Letter from Karachi

Dear friends,

On Tuesday this week my phone lit up with a message from Dr. Rizwana in the JPMC emergency room. Sixty-year-old man, right side not moving, words not coming. NIHSS 18. Last known well that morning. Somewhere outside that room, people who loved him were waiting to learn whether he would ever speak to them again. I looked at the scans on my phone, typed four words, Let’s move to Cath, and within minutes a team of nurses, technologists and doctors was racing a stranger toward the one treatment that might give him back his voice.

Three months ago there was no one to send that message. There was no WhatsApp group for it to land in, no stroke bay in the emergency room, no protocol for the resident to follow, and no cath lab to move to. A man like him would have been admitted to a ward, made comfortable, and sent home months later unable to speak, unable to work, unable to hold his grandchildren the way he used to. That is what stroke has meant in this city for as long as I can remember. I want to use this letter to tell you, as honestly as I can, how we began to change it. It is a long letter. Ninety days turned out to hold a great deal, and many of you have earned the full story.

Most of you know the outline. I took a sabbatical from the University of Toledo and ProMedica, stepped away from my practice and my department, and came home to Karachi to try to build something that did not exist: a comprehensive, round-the-clock stroke and neurointerventional service inside a public hospital, where patients are treated regardless of what they can pay.

The reason is simple, and it has followed me throughout my career. Every one of us who trained in Pakistan carries faces we cannot forget: the young father who could no longer lift his child, the grandmother who went silent mid-sentence and never found her words again, the families who sold what little they had for treatment that came too late or never came at all. In Toledo or Houston or London, those strokes would have been treated within the hour. Here, in a city of more than twenty million, a patient with a large vessel occlusion arriving at a government hospital had almost nowhere to go. The Pakistan Stroke Initiative was founded so that this would stop being true. Every thrombolytic and every thrombectomy we have performed at JPMC so far has been offered free of cost, paid for by the donations so many of you made in the United States. Your generosity is the reason a laborer and a landowner now get the same treatment in the same room.

Before I say anything about the team on the ground, I need to thank the people without whom none of this would have started.

This project would not exist without the Patients’ Aid Foundation. Mr. Mushtaq Chhapra and Dr. Tariq Mahmood believed in the idea when it was still a proposal on paper. PAF has given us the physical space from which this entire operation runs, along with the administrative and logistical backbone that a new program inside a large public hospital cannot do without.

The JPMC administration has been invested in this program from the first day, and none more so than the Executive Director, Dr. Khalid Sher. He has cleared obstacles, opened doors, and still walks through our unit on his rounds. A program like this cannot survive inside a hospital that does not want it. JPMC has wanted it.

We have had real support from the Government of Sindh as well. The Sindh Health Minister approved tenecteplase for our program, which means the clot-dissolving drug at the center of modern stroke care is available to the patients who reach us in time.

And in July I had the privilege of sitting down with the First Lady, Ms. Aseefa Bhutto Zardari, to present our proposal for a comprehensive stroke centre. She was extraordinarily generous with her time, asked thoughtful questions, and her interest gave the project momentum at a moment when it needed it most.

The PSI team group chat was created on July 16 with a two-line message: Salam and welcome on board. At that point the “team” was a handful of us and an idea.

Within four days Dr. Ayeesha Kamal, our Stroke Director and my partner in every sense in this work, was interviewing candidates: neurology faculty, fellows, a physiotherapist, a dietitian, nurses. By the start of August she had sat across the table from twenty-two people. Five nurses, three nurse attendants, a physiotherapist and four cath lab technologists said yes and joined us. Many of them were new to dedicated stroke care. They came anyway, on the strength of a promise that this would be different.

Two people deserve particular mention here, because they were there from the very beginning. Dr. Irfan Amjad Lutfi, our Director of Neurointervention, has been the lynchpin of this program for me. He joined in the first weeks, before there was a working lab, and he has carried an enormous share of the clinical load ever since: performing the first procedure under the PSI name, training our technologists and nurses, and being the steady hand the whole team looks to when a case gets hard. On one exceedingly busy day this month he led the lab through eight cases. Dr. Kamal’s poem calls him “a solid rock when the waters rise,” and I cannot improve on that. Beside him from day one has been Abdul Samad Soomro, our center manager, whom the same poem calls the “manager extraordinaire, magician on call.” It is accurate. Mention a ramp, a board or a chair, and in a matter of hours it is there.

