diplomatic niceties aside, the point isn't whether 10 Downing Street should or shouldn't intervene on behalf of visiting dignitaries. What should be relevant to the British public is whether their health authorities are taking steps to make sure stroke patients get their scans and tPA within the first three hours.
While they are at it, they should also ask their authorities if patients with acute heart attacks are being given tPA within the first six hours, a maxim in the US since the early 1990s.
They wouldn't be asking too much, either. Surely a teaching hospital in London - a First World city - should be able to simultaneously handle both strokes and heart attacks within their critical time periods. If not, should Britain still call itself 'Great'?"
All accounts make it out to be an ischaemic stroke, and the article that follows appears to corroborate this.
She was brought to the Royal London Hospital, where apparently SM Lee was "horrified" that she would not be seen ahead of three cardiac patients, and had to wait in a queue to be seen.
Subsequently, when she had been assessed by the on-call doctors, Mr Lee Kuan Yew was informed at 2 am that she would be admitted, and a CT scan performed at 8am the same morning. Outraged at the delay, Mr Lee's aides then proceeded to telephone 10 Downing Street, to attempt to "pull strings" and bring forwards her CT scan.
Her CT scan was then performed at 3.30 am, confirming an ischaemic stroke (Mr Lee said in a press release that the clot could be seen on the scan. It is probably more likely that he meant that the area of infarction could be seen on the scan) An official press release from Mr Lee went on to state that 10 Downing Street had assisted in obtaining the prompt CT, making it appear that the hospital in question had been ordered to do so. It later transpired that Downing Street had not, in fact intervened to pull strings, which it felt would have been "utterly inappropriate", and the on call doctors had apparently made special provisions to bring in a radiology consultant and organise the CT scan. SM Lee subsequently released an apology to 10 Downing Street, for essentially jumping to conclusions that his requests had been aceded to by the British government.
After 72 hours of treatment at the Royal London, Singapore then sensationalistically, and against medical advice, airlifted Mrs Lee home in a 747, with 2 ITU nurses, a consultant rheumatologist, and a constulant neurologist as an escort party, and, according to the Straits Times (the only main english-language newspaper in Singapore), a "drip", making this a "mobile ITU". No mention was made about ventilatory support equipment or provisions for artificial airways in this news article.
subsequently, in the aftermath of the event, a Straits Times reporter has taken it upon himself to carry implied accusations of negligence and incompetence on the part of the NHS still further, with the following article.
***********
From the Straits Times Commentary
"Why an early brain scan makes sense
By Andy Ho
WHEN Mrs Lee Kuan Yew suffered a stroke in London recently, she was taken to the Royal London Hospital at 12.30am. A brain scan was done at 3.30am, although it had supposedly been scheduled for 8am.
Four days later, accompanied by doctors and nurses, Mrs Lee flew home safely on a Singapore Airlines flight outfitted for the purpose.
Since then, there has been unhappy muttering on the ground about how high officials and members of their family enjoy special treatment. A doctor gave voice to some of these arguments in a posting on the Internet, albeit anonymously.
The imprimatur of his precise medical knowledge makes his arguments hard for the lay public to brush off.
But these guidelines need to be changed - not so that SM Lee may be proven correct, retroactively, but simply because research has now determined that the best time to treat a stroke is within the first three hours.
SM Lee probably did not look at the MOH guidelines but, more likely, would have got in touch with his daughter, Dr Lee Wei Ling, a noted neurologist, who would have apprised him of the golden three hour rule.[/b]
Since the early 1990s, American doctors have been advised to ward patients as quickly as possible if a stroke is suspected.
There are two varieties of strokes. Haemorrhagic strokes occur when a blood vessel within the brain bursts, pouring into the substance of the brain or spaces around brain cells.
Locally, however, 70 per cent of strokes are of the ischaemic variety. These are caused by clots that block blood flow to the brain, thus depriving it of oxygen.
For the ischemic stroke, a very important treatment option is thrombolysis - injecting an enzyme to dissolve the clot.
Here's the reason for the Golden Three Hour Rule: US studies show that damage in the zone surrounding the central area of a stroke is potentially reversible. If thrombolysis is started within three hours, the afflicted area of the brain can be limited.
A brain scan needs to be done within that time window to see if it is an ischaemic, not haemorrhagic, stroke, and thus amenable to thrombolytic therapy.
The drug used to dissolve clots is called tissue plasminogen activator (tPA). A National Institutes of Neurologic Disorders and Stroke trial in the US reported in 1995 that half of patients so treated achieved essentially full recovery.
[b]In Singapore, early scanning and thrombolysis therapy aren't practised widely enough simply because most stroke patients come in too late, 12 to 48 hours later.
In August last year, London clinicians at three medical schools reported in the British Medical Journal that their study of 400 female and 339 male stroke cases showed that UK hospitals should adopt the Golden Three Hour Rule already embraced in Western Europe and North America.
In the end, it wouldn't be right to say that Mrs Lee was granted special treatment: she simply received what everyone with a stroke - rich or poor, powerful or lowly - deserves.
Diplomatic niceties aside, the point isn't whether 10 Downing Street should or shouldn't intervene on behalf of visiting dignitaries. What should be relevant to the British public is whether their health authorities are taking steps to make sure stroke patients get their scans and tPA within the first three hours.
While they are at it, they should also ask their authorities if patients with acute heart attacks are being given tPA within the first six hours, a maxim in the US since the early 1990s.
They wouldn't be asking too much, either. Surely a teaching hospital in London - a First World city - should be able to simultaneously handle both strokes and heart attacks within their critical time periods. If not, should Britain still call itself 'Great'?"
