Stroke

by Ricky Monahan Brown

  I knew it was a leap, a gamble, so I made an announcement. ‘I’ll say it,’ I said. Then because I knew, and because I wanted to help and make it OK, I continued: ‘I love you.’

  The narrator of ‘Classy Girls’ would have said that the hardest part was through. On that clear, springtime Brooklyn night, I might even have agreed with him.

  3

  The Valley of the Shadow of Death

  The intensive care unit at Methodist Hospital was as pleasantly sterile an environment as the ER was on a good day. Wide corridors were floored in peaceful combinations of sky blue, cream and cinnamon. There was one nurse to every two patients, each of whom was allocated their own room. Mostly, the patients were quiet, being too unconscious and hooked up to too many machines to kick up too much of a fuss.

  All day Monday and Tuesday after my brain surgery, the drains in my skull quietly did their job and I regained a type of consciousness, although I wasn’t yet able to create memories. On Wednesday, the medical team let me start to wake up and took out my breathing tube. This was a big step, because breathing tubes are very vexing, and the possibility of me trying to pull mine out had been a big concern.

  Although the breathing tube had been removed, alien tubes still emerged from my body at all angles. As well as the two tubes that were inserted into my skull, an arterial line had been inserted into the radial artery in each of my wrists, to constantly monitor that pesky blood pressure. It was still worryingly high. A line was put in my left wrist first. Then, later, it was changed to my right. I also had a regular blood pressure cuff, a kind of line that could provide intravenous access over a prolonged period of time, and leads on my chest for an ECG. As well as all that, the same day as the breathing tube was removed, I was fitted with a Foley catheter.

  A Foley catheter is a diabolical and complex thing, but in simple terms, it involves running a tube up the patient’s urethra and into the bladder. After insertion, a balloon on the inside end of the tube is inflated with water to keep the catheter in place. Once my Foley had been inserted, the first of what the doctors called the activities of daily living could begin, and I could take the first steps out of the valley of the shadow of death.

  Soon after the breathing tube was removed, my doctors declared that the most important thing now was to get me eating. A swallowing test was quickly administered. As Beth looked on, a speech pathologist came to my bedside. She checked the suction apparatus on the wall for use in case of aspiration, then she raised the bed, presented me with a viscous solution, and asked me to swallow. This was followed by a glass of water, more challenging because water is more difficult to detect for a throat numbed by stroke. Each time I swallowed, the pathologist would feel my throat to check that the reflex was in order.

  ‘Well done!’ she said, after each swallow. ‘How did that feel?’

  It felt fine, and I was allowed to begin eating again. Or so I thought. Shortly after the swallowing test, a nurse brought the first item of solid food that was to pass my lips after the stroke, and placed it on the table that slid over the heavy bed.

  I registered a piece of bread. Not exciting, but something. I trustingly took a bite.

  The soft, wet substance in my mouth had neither the consistency nor the taste of bread.

  ‘What is this?’ I spat at the nurse.

  ‘It’s bread.’

  ‘No it’s not, it’s Soylent Green!’

  This was a sharp, instinctual response. Beth, looking on, was surprised to find herself laughing out loud. In these early days, she was particularly worried about my confused state. Then, without missing a beat, this reference was interjected with the confident delivery of the sharply dressed lawyer who had died at the end of September. Years later, I’ve still not seen the 1973 movie Soylent Green, about a future in which the population of a dilapidated New York City survives on green wafers supposedly containing high-energy plankton. But I had absorbed enough pop culture to know that Soylent Green is people!

  Of course, this limp offering wasn’t people-food. Nor was it food for people. A little water had been added to some bread, and the mixture pureed per guidelines ‘to have the look and texture of pudding or mousse’. Most of the sustenance that was now being provided to me was appetising to the same extent.

  Nevertheless, I had now started to take on limited amounts of food and water. Between the stroke and all the tubes, I couldn’t get out of bed. One day, not long after I had woken up, Beth and Kathy were sitting quietly with me when an anguished look passed over my face.

  ‘I need to pee!’ I told them.

  ‘It’s OK,’ Beth said. ‘Just go.’

  ‘What? Here in bed?’

  ‘Yes. Go ahead.’

  The Foley catheter did its job. There was a long list of risks associated with its use, though. Among the most severe was that the patient may pull out the catheter while the balloon holding it in place is inflated. This can lead to what is delicately referred to as ‘major complications or death’, particularly when the patient is mentally impaired. After all that had happened, I certainly qualified for that description.