On July 22 we met with the emergency department leadership and they gave us Room 6, which became our Stroke Assessment Bay, or the SAB, as everyone now calls it. It sounds small. It is not. Having a fixed physical place where every suspected stroke goes, staffed around the clock by two house officers and a nurse, is the single most important structural decision in any stroke system. We also secured direct access to the CT scanner without the usual queue, because in stroke the queue is where brain goes to die.

On August 3 the team celebrated Umair, our cath lab technician, receiving his first salary from the stroke center. It was a small gathering, some sweets and a lot of teasing, but I remember it vividly because someone wrote in the group that day, Ghar ka mahol hai. It feels like home. I have read that sentence more times than I can count, usually late at night when I am tired and far from my own home, and every time it reminds me why I am here. In October, two of our own became fathers within days of each other: Arsalan, who runs nights for the SAB, and Mushahid, who quietly walks lost interview candidates to our door without ever being asked. You cannot buy that kind of team with equipment. You build it, one person at a time, and then one day you realize it has become a family.

If there is one thing I want my colleagues in Pakistan to take from this letter, it is this: the procedures are the visible part, but the work is training. I will be returning to Toledo. PSI’s success will be measured by what JPMC can do when I am on the other side of the world, and that depends entirely on the people we have trained.

So we trained, relentlessly. On August 21 Dr. Lutfi began formal teaching sessions for our cath lab technologists and nurses, covering everything from room setup and sterile technique to device preparation and what to watch for on the monitor. Our nurses and staff were sent out for additional training through August. In late August, the entire interprofessional Brain Attack Team spent a day and a half in the CIME simulation lab at Aga Khan University, running mock stroke codes from triage to groin puncture. It was practical, it was interactive and, against all expectation, it was fun. Our gratitude to AKU for opening its doors.

On August 28 we created a separate group for the stroke ER and added twelve emergency residents to it. That same day we ran a full dry run of the hyperacute pathway, start to finish, before a single real patient came through. Dr. Kamal put it best that week: One arm is fixing the machine, the other is training the people.

Today, when a resident posts a stroke code, it arrives in the same fixed format every time: age, history, symptoms, last known well, NIHSS, blood pressure, blood sugar, cortical signs. Our attendings reply in real time, and every case becomes a small lesson. Just last week Dr. Lutfi posted the radiological thresholds for malignant MCA infarction, with a short note: For the fellows. We hold morning huddles. We have a fellow from Quetta in the lab now, and I will admit that teaching someone who will take these skills back to Balochistan is among the most satisfying things I have done in my career.

We are also building something more permanent. In July we met with Dr. Sahar Abbasi, Director of Medical Education at the College of Physicians and Surgeons Pakistan, to begin creating a CPSP-accredited training pathway in neurointervention. If that succeeds, JPMC will not only treat stroke; it will produce the people who treat stroke across Pakistan. Alongside that, we have brought over the informed consents we use at the University for thrombolysis, thrombectomy, angiography, embolization and aneurysm repair, and are adapting them into Urdu so that families understand what they are agreeing to in their own language.

Earlier this week I looked through the control-room glass and realized that every person in the lab was a woman: the neurointerventional fellow, the first assist, the technologists and the nurses. Neurointervention is still an overwhelmingly male field, in Pakistan and in America alike. Seeing that room run calmly and expertly by an all-women team made me prouder than almost anything else these three months have given me.

I promised honesty, so here is the less glamorous part. Our angiography system is a Canon unit, and when it was unpacked in early August we discovered that several of its boards had absorbed moisture in transit. Karachi humidity is not kind to electronics. There were delays, recalibrations, and a few evenings when I wondered whether we had been too ambitious. In September the CT scanner went down for a stretch. We have spent real time discussing how to keep humid air away from the CT door, and in October we finally received air-conditioning units for the spaces that needed them. None of this appears in conference slides, but anyone who has tried to build anything in a public hospital in Pakistan will recognize it.

The machine came up, and on August 5 we did our first diagnostic angiograms. Even before that, on July 25, Dr. Lutfi and Abdul Samad had performed a direct repair of a carotid-cavernous fistula, the first procedure done under the PSI name. Small beginnings, but beginnings. At the end of August a CT scanner on wheels arrived and was set up outside the neurology building, a short walk from the SAB.

