Can you imagine the fate of a stroke patient if the nearest stroke hospital was only accessible by water transportation and the journey by express boat took around two-and-a-half hours?
Until not so long ago this was not just an imagined scenario but a harsh reality for the residents of Kapit in Malaysia.
Kapit is the largest division in Malaysia making up almost one-third of the total land area of Sarawak, the largest state in Malaysia. It is a mountainous region and almost 80 percent of the territory is covered by dense primary forests.
Its population is primarily composed of the indigenous Iban ethnic group. Younger adults often migrate to cities in search of better job opportunities, leaving behind an older population that continues to engage in traditional economic activities such as agriculture, fishing, and timber work. Many of the locals still live in traditional longhouses deep in the forest, and have limited access to formal education.
The majestic Rajang River, the longest in Malaysia, flows through Kapit, shaping its landscape and way of life. Before the road was built, express boats were a lifeline; they were the only way to travel to nearby towns. These sleek, narrow vessels, humorously dubbed “flying coffins” due to their design and seating arrangement, remain an iconic sight on the river.
In late 2020, Kapit was finally connected by road to the city of Sibu where the referral hospital for central Sarawak is located. This opened up new possibilities for travel. Although some areas, like Belaga and Punan Bah, still rely heavily on river transport, most residents are no longer tied to the express boat schedule and can travel between Sibu and Kapit using various modes of transport such as vans, buses, and cars.
But while the two towns are just 160 km apart, the journey can be quite the adventure due to the hilly, single-lane road. Heavy vehicles often obstruct the path, causing delays and turning the trip from Kapit Hospital to Sibu Hospital into a three-hour expedition.
Healthcare remains a challenge as Kapit Hospital is the only hospital in the division. For residents living in the very remote parts of the division, reaching medical care can mean a gruelling six-hour journey.
Official records put stroke incidence in Kapit at about 30 cases per year but the actual number is likely higher due to low awareness and a lack of knowledge about stroke symptoms. Many residents are more inclined to seek help from traditional healers within their community rather than make the long trek to hospital. But the situation changed dramatically in April 2024 with the inception of a stroke service at Kapit Hospital.
The journey began at the start of 2024 when a dedicated physician, Dr Chai Siew Yap began setting up a multidisciplinary stroke team and stroke protocol for his hospital. His project enjoyed the support of the hospital director, Dr Francis Lee Ngie Ping, and he received guidance from a visiting neurologist from Sibu Hospital, Dr Benjamin Ng Han Sim.
Dr Chai, who is originally from Pusing in Perak, Malaysia, chose a career in medicine under the influence of his sister, who is now a paediatrician. But it was his personal battle during his adolescent years with Ewing’s sarcoma, a rare and aggressive form of cancer, that destined him to become a committed and compassionate doctor.
While working as a junior doctor far away from his hometown, he received the news that his mother had been diagnosed with vascular dementia, a condition caused by stroke. Watching his mother’s memory slowly deteriorate until she could no longer recognize her own son, left an indelible mark on his heart.
Just as Dr Chai was settling into his role as an internal medicine specialist at Kapit Hospital, tragedy struck again when his father suffered a debilitating stroke, leaving him paralyzed and unable to care for himself. These profound experiences only strengthened Dr Chai's determination to make a difference and fueled his resolve to establish a stroke thrombolysis service at the hospital. When Kapit Hospital finally received a CT scanner in February 2024, nothing more stood in his way.
The key connection between Kapit Hospital and Angels Initiative was made through Dr Benjamin of Sibu Hospital where I was consulting at the time. Although I had never heard of Kapit, I was more than ready to support the hospital with the essential resources and tools to transform stroke care in this remote town.
During my first virtual call with the hospital stroke team, I learned that they already had a stroke pathway in place, which was a promising start. I suggested conducting a stroke simulation to provide a controlled environment for the team to practice and perfect their response to stroke emergencies. They were enthusiastic about the idea and we agreed on a date for the simulation.
Meanwhile, to kickstart community awareness in Kapit, I sent stroke awareness buntings and brochures to the hospital via courier.
Kapit Hospital reached a medical milestone within the first week of launching their stroke service. The first patient treated with thrombolysis by the newly minted stroke team was a 101-year-old gentleman who happened to be the grandfather of one of the nurses. Despite having lived for over a century, he’d been active and independent before the stroke. He arrived at the hospital 2 hours and 40 minutes after experiencing weakness. His NIHSS score upon admission was 11, improving to 9 at discharge, with a corresponding MRS score of 4. He is currently undergoing outpatient stroke rehabilitation.
When the date of the stroke simulation arrived, I took a two-hour flight to Sibu, followed by an early-morning trip to Kapit the next day. I hired a taxi for the two-and-a-half-hour drive, prepared with motion sickness medications to handle the windy and hilly roads. Although the driver was a local and familiar with the road, the many twists and turns within the dense forest demanded his full attention.
Upon arrival in Kapit, I was warmly greeted by a hospital team eager to start their stroke simulation. In the simulation scenario, the “patient” was transported via ambulance. The hospital was prenotified and the stroke team was ready when the patient arrived. Five minutes were sacrificed to convey the patient to the CT scan in a different block, and once the decision had been made to treat, the patient was transferred to the ICU (in a different block, on a different level) for treatment to commence. During the discussion that followed, we talked about ways to overcome these obstacles – including such simple remedies as sending someone ahead to call and hold the elevator to eliminate waiting time.
The return journey, another two-and-a-half hours on the same windy roads, provided ample time for reflection. Despite the physical toll of the trip, I knew I was part of the mission of bringing specialized care to this underserved region nestled deep inside Sarawak.
Since my visit Kapit Hospital have already reduced their door-to-needle time from 60 to 50 minutes. They have prioritized rigorous and ongoing staff training to ensure each team member possesses the expertise and confidence to independently identify stroke patients, initiate stroke protocols, conduct NIHSS assessments, interpret CT scans, and administer the thrombolytic drug. They are also committed to expanding their community outreach to enhance awareness and encourage proactive health-seeking behaviors.
The journey of transforming stroke care in Kapit has just begun, but it already stands as a beacon of hope and a model of excellence for other regions to emulate. The strides made in such a short period are a powerful reminder that with dedication and the right resources, we can change the fate of stroke patients for the better, one community at a time.
