Ep 19: Closing the Gap: Rural Stroke Care with Dr. Gauhar Chaudhary

[00:00:11] Hello and welcome to the Nurse Rosas Insights Podcast. I'm your host, Rosa Hart, and today I get to interview one of my mentors, Dr. Gauhar Chaudhary. Thank you so much for being with me today. Thank you for having me. I appreciate that. Yeah, gotta see virtually because you're far away in Montana now. We are, yeah, far away. At least, well, 23 hours away driving. I've done it. Oh, what? Yeah, yeah. Oh dear. Yeah, let's not drive that far. Gosh.

[00:00:40] Yeah. So I invited you here today because on the Nurse Rosas Insights Podcast, I like to ask healthcare stakeholders for their perspective on the state of healthcare, where it's at today. And then at the end, we all go the billion dollar question on how you think you'd like to see it fixed.

[00:01:02] But let's get into some of your background. And how did you get into working in healthcare and really inform your story? Yeah, so it started actually as a child when I had severe asthma as a child and I was hospitalized almost on a regular basis, at least once or twice a year. And I remember, even as a toddler, I still remember those memories.

[00:01:31] And I guess I just seeing growing up, being in the hospital, admitted to the hospital for asthma attacks, basically severe asthma attacks, just seeing all the doctors take care of you, you know, the residents. And I was just fascinated. And I'm like, I want to do that. That kind of just, that's what started this whole pathway. Although I didn't choose pediatric. I ended up going into neurology. Your edict mom? Yeah. Or pulmonologist, that's right.

[00:02:01] Respiratory at all. Right, right. And so during medical school, when I was doing my rotations in radiology, I loved looking at the brain images, especially MRIs or CTs. It was just fascinating and just came easy to me. And so I thought about radiology at one point, but I don't think it was for me because I do like interactions with patients.

[00:02:25] Not saying that radiologists don't, but kind of a more continuous interaction with patient population. And so neurology was the best fit. And so... What had it into neurology? Did you get randomly assigned to it and get surprised kind of like you did with radiology or...? No, no. I mean, I enjoyed my neurology rotation. I enjoyed my radiology rotation, but actually I did radiology before I did neurology. And so I think when I did neurology, I was like, okay, this is a better fit. Because you're a lot of system.

[00:02:55] Right, right, right. And yeah, I ended up getting accepted to the University of Kentucky for a neurology residency. Did one year of internship medicine. Three years of residency of neurology, which was pretty hard. Especially second year was pretty, pretty tough. But we had excellent teachers, excellent senior residents that kind of helped us through.

[00:03:22] And then I did one year of a vascular or stroke fellowship at the University of Kentucky. So, and then from there, I came to Louisville, Kentucky. And that's where we met when I was at Norton Brownsboro Hospital. Well, actually, I think we met in the middle of the night when I was downtown because we were covering stroke call for... Right. ...because I was a new baby nurse and I would call the stroke call in the middle of the night. So...

[00:03:50] Well, and also like as a new nurse, like unfortunately we don't get a fellowship or something to lay on our own knowledge. Absolutely. Like we have a lot of learning on the job. And so I really, that's why I call you one of my mentors because you really taught how to do a neuro assessment, even like talking me through it over the phone, which is more than just not yelling at somebody. Oh, no, no. Yeah, no. What do you look for? What does this mean?

[00:04:18] And taking that teaching approach in basically all the interactions. And so I felt like the, that's kind of what really kept me in neurology was the attitude of the only dumb question is the one you don't ask because you need to know the answer to the best care of the patient. And I really love that whole approach.

[00:04:41] And that's one thing that really impressed me, like as an ICU nurse seeing all the different specialties, the neurologists had to hear the patient's story usually in order to make diagnosis. Like, yes, you need a scan, but you need a physical assessment and you need to hear their story for the context of their symptoms. And so I really, really appreciate that. Oh, yeah, no. I had excellent mentors too. So I kind of pass it on.

[00:05:10] Yeah, like Dr. Jessica Lee. That's right. Dr. Jessica Lee was an excellent mentor. At one point, I remember I was thinking about neuro-oncology at one point and she convinced me to go to stroke and I'm glad she did because it was the right decision for me. You know, neuro-oncology is great too, but I think it was a better fit doing stroke for me. I do like the, I guess, the dopamine or adrenaline rush a little bit you get for stroke.

[00:05:40] You know, trying to figure out if you can reverse these stroke symptoms. You know, is there a large vessel occlusion that we can take out of and do amazing things? And so that was a better fit for me because it was amazing to see all these amazing results. Yeah. Yeah. Dramatic improvements, like almost sometimes rapidly, actually, in many cases. Definitely. I mean, I love to say, like, stroke is the thing in neurology that is not a chronic degenerative disease. It's something that can be reversed and fixed. Right. Absolutely.

