February 15th 2011
I am in the kitchen and my mother has made me scrambled eggs on toast.
Have you had enough to eat? she asks.
Yes thanks. That was great, Mum. It will set me up for the day.
Are you sure now? It’s a long way to drive.
I reassure mum that I’ll be fine. I’m obviously very excited about this trip.
I’m worried about you driving in this weather. It’s very windy.
I’ll be fine Mum.
Where are you meeting him?
In the cemetery.
We both laugh. Mum has been worried about me meeting a man alone who I’d never met before. I love this worrying thing she’s doing. In a way, anyway. I haven’t been used to having a mothering-type mother. Mum has been absent for so much of my life and we’ve only just become friends again five years ago.
Are you sure this is a good idea now, Belinda?
Mum is leaning back against the kitchen sink, and I can see the garden shrubbery launch excess foliage skyward with each more frequently occurring gust of wind. Gale force eight rising nine today, the weather man said.
You don’t really know anything about this man. He could attack you and chop up your body and bury you right there.
Mum, this is ridiculous.
We’ve watched the documentary about this historian on Irish television lately. He doesn’t look like an axe murderer. This man is a gift. I found him on the internet and he is helping me with research for my book about our family and The Troubles in Northern Ireland. I have also found my grandmother’s only living family member still in the north of Ireland. He is her nephew and holds the key to some family secrets. I can’t wait to meet him later today.
Come here, mum.
She does, and we hold each other close for as long as her stiff-upper-lip, don’t-show-emotion self will allow.
The phone rings. It is twenty minutes before the car rental agency man is to pick me up. He needs directions to the house, and Mum tells him how to find us.
It is fifteen minutes before the driver is to pick me up, and my mother collapses in her kitchen.
I know immediately that this is a stroke. I was experienced in working with stroke patients long before I was a writer, before I lived in America. I used to be a speech and language pathologist. I specialized in stroke for a while, taught at a university and supervised clinical placements of students working with stroke patients. Within 60 seconds I phone the ambulance. Within five minutes the ambulance arrives at Mum’s house. The hardest thing in those five minutes is propping up Mum’s body. She’s slumped on a chair, a chair I hate with metal legs, one of four chairs with metal legs in the kitchen. I hate them because the chair legs are turned out. They twist outwards, ready to catch whoever is walking by. So many times I’ve tripped on them, stubbed my toes on one of them, almost fallen over as my ankles hit against one of them. And here one of these chairs is the difference between my mother’s head smashed on the ground, probably dead, and keeping her alive. Getting to the phone is my biggest problem because the damn thing is in the living room, and we are in the kitchen.
Mum is still conscious a lot of time, crying out in slurred speech What’s happening? I’m weak, and Belinda don’t, don’t, when I tell her Mum, you’ve had a stroke. I’m going to call an ambulance. She interjects: Wait now, wait now, as she drifts back into consciousness for as long as that lasts. Within her slurred speech you can still hear the music of her soft Irish accent.
But what do you do with a heavy head balanced precariously on a glass-top table? What do you do with flailing, jerking limbs rendering the right side of a body useless, heavy, a danger to the rest of it? I look around for ways to support Mum’s body, ways to stop her from crashing onto the ever-so-fashionable stone tiled floor. All I need is time enough to reach the phone. To run for it, like you do, talking to yourself out loud saying stay there, to the head in the next room balancing precariously. I feel like I’m spinning plates in the circus. I’m running from one plate to another, judging the time between them, desperately hoping not to drop one. It’s amazing what you think of at times like this, and the number of thoughts simultaneously bombarding you and you need to stay calm, be in control, do the right thing and don’t for god’s sake allow yourself to feel. Not for a long time. Shock is not an option.
But this is my mother’s head and all there is around me are more wretched metal legged chairs, a tea cozy, and a fruit bowl. A fruit bowl. I chuck the oranges out of the bowl onto the floor behind me and cradling my mother’s head between my hands with her beautiful blond-silver hair hiding her face from the contortions it is going through, I secure her head as far into the fruit bowl as I can. The shape of the fruit bowl means it won’t move if I shove the tea-cozy under it and keep it on a slant. It looks like an upside-down sombrero made of orange wood.
