The first time Dr Miguel Vences treated a stroke patient with thrombolysis was in the second month of the second year of his residency at Lima’s Edgardo Rebagliati Martins Hospital.
His patient had arrived four hours after symptom onset, and an NIHSS score of 25 indicated a severe stroke. The patient’s eligibility for thrombolysis was determined within 30 minutes. At 4,5 hours they would be testing the outer limit of the standard of care for most ischemic stroke patients, and there was something else – the patient was 93 years old.
For landing in this quandary Dr Vences only had himself to blame.
Very soon after commencing on his neurology residency at Rebagliati Hospital, he’d started to “knock on doors” looking for support for the treatment for acute stroke. A door had opened, and now the 25-year-old was learning the meaning of the phrase, “be careful what you wish for”.
He’d made the decision to study medicine because of challenges in the Peruvian healthcare system. He’d made the decision to become a neurologist because there were changes to be made in stroke care and no-one else was making them. But as he weighed the decision whether to treat his elderly patient, he was “really scared”, he tells us from Madrid on Tuesday 4 Juli 2023.
It’s early evening in Spain and he has just completed his first day as a fellow of neurointerventionism at Madrid’s rather famous Jiménez Díaz Foundation Hospital. Why embark on this new specialization barely a year after becoming a certified neurologist?
The answer tells you a lot about the world according to Dr Miguel Vences: Peru has only five certified interventional neuroradiologists to serve its 33 million population. When Dr Vences returns to Lima two years from now, there will be six.
We need not wait to see what others do
“Be the change you want to see in the world,” is a phrase often misattributed to Mahatma Ghandi. In fact he said that if we could change ourselves the world would also change. Diction aside, it adds up to the same thing – the imperative to stand in the gap between what is and what ought to be, summed up in words that Ghandi did say: “We need not wait to see what others do.”
Dr Vences’s drive for change found another gear in April 2022 when he attended a stroke meeting in Colombia along with delegates from other Latin American countries. He was still a resident, two months away from earning his spurs. The meeting stirred up some big emotions, he says. Hearing what was being accomplished in countries not that dissimilar to his own made him angry, at first, and then determined.
He also met and was captivated by Prof Sheila Martins, architect of stroke care transformation in Brazil, who in another six months would become president of the World Stroke Organization. He returned to Lima intent on replicating the Brazilian example in Peru.
His first goal was to obtain WSO certification for Rebagliati Hospital, a complex and sometimes arduous process that would occupy him for the next several months. He recalls “crazy weeks” of training, retraining and reviewing processes and pathways in order to meet stringent standards across the entire chain of care. But however attractive the distinction bestowed by WSO certification, this was not about having something to hang on the wall, Dr Vences says.
The implementation of evidence-based strategies at Rebagliati Hospital produced the intended results. Decision-making improved thanks to greater clarity about the criteria for inclusion; mortality went down, treatment rates went up.
“It wasn’t about recognition, but so all patients could have another chance,” Dr Vences says. “I knew certification would procure a better journey for the patient. All the points for which compliance was required were going to improve that journey.”
Another hard decision
Miguel already knew he would be going to Madrid when in December 2022 he joined San Borja Clinic, a private hospital in Lima that wanted to start treating stroke. Another intense period of training ensued, aided by Angels support and resources and the enthusiasm of the hospital’s head of critical care (Dr. José Portugal). Late in May when a stroke patient was admitted, they were ready.
As with Dr Vences’ first case at Rebagliati, the first patient at San Borja presented a quandary, but for contrasting reasons. This patient was a young female teacher, 35 years old, with aphasia and NIHSS score of 3 indicating a mild stroke, but in this patient's case it was a disabling condition. While not an absolute contraindication, an NIHSS score of less than 5 is often used as a relative exclusion criteria for thrombolysis.
“It was a hard decision,” Dr Vences admits. “You start doubting yourself.” In the end, the probability that without treatment the patient would have trouble speaking, made up his mind. And as with his 93-year-old patient, a difficult decision lead to a successful outcome.
One month later, Miguel Vences arrived in Madrid, a beneficiary of the SILAN-HUFJD Scholarship offered at Jiménez Díaz Foundation to medical specialists who want to continue their training in Interventional Neuroradiology. These neurologists and radiologists and neurosurgeons are there for many reasons; only one is there to become his country’s sixth neurointerventionist.
It’s his first time in Madrid, Dr Vences says. His first time in Spain. It’s his first time in Europe, come to think of it. He misses Peruvian cooking and his family, of course.
A young voice of experience
Over 9,000 km and an ocean away, in a different time zone, Dr Vences continues to drive change in Peru. For Angels consultant Sol Plamenatz he is, even at 30, the “voice of experience” when it comes to advising other hospitals on the route to certification. With a master's degree in clinical epidemiology and internships in stroke and neurosonology, he has published many articles in scientific journals, is a university teacher and an active member of the Peruvian Society of Neurology, the Peruvian Stroke Group and of ALATAC, a group of young physicians that make up the Young Stroke Latin American Task Force.
You don’t just need doctors to bring about change, he explains. “You need societies and alliances to create change at a different level, to engage the ministry of health about national guidelines and tele stroke networks, to motivate doctors to become neurologists and take an interest in stroke.”
There is finally also a personal reason why Miguel Vences decided to stand in the gap and be the change he wanted to see.
Three times stroke has delivered a blow to his family; he knows it isn’t only the patient’s life that is changed by stroke. Growing up with his grandmother and a paternal aunt, he was encouraged to follow his heart and to change what he didn’t like.
Among the things he didn’t like was stroke and the failure to treat it. And he did not wait to see what others did.