[00:06:09] There's so much hope in it and there's so much we can do to prevent another one. And so all this education that people in stroke do is from the knowledge that it can make a very huge difference. And we see it. Right. It's a balance between lifestyle and also medications, right? It's not just one. It's both really too. Well, and everybody's different, right? So they might do different things.

[00:06:34] And so I know you said you liked those puzzle pieces together, but as you mentioned, you started working in rural, serving the populations of rural Kentucky, and now you're serving the rural populations of Montana. That's right. So what would you say would be some of the similarities there and what would be some of the differences? I guess similarities are, you know, there may be some small access hospitals. There's probably more differences than similarities.

[00:07:03] I guess you could say that maybe the patient population in the rural areas are very similar, like farmers, ranchers, maybe. It's very similar in these smaller communities. I think that probably one is similarities. And I think the key differences, I would say, is I think in Kentucky they probably have a little better access to hospitals because there's more probably denser network of outside hospitals besides Norton.

[00:07:31] And, of course, the University of Kentucky, which are the hubs. Sure, though, it's much different. You know, when I first got here, there was no comprehensive stroke center. You were just a primary care, you know, primary stroke center. That was it. So if a rural hospital gave TPA at that time, you know, they would send them over to us. But if they had a large vessel, there's nothing we couldn't do anything about it. They would have to ship them straight to – they would have to go to Denver. And so – But they do that within the time frame?

[00:08:01] For a large – so they would get, you know, depending – they would probably get TPA if they were accounted for that at the local critical access hospital. But if they also had evidence of a large vessel blockage, then they would have to fly straight to Denver. And I think Denver from Billings is roughly like an hour, hour and a half flight. On a helicopter or fixed wing? No, no, no, on a fixed wing. So that's another key difference is distance. Kentucky is a lot smaller than Montana.

[00:08:29] So we have a lot of fixed wing flights from all over Montana and Wyoming. We have to include Wyoming, too, because we cover almost a half of Wyoming. And so, yes. So – and weather is a big difference here, too. So, you know, I mean, there are some weather issues in Kentucky. But probably not as frequent as they are here. Like here we get bad snowstorms.

[00:08:50] And so, you know, you could have a large vessel occlusion and a post-TPA patient sitting in an access hospital until, you know, the weather clears up and they can fly him in, right? It has to be safely done. And there's not enough flight crews, unfortunately. So sometimes they've got to wait. But, yeah, I mean, they do their best. And the flight crews here have been – and the grand crews, too, both have been amazing.

[00:09:16] They do an amazing job keeping that penumbra open or at least as large as possible until they get here. And we still see dramatic things even if there's a delay. There's some really great improvements. So it's always worth calling 911, right? Yes, right. Although, you know, over here, though, I think you talked to a lot of patients. You know, they live maybe 10 miles away from the local access hospital.

[00:09:43] And so they will just take their family members having the stroke-ex symptoms. They'll drive them to the hospital because it's faster than waiting for an EMS crew to arrive to them. Yeah. So, yeah. Can't really fault them for that in some cases. Right. Now, did I hear you have a lot of, like, volunteer EMS crews in Montana? I think we do. Probably in the local communities. Probably, yes. That's a very good question. I don't have the numbers for that here.

[00:10:11] In Billings, of course, is all – we have – I think it's called EMS, American Medical Service. It's – it's called EMS, so I apologize. Maybe you have the – But that's like the – that's what's available in town. Correct. And then we also have a fire department. They have their own medical crews, too. So, yeah. Like, here in Kentucky, each individual county is responsible for, like, funding and staffing their own EMS. Right. And so it's not, like, synchronized across the state. Right. Right.

[00:10:40] But I'm not aware of any that are volunteer-operated and run. Right. And I know the firefighters are, but I don't think the ambulance crews are in Kentucky. But we do have areas of Kentucky that it might take two hours for an ambulance to get – Right. Due to lack of humans to put in trucks, let alone lack of trucks and those little roads on the hills. I remember when I was there, Evansville, Indiana was one place.

[00:11:09] I think they would have some coverage sometimes, but they would have a neurosurgeon that could do their stuff. But when they were not available, I think it was like a two-hour rotor flight, helicopter flight. Yeah. So – Yeah. So – Well, and I wanted to ask you as well, like, coming from growing up in Canada and benefiting from the healthcare there a lot, like you did as a patient. Yeah. Yeah. Yeah. Yeah.