  When Beth and Kathy left, I started to try to pull the Foley out.

  Shortly after this incident, the Foley was removed, and I was fitted with a series of Texas, or condom, catheters for the remainder of my stay at Methodist Hospital. I learned that a stroke and the related pain and numbness did not lend themselves to the state of magnificence for which a condom is manufactured. I complained to Beth about the constant readjustment the catheters required.

  ‘I feel like my penis is under incessant threat.’

  Beth decided against expressing her amazement that my vocabulary seemed to be intact, and tried to reassure me. ‘Baby, your penis is fine.’

  ‘OK. Then you should keep it in your mouth at all times, just to make sure.’

  We were discovering that a common symptom of brain injury is acting or speaking inappropriately and impulsively. Because stroke patients tend to behave inappropriately and impulsively, the nurses had me wearing mitts. As a very premature baby, I had worn little mittens, because I couldn’t be allowed to scratch my delicate skin. As a thirty-eight-year-old whose brain was open to the elements, I couldn’t be allowed to touch pretty much anything. I hated those mitts, and from time to time, could be found lying in bed gazing uncomprehendingly at them, trying to figure out what the hell had happened to me.

  Yet somehow, through all this, the extra ventricular drains continued to work. This was great, because it was important to get me out of intensive care and into rehabilitation as quickly as possible. Research shows an association between earlier admission to intensive rehabilitation and better outcomes for haemorrhagic stroke victims. This is particularly the case for the most severely impaired patients. Patients like me.

  Then, on Thursday, one of the drains stopped working. It was clogged with the sticky mixture of cerebrospinal fluid and blood, which is some pretty crappy wine in anyone’s language. Although they entered on different sides of my head, the two tubes drained out of the same place so it wasn’t a massive problem if one of them stopped working. Except, it’s like a plane: if one engine goes down, you can limp home on the other. If that second engine fails, limping is the least of your worries.

  To compound the problem, I went on to pull the dressing off my head one night in a sweaty, sticky state of uncomprehending agitation and ruined the sterility of the tubes.

  The doctors took out the blocked tube. The remaining tube worked through the Monday a week after surgery. Then I became lethargic. Almost unresponsive. Admittedly, it would have been hard for most people to notice any difference, what with the brain injury and all. However, put together with the fact that the drain hadn’t produced any wine for a good hour or so, the signs weren’t good.

  I was taken for another CAT scan. The scan showed that the remaining tube had moved four centimetres out from where it needed to be, and the medical staff couldn’t just go ramming that now non-sterile tube
back into my brain.

  There were two options. They could remove the non-sterile, disgusting, germ-infested tube and put in a new sterile drain. Or, they could put in a lumbar drain. This had the dual benefits of being a somewhat less delicate procedure, and also leaving me with a type of artificial appendage that I was less likely to pull out.

  Without wanting to blind you with science, to put in a lumbar drain, the doctor punches a hole in the patient and runs in a plastic tube. So far, so much like the other drains. Except this time, instead of pushing a plastic tube into my skull, the doctor pushed the tube up the inside of my spinal column. Instead of using gravity, the tube was connected to a burette and a drainage bag. A nurse would come by every hour, open up the tap, and drain a specified amount of the fluid into the bag.

  If the lumbar drain worked, the doctors would be able to think about moving me to the intensive care step-down unit. Thankfully, it did work, but I was kept in intensive care for a further week because whatever they did, they couldn’t get my blood pressure down to an acceptable level.

  The problem with all these wee plastic tubes was that, while they had solved the immediate problem, I couldn’t have them in me forever. Eventually, it would have to be established whether my brain could start regulating the cerebrospinal fluid on its own, so the doctors had to challenge the drain. Well, they said ‘challenge’. They meant, ‘switch it off for twenty-four hours’. Meanwhile, the nurses would watch for symptoms that might show fluid was building up. As well as lethargy, these symptoms could include headaches, and – of course – death. So, the spigot was switched off.

  Pretty quickly, I started leaking fluid out of my back. This, Beth was told, constituted a fail on the test. Given that it seemed I couldn’t drain my brain on my own, the alternative was to put in a shunt – in this case, a kind of valve – which would stay in permanently and drain the cerebrospinal fluid as necessary.

