El Hierro is a tiny volcanic island that emerged out of the ocean about 1,2 million years ago. Scarcely more than a dot in the ocean off the coast of Africa, it forms the very southwest part of the Spanish archipelago known as the Canary Islands. To visitors, it is a small paradise of wild volcanic beauty where it is spring all year round and to which scuba-divers, paragliders and hikers are drawn by the jagged coastline, crystal-clear water and cloud-milking forests.
Its population of around 12,000 enjoys this loveliness for as long as possible, many of them living to a great old age. But on average 22 times a year, paradise is interrupted when someone on the island suffers a stroke. With no stroke treatment available at the island’s only hospital and the nearest comprehensive centre a helicopter ride away on distant Tenerife, for decades it has been inevitable that for around 22 El Hierro families every single year, paradise was lost.
The archipelago consists of two provinces, each with its own capital and each served by a single helicopter that offers a lifeline to the critically ill. But stroke, with its unforgiving timeline, makes no exceptions for distances between islands and by the time patients from El Hierro reached Santa Cruz, their lives were already irrevocably altered.
After Alicia Arjona joined Angels as a consultant in the early days of the Covid pandemic, she often measured the distance between her home province of Málaga and El Hierro’s capital, Valverde. Documents left by her predecessor showed that the island’s Hospital Nuestra Señora de los Reyes had all the resources they needed to give life a chance – it had a 24-hour emergency department, CT imaging available round the clock, and the team had received training from a neurologist from Santa Cruz. And yet 22 lives continued to be lost or ruined every year while waiting for a helicopter that couldn’t possibly arrive in time.
Life moved slowly on paradise island, the EMS regional co-ordinator confirmed to Alicia after she had been trying to reach the hospital for some time. It had taken a decade for heart attack to be treated on El Hierro, he told her. Treat stroke? She should either forget it or be prepared to wait 10 years.
But in September 2021 he was proved wrong. Alicia received an invitation from the gerente at Hospital Nuestra Señora de los Reyes and soon found herself with trembling hands and knees addressing a room filled with directors and managers who were shocked to learn that their hospital was the only one in the Canary Islands that was not treating acute stroke.
Alicia had already decided that what would keep this intervention from failing like the last one was an action plan that set firm dates for key actions such as a multi-disciplinary meeting in December, a protocol review in January, and three days of face-to-face training in March, during which she delivered what would turn out to be a master stroke.
Instead of opening the event with experts telling a passive audience what they ought to do, she gave the podium to the hospital. Emotions ran high as doctors shared the sombre histories of El Hierro’s stroke victims. Over the next couple of days, as experts stepped up to the podium to provide training to both doctors and nurses, emotion turned into motivation as the team from Hospital Nuestra Señora de los Reyes resolved to write different endings for these stories and their own.
On the agenda for day three was a stroke pathway simulation which was attended by the mayor and reported in the local press. By the time Alicia returned to Málaga, the hospital had committed to a date on which they would commence treating – the second day in May – and a unique goal: Since they were one of the smallest islands in this paradise, their door-to-needle time should also be among the smallest.
Fast forward to 20 April and the first hint that something extraordinary had occurred on El Hierro ahead of schedule was an email from a neurologist in Santa Cruz congratulating his colleagues at Señora de los Reyes on performing their first thrombolysis. Next, Alicia’s cell phone lit up with WhatsApp messages sent from El Hierro, and then the local press took up the story.
On the website of Diario El Hierro it was reported that the “first patient to have received fibrinolysis at the hospital in El Hierro is a man over 80 years of age, who was initially assessed at home after the arrival of the advanced life support ambulance from the Canary Islands Emergency Service due to symptoms compatible with stroke.
“When starting fibrinolysis, he presented a slight improvement, beginning to mobilise his limbs and respond to external stimuli. He was transferred to the Hospital Universitario Nuestra Señora de Candelaria where it was confirmed that the thrombus had effectively dissolved with fibrinolysis, and therefore did not require a thrombectomy. He is currently stable and admitted to the stroke unit of the referral hospital.”
Alicia and the stroke team from El Hierro couldn’t have hoped for a better beginning. Although the exact door-to-needle time is not known, treatment commenced with 45 minutes of the ambulance arriving at the patient’s home. The case was straightforward and the decision clear; the patient had no contra-indications and while undergoing thrombolysis his condition improved before their very eyes.
The story of El Hierro was a life-changing one – and not only for the 22 patients that will in the coming year, and every year thereafter, receive a second chance at life in their tiny paradise. Back in Málaga there were tears of pride and relief, and a “new” Alicia going about her work with fresh resolve.