[00:11:37] Being here and serving in the United States healthcare workforce, what do you see as far as, like, any benefits or as – or one over the other? I mean, there's pros and cons for both. I mean, of course, I just would – you know, for me, it was just, you know, just following seeing a primary care doctor in Canada growing up, though, that was – you know, I mean, it was pretty quick. I could see them pretty quickly.

[00:12:07] I think – and if you were to look at that from, like, more like a stroke standpoint or just neurology standpoint, I think that – Well, you would have had a stroke standpoint as a child. Right. But just talking to patients – because we do get Canadians over here, because we're not too far from Canada, actually, right? Oh, that's true. And I can give you some – yeah. Yeah. I'll give you two examples, actually, because we get a lot of tours here, right, to Yellowstone, which is only about two hours away if you're two and a half hours away. But I had a patient here who – they were from France.

[00:12:36] It was a couple from France who he fell, had a bleed, and had a seizure, or the seizure, you know, came first, then had a bleed. And sorry about the dog. I apologize for that. And they lived in Lyon, France, and apparently has one of the premier – from what they told me, one of the best neurological hospitals in the country. It's not Europe.

[00:13:02] But their husband was having issues, I think, you know, with some other prior issues, like maybe syncope or, you know, some waxing and waning symptoms. And when he came to the hospital, we did, you know, we did all the standard stuff, CT, CTAs, MRI brain, even an EG on them, if I remember correctly. And they were so impressed that all that was done, like, within less than 24 hours.

[00:13:28] And, you know, over there, you know, it's basically social medicine. You know, it's medicine that's more administered by the state, I guess. So I guess costs are looked at very carefully. But, yeah, I think, you know, we can get stuff a lot done faster, but I think it's probably more expensive here than other places, you know. Yeah, right. Don't be alive to pay the bill later, right? Right, right, right.

[00:13:57] But then again, you know, a lot of people do go bankrupt because of medical bills here too, right? So there are pros and cons. Well, and that, you know, we'll talk about is healthcare a human right as an idea, right? Right. Which is usually used to support the idea of having the government covering all the medicine and not having it privately funded and on a more competition model.

[00:14:23] But at the same time, I could see how that could create its own set of issues out in like a rural area. Like, how are you able to provide the same level of service qualitatively, which is what we measure all our quality measures where we're trying to get everything done as quickly as possible, but also as accurately as possible.

[00:14:45] And how are you supposed to give that to somebody in a rural area like you would in a downtown urban area where you've got all that infrastructure support? So how do you see that conversation? No, I agree with you. I mean, healthcare is a human right. But like, yeah, how do you do that on a practical level, right? Legisitably, yeah.

[00:15:06] I think some things we could do is I think telemedicine can maybe bounce that a little bit, although it's not as great as being in person, but it does provide some service at least. You can see a specialist that is not over there in that small little community, such as neurology or cardiology or various other services. Having better partnerships with them, I think.

[00:15:32] Education, going out there, educating the local physicians over there, making sure they have, you know, they're aware of all the current stroke guidelines, provide them all the data, all the information I think is important too. That's been very helpful. And we do do that. We do travel. We've traveled through many of the hospitals, local hospitals in Wyoming and have done stroke talks and have helped them with their stroke protocols. Because they ask very simple questions like, do you do CTAs in all strokes?

[00:15:58] You know, because sometimes their radiologists don't want to do because they worry about kidney function. But we always reiterate, at least as neurologists, is that, you know, neurons over nephrons. Oh, no. They probably don't think that, do they? Probably not, right. I'm sure a neurologist may be not happy with that. But in an emergency situation, we need to know. And, you know, I think it's important. And because, yes, even if it's a TIA, I've seen a situation where there's a TIA where they're back normal. But I like to do the CTAs.

[00:16:27] As long as kidney function is decent and we can tolerate the contrast, we'll do it. Because sometimes we find situations where they have a partial occlusion, you know, maybe in the middle of the artery that we'll have to watch closely and maybe even do some intervention. If we didn't do the CTA, we wouldn't be aware. And, of course, we can also do MRAs or, you know, MRI angiograms. You know, if it's not emergent and we can wait, we'll do that as well. We'll worry about the kidney function. Yeah.

[00:16:57] So that education of other professionals out there who are competing priorities is really key. Mm-hmm. Providing that in the rural access hospitals. Correct. So education, right, reaching out to them. Sometimes we'll do even like kind of like what we're doing right now, just do a Zoom call or a Teams call with their ER physicians. They ask questions, try to answer them. And sometimes, you know, although we have to work on staff limitations, but like providing feedback for transfers.

