Introducing Skye Coote
The Australian Stroke Alliance is home to the country’s first mobile stroke ambulance in Melbourne. It has been covering a wide diameter around the city since November 2017. Skye Coote is a pioneer as Australia’s first mobile stroke unit nurse practitioner and has been onboard since the tyres first hit the bitumen. As our data custodian, Skye works with our partner, Ambulance Victoria, as well as various Melbourne hospitals, constantly assessing the performance of the ambulance’s response, and the all-important patient outcomes.
Skye, you are a member of an unusual team of health professionals, out on the road with the mobile stroke unit (MSU). How many people are on the roster?
The key to the successful operation of the MSU is the team. We are so fortunate to have a fantastic expert multidisciplinary stroke team on our Melbourne MSU.
On each shift the MSU has a crew of five – two ambulance paramedics (usually one Mobile Intensive Care [MICA] paramedic, and one Advanced Life Support paramedic), a radiographer, neurologist and a stroke nurse.
Each team member has set responsibilities on the MSU, both within the vehicle itself and when we are on scene with a patient. Probably the most unique role we have is that of the radiographer who is the sole operator of the CT scanner and is the radiation safety officer. They not only work tirelessly to ensure staff and public safety at all times, but without the CT scan, we would not be able to treat our patients. The CT scanner and the whole MSU staff expertise sets us apart from a normal ambulance. Each team member has a vital role and we work collaboratively for the good of the patient.
Could you share with us a typical call-out for a suspected stroke?
As soon as we get a page with a job, we head straight to the MSU and take our seats. The nurse immediately starts documenting the details of the case, before we have even left the hospital driveway. As we drive, we sometimes get additional details, either from the caller who is talking to the 000 operator, or from another ambulance crew (the MSU is always sent alongside another ambulance). These details are discussed with our whole crew so we can make a plan of care before we even arrive. If the other ambulance crew assesses the patient and determines they are not having a stroke, they will cancel us, leaving us free to respond to the next case.
When we arrive on scene, our standard (pre-COVID) workflow is: a paramedic, the neurologist and the nurse jump out and head in to see the patient. The paramedics are responsible for on-scene safety management, so they always lead the way and ensure the area is safe and free of hazards. The other paramedic and the radiographer prep the vehicle and the scanner (to save time, we always work on the assumption that a scan will be needed).
When we reach the patient, we get a handover from the other crew who have typically arrived a few minutes before us. At the point that it becomes clear the patient has stroke symptoms, the neurologist will break off and start their assessment, while the nurse and the paramedic finish receiving handover. The nurse then goes about collecting important information that is needed for the team to make a treatment decision, including the patient’s past medical history, current medication list, and determining the patient’s usual level of health (ie: how much could they usually do for themselves before this event). At the same time, the MSU paramedic assists the other paramedics with monitoring the patient, performing the vital signs (obs), inserting the IV, and most importantly, moving the patient onto the stretcher and out to the waiting ambulances. All these tasks are happening simultaneously in order to provide our patient with the best possible care. We have to avoid unnecessary delays in diagnosis and treatment, and so we all must work as one. We don’t have the luxury of time to allow each person to do their tasks one after the other.
The nurse, doctor and paramedics come together and discuss their findings. If a scan is indicated, the patient is loaded into the back of the MSU. The radiographer preforms the scans which the neurologist reviews. Once the doctor has read the scans, they update the team and if treatment is indicated, the nurse draws these up and administers them.
Throughout all of this, the team is talking to the patient and their family, many of whom don’t know about the MSU and are unsure why so many ambulances have turned up! This is an incredibly frightening time for them, so we make sure they are kept informed at all times.
We know the MSU is saving vital minutes by taking the emergency room to the patient. Give us some stats, demonstrating the impact of urgent care and how you’re impacting the concept of ‘time is brain’ when it comes to stroke.
We’ve had some incredible achievements in the three years that we’ve been operational. We have been dispatched more than 4200 times, that’s an average of 6-7 calls per day, and have seen more than 1600 patients. About 40 per cent of our patients receive a CT scan with us, which provides rapid diagnosis and allows us to determine which is the best hospital for their care, as not all stroke centres can provide specialist stroke services like clot retrieval or neurosurgery.