As I write this, a second suite is coming to life. Our new Canon biplane arrived on September 25 and is being commissioned now; it should be treating patients within a week. When it is, JPMC will be, to the best of our knowledge, the only center in Pakistan, public or private, with two dedicated neuro biplane suites. Three months ago this lab had not yet opened its doors.

The angiography suite gave us two firsts within a week. On August 5, Dr. Hisham Salahuddin, PSI’s president, performed the first radial case at JPMC: a diagnostic angiogram done through the wrist rather than the groin, which is more comfortable for patients and safer for those who need to be up and moving afterward.

Six days later, on August 11, Hisham and I treated our first aneurysm together at JPMC. The aneurysm sat on the anterior communicating artery, at the center of the brain’s circulation, where a rupture is often fatal. We closed it from inside the artery with an intrasaccular seal device, a single implant that costs roughly $15,000, placed through a catheter the width of a few hairs. He recovered well. Until this year, a patient in this city with a brain aneurysm could be treated in only a handful of private hospitals, and only if the family could pay. That week, a patient was treated in a public hospital, free of charge.

On September 2 the stroke team was formally deployed in the emergency department. The next day, September 3, I treated a patient with an acute symptomatic complete carotid occlusion. Dr. Lutfi wrote in the group afterward that it was the first carotid stenting case performed in the history of JPMC. I did not think about that at the time. You never do. You think about the patient in front of you, and about the life waiting for him on the other side of the procedure. It was only later that night that the weight of it reached me: after decades of patients being turned away, this hospital had finally said yes.

That same day we performed our first mechanical thrombectomy: a 38-year-old with a right M1 occlusion. Thirty-eight. A man in the middle of his life, with everything still in front of him. He received tenecteplase in the ER and went straight to the lab, and when the artery opened and blood rushed back into his brain on the screen, the room went quiet in the way only those of us who do this work will understand. And because stroke does not wait for a team to be ready, we then ran two code strokes simultaneously, one of which became our second thrombectomy. A team that had not existed two months earlier handled it with a calm I can only describe as professional, and a pride I could see in every face.

Before

After

I promised everyone nihari after the first thrombectomy. I am told, repeatedly, that I still owe it. I intend to pay.

September in Karachi, as Dr. Kamal warned us, is “ICH season, SAH season, and big stroke season.” We implemented the INTERACT-3 care bundle for intracerebral hemorrhage. Our case mix grew quickly in complexity: aneurysm coiling, AVM embolization with Onyx, a carotid body tumor embolized with Onyx and coils, a complex basilar aneurysm. These are cases that, until now, most patients in this city could only receive in a handful of private hospitals, if they could afford them at all.

One moment from those weeks has stayed with me more than any procedure. A patient who had been critically ill came to us for treatment of a brain aneurysm and spent two weeks in our ICU, and there were days when none of us were sure he would leave it. On September 29 he came back for his follow-up, doing perfectly well. The team was so overjoyed to see him that everyone insisted he come upstairs, family and all, for a photograph with the people who had fought for him. The nurses who had cared for him through those nights and the fellows who had watched over him stood shoulder to shoulder around him. I looked at that photograph for a long time. It is the reason we do this.

I do not use the word lightly, but I believe JPMC now runs one of the most sophisticated round-the-clock stroke services in Karachi, and it does so in a public hospital for patients who pay nothing. Here is what that means in practice.

A patient with stroke symptoms who reaches JPMC at any hour goes to the SAB, our dedicated stroke assessment bay, staffed by trained residents and a nurse. They are scored and scanned through a fast-track CT pathway, discussed in real time with a stroke neurologist and an interventionalist, and offered tenecteplase when appropriate. If there is a large vessel occlusion, they go to the cath lab for thrombectomy. Patients with brain hemorrhage are treated with an evidence-based bundle. Patients with aneurysms, AVMs, fistulas and vascular tumors can be treated endovascularly. After the acute phase, they are admitted to our neuro ICU or stroke unit, and the neuro ICU has been running full more often than not lately. We are also working on a formal rehabilitation partnership with KINDR, whose team visited us in late August and wants to sign an MoU.