[00:17:27] Yeah, definitely. Yeah. So I think you kind of already addressed this as far as like, would you say there's more like chronic diseases in the rural populations you see out there? Like, you know, living in the stroke belt, we have really high rates of movies, things like that. But do you see that as much in Montana or are the populations more active overall? What do you think? I see. So I see a couple of things.

[00:17:57] I see people not seeing doctors. So, you know, they're not aware if they have any chronic issues. We see that a lot. Well, I do see that still. They're like, I didn't have diabetes and high blood pressure till I had that stroke and went in the hospital. It's like you did. Right, right. Or we see, I mean, there are people, I mean, the pretty healthy populations, especially the ranchers and, I mean, they're pretty healthy and strong people.

[00:18:24] But I think sometimes they'll see where, you know, they're having maybe some mild stroke symptoms, but they'll just kind of like delay it because they think they'll get better. You know, and so unless, you know, they have family members. But I've seen also occasionally where, no, no, you're going to the hospital, you know, I'm bringing my straight to the hospital. You know, they come in reluctantly. But, yeah, I mean, we see, I mean, it's not a high obesity, you know, for my population over here, as we do see more in the south.

[00:18:53] I mean, do you see a lot of strokes related to meth use here? Which I remember that wasn't very common in Kentucky for, at least when I was there last, over five years ago. I think heroin was a big thing over there. But we do see a lot of some strokes from meth use, right? Because that can cause strokes as well. Is that more recently in the development there? No, I think it was here since I came here. So it's been a, it seems like it's like a Northwest issue.

[00:19:22] Well, yeah, we see that a lot here too. Right. But interestingly, the one, do patients. It's been planned, right? Yeah. Stop being meth. Right. Do you have any good rehabilitation programs for people for stroke prevention? I mean, yeah. I mean, there are rehab facilities here, of course, to help out with that. But, you know, getting back to patients who don't see doctors, you know, stop taking their medications.

[00:19:50] I usually will tell them that, you know, you know, if you don't see a doctor on a regular basis to kind of prevent this from happening in first place, controlling blood pressure, cholesterol and all that stuff, that you're going to see a whole bunch of doctors all at once when you have that stroke. And make up for loss to them. Right. I think you told me it was hard to find a primary care doctor even for yourself when you got there, right? Yeah. Well, I hear a billing is not as bad. There's more providers here.

[00:20:17] But in the rural areas, you know, sometimes they don't have a physician. They have, you know, MPAs and MPPs who do phenomenal jobs, actually, as well. They do really great jobs up there. But sometimes they leave. And so, you know, you get used to one, whoever the clinician is, and then they leave or whatever, you know, after a couple of years. And then, you know, they don't like the new person sometimes. And so they just don't go to the doctor. And so, yeah. Right. I think it's common a lot.

[00:20:46] Because people sign up for those, like, loan repayment programs where you work there a couple of years. They do. And they pay for school loans and things like that. And so after that's over, their time commitment's done, right? Potentially, yeah. That's for your reason, too. Or they just do a two-year stint or whatever their contract says. And sometimes, you know, they move on, unfortunately. But there's also a lot of physicians who've remained in certain regions for a very long time in Wyoming and Montana. And so it becomes like a bedrock for those communities.

[00:21:15] Well, you've already been out there five, almost? Almost six years. Six years, yeah. Six years in June. In some ways, it seems like just yesterday. It does, yeah. So what do you like the most about living and working there? I do. If you're going to convince other doctors to come out there and be air providers, right? There's a lot of outdoor stuff you can do here. I don't hunt, but there's a lot of hunting over here if you like hunting.

[00:21:45] There's a lot of hiking even here in Billings. Tons of hiking in surrounding areas. We're, like, I'm about one hour away from the mountains. There's a nice little town over there called Red Lodge. We've gone there a few times. I think the community here are phenomenal. They're very kind people. They were very nice, of course, in Kentucky. I think there's a lot of similarities, actually.

[00:22:09] But the people are very, very, yeah, great, kind and very patient, which is great. That is good. Yeah. That is good to have patience as a baseline personality trait. Right. For there. Right. We've got people come here, like, from New York, because we have, like, we use Locans occasionally, and they're from New York, and they come here. And I usually tell them, like, the patients here are really nice, and the families are phenomenal. And, you know, they just take that when I say that. But they're like, no.

[00:22:39] It's like, yes, you're right. They're so kind. And not just that. The staff, too, because most of the people that work here are from Montana, originally. Yeah. I think I saw that the Billings Clinic is, like, the largest employer of Billings. Correct. Correct. We just recently merged with another system called Logan Health, which is northwest. So we've become larger. Does that mean, do you do more with their hospitals as far as their stroke care?

