Providing society with the right brain treatment

An ongoing conversation with Jacques Moret

This year is the 20th anniversary of the LINNC Paris Course, the distinctive “Live” case Course that has set the pace for the evolution in the practice of Interventional Neuroradiology.
LINNC online spoke with the founder of LINNC, Professor Jacques Moret, on his feelings during this special anniversary year – where we are, what will happen now – and how the profession of Interventional Neuroradiology can take the lead in public efforts to offer the best care for all patients…

Part 2

FUTURE PERSPECTIVES IN PROVIDING SOCIETY WITH THE RIGHT BRAIN TREATMENT
  • Can other specialties play a role?
  • How can we provide the best care to a maximum of patients?

 

Jacques Moret at LINNC Paris

With the clinical success of mechanical thrombectomies, there is a growing interest on the part of other specialists, for instance interventional cardiologists or neurologists, in performing these interventions. What do you feel about this?

How can interventional neuroradiology, as a discipline, drive the discussion – and evolution - of these various techniques both clinically and publically?

This is a tough question concerning a tough problem and my answer will be tough as well…nevertheless… 

There is a need on the part of the population. The population needs to have access to these kind of treatments…  When you live in a large city with university hospital centers and all kinds of medical services it is not a problem…  But, what happens when you live in a city with 50,000 or 100,000 inhabitants – small city, where you cannot provide a good active neuroradiology department with good training…and, thus, good results for the population?  However, when there is a true emergency – and each time you lose 10 minutes, you lose millions of neurons – you definitely have to act fast

Going fast, depending on the geography, is difficult. There is no question that to cover the population we will probably need to increase the number of centers that offer stroke treatment and of course, all treatments need experience! The problem that arises is how to manage the skill of the operator? Especially if they do not have enough patients…

“ENDOVASCULAR TREATMENTS REQUIRES EXPERIENCE AND VOLUME…”

Take a very active center like our own where our department, our operators, perform 8 to 10 thrombectomies per week, 24 hours a day. In a smaller environment, a smaller recruitment zone, how can you keep up your skill-set if you only have one thrombectomy a week? And, what do you do with the rest of your time? You cannot do aneurysm treatment, you cannot do other brain treatments because the technical scale for these is far more difficult and you must have the additional training and experience that these other treatments require.

Looking at small cities, we see a need for mechanical thrombectomy covering the large geographical zones surrounding these cities – a zone where the total population is not large – this is a major concern and for the time being I personally don’t have a clear solution! 

So, from my point of view as an interventional neuroradiologist, understanding the level of skill and the number of cases needed to preserve this skill, I would opt for a better reinforcement of the already existing centers, in association with a faster, more immediate local care in association with a much better organization of the quick long-range transportation system in order to cover a circle of 150 km from a referring center.

Seen this way, we are looking at a political issue and, as usual, politics is often more complicated than medicine!

*************************************

“THERE IS A NEURORADIOLOGY POINT OF VIEW THAT WE HAVE TO MAINTAIN….”

Let’s look at it this way… if you lose 60 minutes in transportation, but in the end, you have access to a well-organized and perfectly trained department where the patient receives the very best treatment at the highest level of quality and expertise…that is good. For small distances, the faster you go the better, but we have a window of up to 5 hours, so if you lost 45 minutes in this 5 hour window, it is not such a big problem if you have access to a good center.

Develop the centers – develop the workflow…this is not that difficult to accomplish. Take France, for example, and look at a city like Orleans, which has a population of around 100,000 inhabitants and is located 100 km from Paris.
If you are a politician, the real question is whether you should invest in a stroke treatment center in Orleans with all the equipment and all the doctors that it requires – 24 hours a day, 7 days a week – when, 100 km away, you have 10 or 11 leading centers fully equipped with all the doctors, the nurses, the technicians and equipment and, importantly, a clinical environment that includes neurosurgeons and neurologists.

This is the question…

Now there is a highway between Orleans and Paris and an ambulance can do this in 50 minutes…so the next question, the next concern from the point of view of public health, is why is this a medical ambulance?
Should you transport the patient with a medical ambulance, or should you transport the patient just as a patient? Many of these patients will not need to be intubated, they will not need a real doctor’s care…but for the time being it is done with a doctor present…

This seems to require a national organization and understanding of what is at stake…you are saying that you, as interventional neuroradiologists, should be leading the public discussion on how to organize treatment…

We have the experience, we have the centers, but, importantly, in collaboration with our colleagues from neurology, we also drive the research and the future development in our field.

We are not simply workers who apply a technology, but are the movers behind the tremendous evolution in our practice. A lot of research must take place and, as I said before, it should take place in an environment that is dedicated to it…so it is not just doing something, but having “something” participate in the evolution of the way we practice.

What we do now, will be different than what we will be doing in 2 years – How can you train a small center to do what we do today and guarantee it will be ready for tomorrow? This is difficult. 

And so, interventional neuroradiologists should lead the development and the organization and I think one of the ways of doing this – depending on the geography – is to have a regional agreement linking interventional neuroradiologists from a “mother” center on duty…and using these centers to cover the needs of the population.
But this can only come after recognition and improvement of the transportation which is very important…

Sometimes it takes more time for a medical ambulance to arrive on the scene than it takes it afterwards to get to the hospital. This is not fair…

Create a “mother” center – which comes after improvement of transportation – helicopters are a way to go fast, but they depend on the weather conditions and, more importantly, they are in great demand for more urgent cases…

Re-organize transportation…and educate the population as well…
This is not difficult because there are only 3 or 4 clinical signs that will be easy to recognize for everybody. Simple…

Then you need to have a network that is easy to access and an alarm designed to go through that network. If you have an application for smartphones dedicated to strokes, so that everyone can download this App you have a tool…
You are worried, you open the App. It notes your location using GPS. You click one or two of the clinical signs and an alarm alerts – not only the transportation – but also the center that is supposed to receive the patient…all at the same time.

So, instead of trying to put a very specialized organization with very specialized doctors at everyone’s door, it is far better to reorganize transportation, to educate the population with a series of simple signs and then, especially for stroke, to have a smartphone application that the population can easily use and – with a click – the system works… 

Perhaps 95% of the population could be covered this way….

Video consultations are not necessary, what is necessary is to have access to well-trained centers with all the possible doctors and equipment…and there you will have neurologists and interventional neuroradiologists and neurosurgeons who can properly decide whether you need fibrinolysis or thrombectomy or both…

 

>>> READ PART 1 ON INNOVATIONS AND CHALLENGES IN INTERVENTIONAL NEURORADIOLOGY TODAY

Please log in to react and view comments