There is no doubt that heads are heavy. Mum will most likely be safe for a few seconds, and I can get the phone and get help. I jam one of the chairs under her left shoulder and prop another under her knees. Time marks the race on the clock in the kitchen, tocking, not ticking, for tocking is far more serious.
My mother’s having a stroke. I need an ambulance.
How do you know she’s having a stroke?
For god’s sake, what do you want? A differential diagnosis?
It isn’t the woman on the phone’s fault that I know as much as I know about strokes and that includes that wasting time with unnecessary questions is unacceptable. Time is everything. Time is the difference between life and death. I answer her questions rapidly. Yes, to slurred speech. Yes, to one side of the body being weaker than the other. Yes, to falling in and out of consciousness. Get the god dammed ambulance – a thought, I didn’t say it out loud. I’ve taken the phone back to the kitchen and I am sitting on the floor considering rolling my mother towards me and lowering her onto the floor too. Her head would land in my lap where I could stroke it and say everything will be okay. Trust me, Mum, I say as she occasionally slips a sound from her lips. I’m in charge now. It’s all going to be alright. She is too heavy to move, so I sit on the floor, my legs taking over from the chairs for support, her head still in the fruit bowl.
The telephone lady speaks – Okay dear. The ambulance is close by and will be with you in a few minutes. You need to open the front door.
Damn it. I’ve just secured mum and now I need to go through the whole propping-up thing again and this time make it to the front door and the door in the courtyard. Maybe, I think, I can manage it this time. Maybe I can slide her head out of the fruit-bowl, onto my shoulder. Maybe I can roll her head gently down my arm and rest her head in my lap. Maybe I could rip the cushions from the chair and place them under her instead of me. Maybe I can make it to the door without killing her. I stick with the original plan, the jammed chairs and fruit-bowl. The spinning plates are too far apart for comfort this time.
I made it. Back in the kitchen all is the same.
Five minutes it took. That’s all. The woman waited on the phone with me and I could hear the sirens in the distance. The paramedics arrive and calmly take control. I stand back. What meds is she on? The tall thin grey-haired man asks.
I’m not sure. (I’m an Idiot. Why did I not know these things? ) I can phone the doctor. She saw him yesterday.
What was wrong yesterday?
Blood pressure medicine. She didn’t like the new medicine she was taking and so she stopped it and went to the doctor.
The receptionist puts me through to the doctor immediately and I hand the phone to the ambulance man. I shove a note-book and pen toward him and he writes a list of her meds on a page. I can see the stroke crawling, getting worse. The monster is moving through her body. I know she is having a series of transient ischemic attacks (TIAs.) Blood clots are preventing her from getting enough oxygen to her brain.
The two men move my mother gently onto a two-wheeled chair. They explain that the hardest part of the journey will be across the gravel driveway and into the ambulance. Mum comes around, her speech slurring more but she has fighting spirit.
Where are you taking me? I want to go to the best place. You hear stories you know.
(I have no idea where we are going. I don’t know the area.)
Loughlinstown the tall man says.
You see? We are going to the best place. I try to reassure Mum, realizing that this has to be a local hospital and not a major Dublin City one.
I can pay. Take me to the best place.
The tall man looks at me and both of us smile, and he winks at me.
Patricia, he says, we’ll be going to the nearest hospital first. They’ll take a look at you. We need to get you there sooner rather than later.
Mum continues. I can pay. Take me to the best place.
Are you always this bossy, Patricia? The man winks at me again. He tries his best to humor my mother.
The man turns to me.
You don’t sound like you’re from around here. Do you know where we’re going?
He’s picked up on my English accent.
Not a clue.
Is there someone can drive you?
No. I’ll follow you in the car.
Mum quiets down as they take her blood-pressure in the back of the ambulance.
260 over 90, the tall man says.
What’s your name love?