[00:23:09] They have also a stroke team, an excellent stroke team. Dr. Kurt Lindsey is their stroke director over there. Yeah. You might have met him. Last year. Phenomenal team. Great person. I enjoy working with them a lot, and a lot of expertise in the telestroke space, among other things. And so I get to get his input and expertise in that area, too. So enjoy working with their team, yeah. Yeah. They seem like a fun group. We all went to the dinner last year. That was really good. That's right. That's right. Yes. It was fun. Yes.

[00:23:39] So this brings me to the billion-dollar question. Billion-dollar question, yeah. Yeah. So if you were given a grant, $1 billion to meet the needs that you see, how would you see it used strategically to have the most sustainable impact? I think a chunk of it would go into research. I think coming up with new medication, I think they're trying to do this right now.

[00:24:07] But I'd love to see more medications that could be given outside of four and a half hours, maybe even up to 24 hours, which would be nice with similar kind of outcomes. So I'd definitely give money for that. Like expanding the window for T&K? Yeah. For T&K. Sorry. Thrombolytics. Correct. Yes. I think a lot of it, I think a chunk would go into education, making people more aware of like, you know, like we talked about BFAST, among other things, being aware of what stroke symptoms are. Yes.

[00:24:37] So they do go to the hospital immediately and not wait and save more brain tissue, right? And I think, so it'll be, you know, a third, a third, and then the last one third would probably be, especially for here and for maybe rather rural areas in the U.S. is to develop a robust kind of like stroke network, where smaller hospitals do have all the tools, if not neurologists,

[00:25:03] but at least maybe telestroke, stroke, all the stroke education protocols. So they know what to do when they do see a kid's stroke. So those would be the three main areas. Well, that would make a huge difference. Right. And talk about sustainable impact. If you're able to reverse somebody's stroke symptoms, they come in and half their body isn't working, like their arm, they only use their leg and might not be able to speak.

[00:25:32] And you're able to give them something through an IV that gives disabilities back. You're preventing disability for that person. Any strain of financially and physically on and everything on the family, preventing them from being on disability, which is their chronic health problems they can develop from the immobility that results from being able to walk, et cetera. Talk about sustainable impact.

[00:26:02] Yeah. Like, it seems simple to you and me, I feel like. And it's just, I feel like a lot of people just have no concept of how impactful it can be. So thank you for realizing that. And I also like to say that a lot of what I know, especially with, you know, telestroke, stroke education, and all the other aspects of stroke that were not necessary, you know, not all of it was trained

[00:26:31] maybe to residency, learn kind of as you go. A lot of it thanks to Lynn Hundley, I think, who was a phenomenal, you know, unfortunately, she's not with us anymore, but she was a phenomenal force, a great person. I learned a lot from her. Even when I left, you know, Norton, I was still in communication with her because I was actually at one point going to bring her here to help us build a comprehensive stroke center. But unfortunately, she passed away. Wait, Hundley? Oh, you mean to bring her up? No, no, as a consultant. We were going to pair as a consultant. Yes, yeah. Not as. No.

[00:26:59] And we made that very clear to her. So, but yeah, she was a phenomenal person and it's a great loss to the stroke community, I think, and too large. So she contributed a lot. And it was an honor to know her and learn from her. Definitely. Yeah, she hired me into my current role as a stroke nurse navigator, which she hired me into that role. You recommended me. Thank you for that. Oh, yeah. No, I was, you, you, you, you would have got it even without my, what?

[00:27:30] She said it was because of your letter. So. Oh, that's really, I was really kind of her. I'm just going to go. I do whatever. But, but yeah, she really changed our lives and the trajectory of a lot of people's lives through improving stroke systems of care, helping to start stroke care network, which is the part still going on between Norton and UK. Mm-hmm. Mm-hmm. So yeah, it really takes a village and. Right. Right.

[00:28:00] It does. It's team effort. So hopefully it makes headway and getting the word out about what we can do in the community to be fast and stop stroke, right? Thank you for all you do. You know, I learn a lot from you too. And it's always good to hear your aspects of stroke care too. So I appreciate everything you do. Aw. Well, thanks. Thank you. I appreciate you coming on today.

[00:28:25] And for our listeners, if there are anything you've learned today, I would really appreciate it if you leave that in the comments. Let me know if you know of someone else who has a billion dollar idea that needs to see the light of day so that maybe it'll get closer to actually happening and make sure you follow and subscribe on if you're watching on YouTube or if you're listening on an audio platform or through the health podcast network. And I will see you in the next episode.