WHEN the email arrived at 13h54 on Wednesday 3 May, Dr De Vries Basson was about to leave his office to attend a meeting. He didn’t have to open it because the entire gist was contained in the subject line: Congratulations to Karl Bremer hospital – WSO ANGELS GOLD AWARD Q1.
Dr Basson is the Head of Internal Medicine at Karl Bremer, a district hospital about 23 km northeast of Cape Town. It’s a state-funded hospital whose diverse patient population ranges from people who have dropped out of private healthcare after losing their insurance, to the poorest of the poor. Its bed occupancy rate exceeds 120 percent on most days of the week, and until the hospital went off-grid at the start of 2023, South Africa’s unstable electricity infrastructure added to its challenges as surgeries were canceled and the CT scanner out of bounds during several hours of planned power outages per day.
Stroke in South Africa claims on average 110 lives per day and leaves 90 survivors disabled. In the Western Cape where Dr Basson’s hospital is located, 35 to 40 percent of these patients are younger than 40. What lies behind this staggering number is a perfect storm of obesity, inactivity, uncontrolled hypertension and diabetes, substance abuse, especially cocaine and amphetamines, and HIV.
The community has limited knowledge of stroke symptoms, often adopting a wait-and-see approach with disastrous consequences: the average onset-to-door time is 1,044 minutes, or more than 17 hours.
Once inside the door, however, they are welcomed into the safe hands of a cohesive stroke team including physiotherapist, occupational therapist, speech therapist and social worker, who will fight for the best possible outcome every step of the way. This team will meet at noon every Tuesday to discuss every patient’s progress and transition of care. Despite their dedication and creativity, a chronic shortage of rehabilitation and stepdown facilities makes it inevitable that some patients, especially those returning to informal settlements, will struggle to access adequate support in their communities. These patients will be back in a matter of weeks, sicker than before.
It’s a tough job but someone’s got to do it, Lou Rawls sang in 1981. Dr Basson has been in his current position since 2005, but when the email arrived on Wednesday 3 May it was the only time he cried.
GROWING up in a small town surrounded by wheat farms, Annelie Bruwer could never have predicted that a love for people and language would lead to her becoming part of an award-winning stroke team at one of the oldest hospitals in the Western Cape.
A graduate of the University of Stellenbosch, she worked in the provincial health department in the drought-stricken Northern Cape province before joining the Child Speech and Hearing Project that introduced speech therapy to primary healthcare in 2014.
When she was seconded to the Karl Bremer Hospital in 2018, there had not been a speech therapist at this hospital in two decades. Within a year of her becoming part of the team, aspiration in stroke patients had dropped by 158 percent.
A common complication during stroke recovery, aspiration occurs when food or fluid is breathed into the lungs as a result of swallowing difficulties (dysphagia) caused by stroke.
Dysphagia affects up to 78 percent of all patients with stroke. Aspiration pneumonia occurs in 10 percent of stroke patients with dysphagia and is associated with a significant number of deaths and higher rates of dependency.
Keeping the patient safe while they’re in hospital is her first goal, Annelie says. Speech and language interventions will follow, but the first step is a dysphagia assessment in the first 24 hours that may be followed by interventions to prevent aspiration, such as positioning, modified diet, and exercises to improve swallowing efficiency. The patient’s feed delivery needs will ultimately shape their discharge plan, and the arc of recovery curves towards discharge almost from the moment of admission.
He’d had no idea how central the role of speech therapists was for stroke patient outcomes, says Dr Basson who has gone from sceptic to convert to advocate. Training for doctors doesn’t expose them to the scope of speech-language pathology or how impactful it can be on among other things time in hospital, which preventing aspiration has reduced by over 50 percent.
Working with stroke patients can lift your heart or break it, Annelie says. It’s creative and intense, and it can be inspiring to see the progress made by patients and their families. But it can be equally hard to let go when a patient returns to a life of unimaginable challenges that they and their families have yet to grasp.