The numbers are beginning to speak for themselves. In September the lab performed 60 procedures: 32 diagnostic cerebral angiograms, 12 mechanical thrombectomies, 8 aneurysm coilings, 4 carotid stents, 2 AVM embolizations, a carotid-cavernous fistula and a carotid body tumor. By the middle of October the team had passed 100 cases, including 18 thrombectomies and 16 aneurysm treatments. We marked the hundredth case the way any Pakistani team would, with cake.

Some of the changes are smaller but matter just as much. In September, for the first time at JPMC, patients in our unit were given proper hospital gowns, which may sound minor until you have seen a stroke patient left in the clothes they collapsed in. We put a rickshaw ambulance into service to shuttle patients from the SAB to the neurology building and the CT scanner, because in stroke even the walk across a hospital campus costs brain. The Sindh Government’s information department has publicly announced the center as offering 24/7 advanced stroke care, completely free of charge.

And sometimes gratitude arrives in a tin. After we treated a complex brain arteriovenous malformation, the patient’s family came back with traditional sweets for the team. I am told I ate more than my share.

Nothing here was done alone, and one friend deserves to be singled out. When I had to return to the United States at the end of September, someone had to cover a service that was barely a month old. Dr. Ahsan Sattar answered at short notice. He canceled a family vacation, flew to Karachi, and stayed for more than a week running the neurointerventional service in my place. He brought donated inventory with him and performed fifteen cases, including some of the most complex we have seen. He did not just keep the lights on; he kept a young team confident at the exact moment it could have faltered. And he intends to do it again in November. I do not have adequate words for that kind of colleague, so I will simply say: thank you, Ahsan.

Dr. Asad Latif, Chair of Anaesthesiology at Aga Khan University Hospital, has been helping us build our intra-procedure and post-procedure protocols, and he was with us in mid-September on the day we embolized two aneurysms. HighNoon Laboratories donated stroke medicines. Dr. Karim Damji, Dean of the Aga Khan University Medical College, visited the center to see our work for himself. The actor Adnan Siddiqui spent a morning with our staff and helped bring public attention to what we are doing. Karachi’s mayor, Murtaza Wahab, recognized the stroke center publicly, and Dawn and The News covered our work. Colleagues in the United States have begun opening doors for us with device manufacturers. Each of these gestures told our young team that the city had noticed.

You asked me, some of you, how I am doing. I will try to answer truthfully.

I left a well-equipped American lab, a department I chair, and a comfortable life in Ohio. None of that is the hard part. The hard part is the empty chair at my own dinner table. My daughter Eleza has been on this journey with me. She is enrolled at Karachi American School this semester, she is doing well, and she is enjoying her time in Karachi more than either of us expected. Having her here has been a gift, and she has become a familiar face around the PSI office. But the rest of the family has carried the larger share of this sacrifice back home, and I owe them more than I can write in a newsletter. There are birthdays and school events and ordinary Sunday dinners that I have missed and will never get back. My own birthday, September 13, came and went in the middle of all this. The next day we embolized two aneurysms, and the team celebrated with me afterward. It was one of the warmest birthdays I can remember, and still, I would be lying if I said I did not think of home that evening and feel the distance in my chest.

My research and academic work have not paused either. I am now principal investigator for the Phase 2b/3 ALLY II trial, and much of that work happens late at night Karachi time, when Ohio is awake. I am also chairing this year’s Annual Meeting of the Society of Vascular and Interventional Neurology, the society’s 20th anniversary meeting in Las Vegas this November, and it has kept me awake on more than a few Karachi nights. I flew back to the U.S. for two weeks at the end of September, and for a few precious days we were all together again. I returned to Karachi on October 11. Thanks to Dr. Sattar and our local team, the stroke codes continued while I was gone, which, I want to stress, is exactly the point.

And yet I have not felt this useful in years. Perhaps ever. In September, Dr. Kamal wrote a long poem for the team called We All Bleed Red. It names nearly everyone, from the fellows on call to the man at the gate who clears the way, and she says it was always about the heroes of Pakistan, our everyday heroes. Its central idea has stayed with me: serving the public is not charity, it is justice. The rickshaw driver and the banker, the patient in Room 6 and the donor in Michigan: we all bleed red. This team, I like to think, also bleeds green.

