“Some men see things as they are and ask why. I dream things that never were and ask why not.”
― George Bernard Shaw
In January 2023, in Sulaymaniyah in the Kurdistan region of Iraq, a dream came true for a man who dreamed of things that never were. The thing that wasn’t – not here nor anywhere in Iraq – was a stroke unit that would provide world-class care to the people living in and around the Sulayman capital.
It had been an exceptionally long dream – the kind that feel as if they span across an entire night, only this one had lasted all of eight years. For eight years Dr Zana Abdulrahman had been asking why not, and each time the answer had been yet another obstacle in the way of progress and treating stroke patients according to global standards.
Stroke patients at this and other Iraqi hospitals were being diagnosed and discharged to such a life as remained to them, after receiving little more than nursing care and aspirin. Dr Zana knew the burden that awaited them and their families, the financial difficulties, the months of rehab, all while global developments in stroke care promised a different outcome. Driven by “personal feeling towards patients” and buoyed a team of likeminded young doctors, he dreamed Iraq’s first stroke unit into existence.
‘It’s for every patient’
To open a new stroke unit you need a person with courage and leadership, says Dr Safin Siwaily, a senior neurology resident at Shar Hospital. He and his fellow residents, Drs Kaiwan Kawa and Mardin Abdulkarim, are grateful for these qualities in their teacher and department head, and for finding themselves in the vanguard of stroke transformation in Iraq.
Eight years of dreaming and planning meant that when Dr Zana’s stroke unit finally opened with funding secured from an NGO, it already had the hallmarks of success. The tailormade protocol included a vigilant stroke nurse in the ER, rapid triage, priority access to CT, a round-the-clock neurology service, a dedicated elevator to minimize delays, and a focus on improvement from day one.
Continuous improvement is marked on the calendar; there’s a monthly meeting, in the last week of every month, to discuss all their cases, and a quarterly meeting to assess their performance of the previous three months, review their protocol and discuss what they could’ve done better.
Of the over 300 patients that have already received thrombolysis in Dr Zana’s stroke unit, there are, inevitably, those that stand out. For Dr Safin it was a widowed mother of three who had arrived with an NIHSS score of 15 and went home free of disability.
“They are all important,” Dr Safin. “But I remember her as being the most important, because it changed the outcome for her family.”
In a different setting this women from a poor family might not have been able to afford the life-saving treatment, but in Dr Zana’s stroke unit, patients are treated for free. “It’s for every patient,” Dr Safin says.
For his colleague, Dr Mardin Abdulkarim, the moment is gravest when the patient on the gurney is someone you know. Having treated both a cousin and the sister of a colleague, he says: “For every patient there’s the possibility of complications but when they are close to you, decision making comes with a different kind of stress.”
Reaching our potential
The key to managing the stress is a very clear, very specific protocol, says Dr Kaiwan Kawa who joined in April this year and strikes a pragmatic note: “You cannot allow the hope of making a difference to make you forget reality. The dream of a stroke unit is really good, but you mustn’t forget to keep your feet on the ground.”
If you have trouble keeping your feet on the ground, the healthcare scenario in Kurdistan might just do it for you. Amid a severe financial crisis in the region, working conditions are less than ideal and salary delays are not uncommon. The drive to deliver world-class care in this context comes from seeing the impact on patients’ lives, and the improved care and outcomes that result from small changes made day by day.
“This is the driving force for most of us,” Dr Mardin says. “As neurologists we derive a high degree of personal satisfaction from seeing the impact of early intervention, and the progress made by someone who would’ve been disabled if there was no stroke unit.”
The product of Dr Zana’s courage and leadership has now brought the stroke team of Shar Hospital recognition beyond their dreams. As winners (together with Al-Diwaniyah Teaching Hospital) of Iraq’s first WSO Angels Awards, they stand shoulder to shoulder with the best stroke-treating hospitals in the world – and the significance of this is greater than stroke.
Dr Kaiwan explains: “This award is proof that the doctors and nurses in Iraq have the capacity to achieve something great; it is a testimony to our energy and potential. The award gives us a standpoint, a hope. It means we can say to young people, look, we are capable. We are capable of making big changes and reaching our potential.”
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“All men dream: but not equally. Those who dream by night in the dusty recesses of their minds wake up in the day to find it was vanity, but the dreamers of the day are dangerous men, for they may act their dreams with open eyes, to make it possible.”
― T.E. Lawrence
At Al-Diwaniyah Teaching Hospital about 500 km south of Sulaymaniyah, we meet a man who dreams by day and makes things possible.
During his training in neurology Dr Mustafa Al-Shahni would often see patients in the disastrous afermath of stroke, aware there was nothing he could do for them.
He says, “I knew there were advanced treatments but they weren’t being implemented here.” He promised himself that once he graduated, he would change all that, and at the end of 2022 he set out to keep his promise.
“I started from zero,” he says. “No one had done this before me.”
It took six months for Dr Mustafa to equip himself with enough knowledge and experience to carry out his plan. He watched a series of educational videos created by the Middle East North Africa Stroke Organization, and visited hospitals in Turkey and Dubai. He had no stroke unit, but an internist at his hospital was prepared to admit Dr Mustafa’s patients to his coronary care unit.
Then, on 12. května 2023, it was reported by the media office of the Diwaniyah Health Department that “a medical team headed by specialist doctor Mustafa Karim Al-Shahni at Al Diwaniya Teaching Hospital managed to save an 80-year-old patient from semi-paralysis”.
Dr Mustafa vividly remembers the conflicting feelings of fear and success that marked this landmark point in his career. Soon afterwards, he set out on a journey to help other doctors in Iraq overcome the same fear.
The Iraqi Stroke Network held its first meeting on World Stroke Day 2023 and that December launched a webinar series to spread knowledge and share experience. The first goal of the network is to “build stamina inside neurologists,” Dr Mustafa says. The second is to help build stroke units; the third, which is written into the blueprint of the organization, is to study stroke In Iraq. Initial research on the epidemiology of stroke in Diwaniyah governorate was presented at the WSC in Abu Dhabi in October. Pursuing work in this field is Dr Mustafa’s dream.
‘I thought perhaps they were wrong’
Dr Mustafa says he chose neurology because he was attrracted by the challenge. “I’d heard while studying that it was a vague topic. They said it was useless; your patients won’t recover. But I thought that perhaps they were wrong.”
Proof of just how wrong they were is in the WSO Angels Award with which Dr Mustafa’s work has been recognized on the international stage. But it is present even more emphatically in the continued health and good fortune of a staff nurse at Al-Diwaniyah Teaching Hospital who had a stroke at the age of 39. He was diagnosed within 20 minutes of symptom onset, and after being treatment with thrombolysis his condition improved partially.
Dr Mustafa recalls, “I got into an ambulance with him and we traveled to a city about an hour away so he could undergo mechanical thrombectomy. He recovered well and I see him frequently here in the hospital.
“I get to see my success every week.”