She’ll be alright with us. Stay calm now and drive safe. Follow close. We won’t let you get lost.
With that I wish him good luck with my mother. He smiles, rolls his eyes, and then winks at me one more time.
I’m Dennis, by the way.
We are about to set off for the hospital. I grab my mother’s handbag. It is heavy and I can’t imagine why she would carry so much around with her. It doesn’t matter. I grab Mum’s mobile phone, and her address book from a drawer. I grab my phone too and make sure I have the house and car keys.
I’m walking out of the door and Christine arrives. Christine is my mother’s housekeeper. She has seen the ambulance and is lost for words.
Christine, Mum’s had a stroke. I take both her hands in mine and squeeze them reassuringly. She’ll be okay. Christine nods. I ask her to wait for the rental agency driver and tell him what’s happened. Christine nods and says No problem.
I snake my way out of the driveway behind the ambulance. I pull up close to the ambulance when we approach a roundabout. I will not let the man out of his driveway on the left to squeeze in between us. He can wait. I know the traffic is heavy on this two lane road, and today is not a day for me to be polite. We make it around the first roundabout with me tailgating the ambulance, but at the second roundabout an aggressive driver inches in between us. We get separated and I can’t see which exit the ambulance has taken off the circle. So I guess and go all the way to the right. Good guess. Nice ambulance driver, he’s pulled over to one side of the road to wait for me.
At the hospital I register my mum with the lady behind the window. I give her all of the information I can and she passes me over to Mick, who is the porter who sits guarding the entrance to A&E.
This way love. Mick is holding me by my arm half way up between my elbow and my shoulder. He marches me in to a cubicle where they are shifting Mum off the ambulance gurney onto another gurney-type-bed.
Where’s Belinda? My mum looks frightened.
I’m here Mum. I go around to her left side in this tiny, definitely can’t swing a cat size cubicle. I hold her hand.
I don’t mean to be a bother. I’m sorry, she says to the medical team fussing around her.
Ah, sure, you’re no bother at all, Patricia.
A doctor and two nurses are working quickly around my mother. I can barely see what they are doing to her. Needles seem to find their way into her veins. It’s as though she has an extension cord, a spider-type one coming out of a vein in her left arm. Plenty of room for more bits to be attached to it, so they can pump medicine into and draw blood out of her body.
Mum continues to drift in and out of consciousness. The nurses begin to undress her and get her into a gown. Mum comes round and looks confused while they gently try to remove her clothes. Dignity. This is what mum needs now, and I must say, they are trying their best. Mum is wearing a grey wool dress. It has tight sleeves with buttons at the wrist. There is an inset panel at the chest. It is a contrasting grey fabric and has decorative buttons on it. You can tell the dress is expensive. The skirt is a knee-length bucket style. I like the dress, but I can’t help thinking it is far too young for her every time I see her wearing it. The dress unzips at the back and when one of the nurses says the zip is stuck and she’ll get a scissors and cut it off, I jump in and take over. You wouldn’t dream of cutting a dress off my mother.
I slip my hands gently down beneath her bottom and pull the skirt up very slowly one side at a time releasing it from her immobile thighs. She cannot help us by lifting a limb. Her limbs don’t work. She doesn’t even know what they are anymore but dignity is everything at a time like this. I work the skirt of the dress up past her bottom and rest it around her waist. Carefully I evaluate the zipper situation, stretch and pull the fabric tight and ease the zipper down. As I go to pull the dress over her head I ask the nurses to cover her front with a gown. Dignity again.
The nurses lay Mum back down gently. She’s allowed to keep her panties and bra on. They stick electrodes all over her to check out her heart. One doctor steps back and another steps in. This new doctor asks for the scoop, though not in so many words. She turns to me.
You’re the daughter? I nod. I’m Rachel Doyle, Consultant, Stroke and Geriatrics.
Mum lies still but then she speaks her confused speech – words that aren’t really words but similar to words. They come out now and again with real words that don’t belong in this situation.
Patricia, can you lift your right arm? Doctor Doyle is gentle.
Mum lifts her left leg.