We have provided 164 patients with clot busting thrombolysis treatment for ischaemic strokes (which is 52% of ischaemic stroke patients presenting within the 4.5 hour treatment window – double the national average). We’re providing this about 40 mins faster than the average metropolitan Melbourne hospital and up to an hour faster when compared with the Australian average treatment time. In stroke “time is brain”, meaning that for each minute stroke treatment is delayed, brain cells are dying at a rate of approximately 1.9 million neurons per minute, therefore that 40 mins we save compared to other Melbourne hospitals, saves approx. 76 million brain cells, or the equivalent of about 2.5 years of normal brain ageing.
We have referred more than 130 with ischaemic strokes caused by very large blood clots in the brain to specialist Melbourne hospitals capable of performing clot retrieval. Due to the MSU diagnosing these patients in the community, they receive this life-changing treatment on average 50 mins faster than if they had been attended by a normal ambulance. The MSU has bypassed the patient’s closest stroke hospitals for these specialist centres on 92 occasions, saving an extra 1-2 hours per patient by negating the need for an inter-hospital transfer.
Tell us the most exciting or satisfying moment you’ve had while out on the road.
I have two patients that have stayed with me. One is a lady who had her stroke on the 2nd floor of her house. Until recently, thrombolysis treatment could only be given within 4.5 hours from the start of the stroke (now it can be given up to nine hours, but only for selected patients), and at the time we arrived, it had already been four hours since her stroke had started. This meant we only had 30 mins to move her out of the house, into the MSU, get the scan done, draw up and administer treatment. She had had a catastrophic stroke and was completely paralysed, so she wasn’t able to help us move her. We walked in, took one look at her and said to all the paramedics, that the priority was getting this lady down the stairs and out of the house. You can imagine how challenging stairs can be with a paralysed patient! Well, the team pulled together incredibly, all recognising the importance of time in this case, and we were able to treat her with only a couple of minutes to spare. Without all the ambulance and MSU crews working together, supported by the patient’s family, we would not have been able to achieve this, and the patient’s outcome would have been dire.
The second patient was also having a severe stroke. He was located outside our normal area, but the first responding crew called for us as they recognised his severe symptoms. We arrived just as they were wheeling him out of the house on the stretcher, so we literally pulled up, opened the doors, dropped our stablising jacks and loaded the patient straight in. We treated this patient 30 mins after we pulled into his street and took him for clot retrieval. We could see the signs of his improvement on our way to hospital, and within hours he was awake, talking, and was no longer paralysed!
A new mobile stroke unit is destined to hit the streets of Sydney. Are you involved at all?
It is incredibly exciting to see MSUs expanding into other states and cities. Alongside the rest of the Melbourne MSU team, I have spoken to key members of the Sydney team, sharing our successes, advice and key learnings. As they get closer, I would see my role as mentoring and supporting the Sydney MSU nurses.
When we started working on the Melbourne MSU, one of the hardest aspects was having to learn everything as we went. Australia has a very different health care environment to the USA and Europe where most of the other MSUs are located, and while international colleagues offered advice and guidance, we really had to learn on the job. I would love to see Sydney benefit from our insights, both positive and negative. I think having the team come down to Melbourne and work on our MSU to gain experience would be invaluable for them. I would also love to be able to head up there and work with them in their first few days, offering on-board help and support as they learn the ropes of pre-hospital stroke care.
What’s it like being a stroke nursing specialist and do you have any advice for nurses considering this as a career option?
This is such a rewarding career and I feel so very privileged to be able to care for patients when they are at their most vulnerable. From a medical perspective, stroke is a fascinating area to work in right now. We have amazing leaders in stroke, across all professions (medical, nursing, paramedicine and allied health) undertaking first-class research and clinical trials. We are all determined to better understand this disease and improve our care for our patients, offering them the best chance of recovery. It was not long ago, that there was simply no care available. Nurses coming into stroke have the ability to be on the cutting-edge of ground-breaking new treatments which could revolutionise the way we care for our patients.
What advice would you give your younger self?
Oh dear, so much. Don’t sweat the small stuff, trust your gut, and in the words of Elsa “Let it go”. I would also say, get on with your academic qualifications earlier, you really did have the time!
Lastly, enjoy every moment, it’s corny, but take pleasure in the little things, enjoy the sunshine on your face, the smell of the flowers in spring and rain in the winter. Tell your loved ones how much you love them every single day, because they are the most precious things in your life; what I wouldn’t give to hug my mum one more time and tell her I love her.