I want to be transparent about money, because many of you have asked. When we started, our budget was an educated guess. Three months of real operations have given us real numbers, and they point to an annual operating need of approximately $3 million.

Staffing is the largest fixed cost. A fully staffed center, covering the stroke bay, the cath lab, the neuro ICU, step-down beds and the stroke unit, needs about 126 people, from nurses and technologists to the security staff at the gate. With employer contributions, insurance and allowances, that comes to roughly $800,000 a year.

Devices are the largest variable cost, and they grow with every patient we save. At current prices in Pakistan, the devices for one thrombectomy cost roughly $2,000 to $3,000. A simple aneurysm coiling costs about $3,000 in coils and catheters, considerably more when a stent is needed, and a single flow diverter costs close to $5,000. At September’s volume that adds up to about $1 million a year, and our volume is still climbing.

The remaining third covers what makes free care actually free: medicines, ICU and ward care for patients who cannot pay, servicing and maintaining equipment in Karachi’s heat and humidity, and the training of the people who will carry this forward. Since we began, our community, most of it physicians, has given close to $2 million. That built the center. Keeping it open is now the work, and I will not pretend it is easy. If the funding stops, the SAB goes dark, and the next 38-year-old goes back to a ward bed and a lifetime of disability. I am not willing to let that happen, and I do not believe you are either.

On September 5, supporters filled a community hall in Orange County for a PSI fundraiser held with the California Cricket Foundation. Dr. Hisham Salahuddin told the story of the stroke center at JPMC, from the first patient to the first hundred cases. Dr. Umair Sajid, Dr. Syed Naqvi and Dr. Ijlal Uddin spoke for PSI as well, and we were joined by guest speakers Azhar Ali, Saeed Anwar and Naeema Butt. The final slide gave every guest a way to give before leaving that night: the PSI website and QR code, Zelle, Venmo or a check.

Thank you to the California Cricket Foundation, to every host and volunteer, and to every guest who came through the door.

We have proven that this can be done. The harder task is to make it last. Our biggest need right now is neurointerventional inventory: aspiration catheters, stent retrievers, microcatheters and microwires, coils, flow diverters, liquid embolics, guide catheters, sheaths and closure devices. Every device we receive becomes a free procedure for a patient who could never otherwise afford one. We also need to keep the people we have trained. Salaries, continued education and certification for our nurses and technologists are what turn a successful pilot into a permanent institution.

We have been working on all fronts. While the team in Karachi built the center, PSI’s team in the United States has been just as busy raising the funds to sustain it. Dr. Hisham Salahuddin, our President; Dr. Umair Sajid, PSI’s co-founder; and Dr. Ijlal Uddin, our Treasurer, have led fundraising events in Seattle (August 29), Orange County (September 5) and San Diego (September 6), and I am grateful to every host and every guest who came through the door. More on the Orange County evening is just above.

More recently I carried the message abroad myself. I owe special thanks to DOGANE, the Dow Graduates Association of Northern Europe, which chose PSI as the charity of choice for its annual event this year and invited the PSI team, myself included, to Manchester on October 17. Standing in a room full of Dow graduates, many of whom trained a few miles from JPMC, and telling them what this team is doing on the ground, was one of the proudest evenings of these three months. The prayers and pledges of support that night reminded me how far this work now reaches.

Closer to home for many of you, we are planning PSI fundraisers in the United States in the coming months, in Florida and Georgia. Dates will be announced soon. If you live in or near those cities and would like to host, help organize or simply bring friends, please write to me.

To my fellow physicians in Pakistan and in the diaspora: come and see us. Spend a morning in the lab, give a lecture to our residents, mentor a fellow. Many of us left this country to learn what we know; this is a chance to bring it home. If you are in industry or know someone who is, an introduction can change everything. And to every donor who has already given: thank you, from the bottom of my heart. Please know that your gift did not disappear into overhead. It became a thrombectomy for a 38-year-old man in a hospital that, a few months ago, would have had nothing to offer him.

You can learn more, follow our progress and support the work at pakistanstroke.com.

I will write again in three months. By then I hope to report on our CPSP training pathway, our rehabilitation partnership, and how many more lives this team has given back. And I hope to report that I have finally paid for the nihari. Until then, please keep this team in your prayers. They are carrying something precious, and they are carrying it beautifully.

With gratitude and affection,