Patricia, show me the house? Where’s the cup?
Mum is failing miserably. She cannot follow her doctor’s instructions. She cannot recognize the stupid black and white line drawings mimicking everyday objects.
Rachel Doyle orders a C.T scan for Mum. I wait patiently for what seems like hours. Mum returns to her cubicle, images, films, pictures of her brain in a brown envelope resting on her chest.
There is a something called The Golden Hour. It is the short period of time in which the majority of critically injured patients can be saved. In people having a stroke, it starts when the patient arrives at the hospital and ends with the administering of potentially life-saving drug therapy. To get the best out of the golden hour you need a really efficient pre-golden hour response time to the injury. In other words, sticking Mum’s head in a fruit-bowl and calling the ambulance really quickly, together with the rapid arrival of the paramedics made for the start of an exceptional golden hour for my mum. Mum collapsed with her stroke at 9:45 am. At 10:00 am she arrived at the hospital. A typical Golden Hour looks like this:
1. Patient arrives at the hospital.
2. Within ten minutes the patient is evaluated by a medical team. This includes a physical exam, and the taking of a detailed case history.
3. Within fifteen minutes the stroke team and a neurologist take over with the patient.
4. Within twenty-five minutes the patient has a C.T. scan, and blood is taken and sent to the lab for analysis.
5. Within forty-five minutes the C.T scan results are analyzed.
6. Within sixty minutes life-saving drugs are administered if appropriate.
We got as far as number five and decisions needed to be made.
She’s getting worse, I tell the doctor. Her speech is more slurred and she’s confused. She isn’t making any sense. Mum can’t remember where she is or what has happened. She knows who I am though, and looks to see if I am beside her still as she drifts in and out.
We need to talk. Dr. Rachel takes me aside.
There isn’t any evidence of a bleed in her brain yet.
I know what this means, it’s as I suspected. Mum has a clot moving through her body, a number of them as it turns out.
There’s a drug we could give her. The problem is that it hasn’t been approved for use in Ireland yet. It’s technically still experimental here. It’s used a lot in mainland Europe though.
I’m still listening.
Your mum’s not capable of making a decision and you’re her next of kin.
What are the risks? It’s my turn to talk. Rachel pulls a patient information leaflet out of a file, and then quickly rips another from her folder. The second sheet is a summary of clinical trials and research findings. Rachel knows I can digest the heavy stuff fast and I’d want to know the details.
I hate to ask you to make a decision on something this serious so quickly.
I’ve gone into emergency mode. (Have I told you I’m good in an emergency?) Mum is no longer my mum. For the time it takes to read the pages in front of me she is a patient.
It’s just that we have to get the medicine into her as fast and as soon as possible to try to break up the clots and prevent as much brain damage as we can.
Rachel is speaking quietly. She is monitoring Mum’s blood pressure, heart rate and oxygen level on the digital display over-head. She tells one of the assistants to push more of something into Mum. Mum’s blood pressure isn’t coming down fast enough and they can’t start this new potentially life-saving infusion until her blood pressure drops considerably.
I put down the paper. I’ve made my decision.
Okay, Rachel. I think I understand, but just let me clarify this.
The drug is called Alteplase. It is used a lot in The United States, where it was invented. Alteplase is commonly referred to as a clot buster. It needs to be given intravenously within three hours of the onset of an acute ischemic stroke for maximum patient benefit. It comes with risks.
I turn to Rachel.
If you give this drug to my mum it could dissolve some of the blood clots that are stopping her blood from circulating correctly now. Right?
But it’s not guaranteed that this will cure her. In fact, it could make her worse, make her more seriously brain-damaged, or it could actually kill her. Right?
I must assess the odds. I read a portion of the patient handout aloud.
“One in three patients will show some improvement, one in ten will improve dramatically, one in thirty-five will be much worse and one in a hundred will die or be left permanently disabled.”
Rachel. If it was your mother would you give it to her?
Yes. If it were my mother, I’d take the risk.
Thank you. Let’s do it. After all, time is of the essence.