The grace with which some families venture into this unfamiliar world is something she witnessed early in her career when a devastating stroke left a devoted school principal suffering from expressive aphasia – the ability to understand speech but not use it. Unable to return to the school to which she had dedicated her life, she continued to find other ways to contribute to her small-town community.
SOME patients you can’t get out of your mind. The cocaine and amphetamine-addicted 31-year-old whose family got him to the hospital in time and who walked out of the hospital seven days later to become a drug-free stroke activist. Or the single mother with an NIHSS score of 18 who, having had to be transported to a private hospital for a CT scan, went home to her two young children one week after treatment with thrombolysis.
“When you see how one patient recovers after treatment, you want the next patient to receive it too,” Dr Basson says.
Karl Bremer has only had a CT scanner since 2015 and patients arriving outside business hours still have to undergo scans at a tertiary hospital 5 kms away – a resource issue for which telemedicine may eventually offer a solution.
A student of stroke in his capacity as principal investigator at a private clinical trial centre that was located at the hospital until the end of 2022, Dr Dr Basson initiated stroke training with the support of Angels in 2017. The first patient was treated with thrombolysis in 2018.
Here, like elsewhere, the pandemic lead to a drop in patients presenting with stroke. Interviewed by local media during the third and most debilitating wave of Covid-19 infections in South Africa, Dr Basson revealed what sustained him through seemingly endless hours in intensive care: “There’s a quote by [American football coach] Vince Lombardi that keeps me strong: ‘I firmly believe that any man’s finest hour, the greatest fulfillment of all that he holds dear, is that moment when he has worked his heart out in a good cause and lies exhausted on the field of battle – victorious.’”
Once the pandemic subsided, a surge in strokes testified to the neglect of chronic disease management during lockdown. Blood glucose levels were up, hypertension was poorly controlled. These and other modifiable or preventable risk factors for stroke are what drives a one-man campaign to educate the community about stroke. A regular guest on local radio stations, Dr Basson never declines an opportunity to talk to communities about stroke prevention, stroke symptoms and the importance of getting the patient to the hospital as quickly as possible.
He is also driven by concern about the burden of stroke and disability on an ailing economy, and, especially in the Western Cape, the disproportionate impact on young adults slated to become future leaders.
He is optimistic that the FAST Heroes campaign (a stroke awareness project that channels stroke education via primary school children) will not only mobilise young people to teach their parents and grandparents about chronic lifestyle diseases but encourage them to adopt healthier lifestyles themselves.
The goal: a generation less burdened by stroke. The dividend: fewer families and lives disrupted by a largely preventable catastrophe.
KARL BREMER is among a small but growing number of hospitals in South Africa that are capturing data in the international stroke care quality improvement registry RES-Q and seeing the rewards. To date, eight South African hospitals have qualified for WSO Angels Awards. Karl Bremer is only the second public hospital (after Steve Biko Academic Hospital in Gauteng province) to achieve this distinction, and the only hospital in the Western Cape.
Dr Basson is a firm believer in data-driven change. He says, “RES-Q captures all the important indicators; the quarterly reports show in which direction you’re moving and give you realistic targets. It gives you all the gold you can use to improve stroke care, motivate for better resources, and advocate for patients. And it’s user-friendly so it doesn’t take a PhD to capture data, report, and use it to benefit your patients.”
What it does take is time, one of the most common reasons cited by hospitals that don’t take part in quality monitoring. It’s his team’s enthusiasm and dedication that motivate him to put his spare hours into data capture, Dr Basson says.
The positive energy flows in both directions, says Annelie Bruwer who credits Dr Basson with the unity, drive and shared focus that characterise her working environment. “He is one of the humblest specialists many of us have encountered, a thoughtful, gentle leader who allows everyone to be heard.”
His servant leadership influences hospital culture at Karl Bremer and checks the incipient arrogance of young doctors fresh out of medical school for whom the coexistence of humility and award-winning performance may be instructive. It may even convert them to Vincent Lombardi’s belief that man’s finest hour arrives when he has worked his heart out in a good cause.
UPDATE: In Q3 of 2023 Dr Basson's team had even more reason to celebrate when it was announced that Karl Bremer had won a Diamond award.