  This would require more brain surgery. A foreign object inside my head. More risk of infection. A delay in getting into rehabilitation. Dr Ayad didn’t have any slots to operate before Monday morning, though, so there was time to do a second test. Second tests aren’t unusual, but I wouldn’t have had one otherwise.

  On Friday, my spigot was turned off again. This time, there was no leakage, and no sign of headaches, lethargy or death, so a CAT scan was scheduled for Saturday morning to determine the success, or otherwise, of the test. It showed a slight enlargement in my temporal horns. Although that’s a brilliantly sci-fi sounding name, temporal horns are merely the part of the lateral ventricle extending downward and forward into the medial part of the temporal lobe. Or, to put it another way, imagine you’ve sliced a cauliflower in half. Now, imagine you find a hole in the cauliflower shaped a little like an inverted comma or a horn. That’s kind of what a temporal horn looks like. It’s part of the ventricular system of cavities in the brain where the cerebrospinal fluid that bathes and cushions the brain is produced. This enlargement in my temporal horns wasn’t sufficient to indicate a failed test. Moreover, I was still responsive. So, the lumbar drain remained switched off. On Sunday I was still fine, and the drain was removed. There wasn’t even any call for a follow-up CAT scan.

  This was great news! There was no need for further brain surgery, with the associated four-day recovery before I could be moved into rehab at the Rusk Institute in Manhattan. Rusk had been designated as the best rehabilitation programme in New York and one of the top ten in the United States since rankings began.

  I had received some therapies at this stage, but these mostly involved being helped out of bed to sit in a chair so I wouldn’t get bedsores. Not at all like the intensive rehabilitation I could receive after my immediate medical issues had been resolved. Now that my body was regulating my cranial pressure and cerebrospinal fluid, and my blood pressure was under a degree of control, the worst of my medical issues were addressed and the success of my recovery was all down to repairing the damage to my body in rehab.

  I was moved to the step-down unit, where four beds separated by comfortingly pastel curtains in primrose, sage and terracotta were monitored by a nurse at a long desk. As a precarious passage to the outside world began to open, I was granted a window with a view north over urban arboretums across the restrained Brooklyn skyline to the unmistakably phallic Williamsburgh Savings Bank Tower. This view was wasted on me, of course. I was in no condition to check it out. Nevertheless, even in my reduced state, I couldn’t leave my friends at Methodist Hospital without one final dose of drama.

  For whatever reason, the arterial line in my wrist bugged the hell out of me. I was damned if I wasn’t going to do something about it, mitts or no mitts. By the time I had been moved to the step-down unit, the equipment was no longer available for the arterial lines to display the continual blood pressure reading. My friend Kirk visited, and was troubled by the scene that confronted him. After they had sat by my bed for an hour or so, Beth walked him to the corridor. Kirk was another Scottish lawyer living in Park Slope, and we had first bonded at a kids’ birthday party over a shared love of depressive pop music. Now, just a few years later, I lay prone in a hospital ward, an intimation that maybe there weren’t better times ahead. A warning that working hard, obeying authority and doing the right thing didn’t necessarily bring its own rewards

  ‘Are you OK?’ Beth asked.

  ‘Yeah, I’m fine,’ said Kirk. ‘But forget about me. How are you?’

  ‘Just got to keep going for now,’ she shrugged.

  ‘And then what? For how long?’

  ‘We don’t know. All we can do is wait and see.’

  A meaningful look passed between them.

  ‘Is he . . . When is he coming back?’

  ‘We don’t know. He might not. Not the same way, anyway.’

  One of the nurses walked by, and smiled.

  Kirk stopped her. ‘Why haven’t you taken that line out of his wrist? Can you not see how agitated he is?’

  She told him it would be removed in the morning.

  When Beth arrived before 8a.m. the next day, she was told that I had had a rough night. This was not unusual. Although the step-down unit had those lovely views, the ICU had no windows, and my body clock had been broken by the time I had spent there. I would sleep through Beth’s visits and lie agitatedly awake through the night. I think I have a memory from that particular night of feeling that malaria-carrying mosquitos were attacking my wrist. It makes a little sense that I might have been thinking that, given my abnormal posturing, occasional sweats and the fact of that hallucinatory idea itself. I thought that weakly murmuring pathetic requests for help would be the best way to get some assistance with my plight. However, when it turned out my pleas were too weak and pathetic to generate any assistance, I had to take matters into my own hands. I suppose that I must have been showing some signs of lucidity during the day, because I was mitt-free.

  I tore the arterial line out of my wrist.

  That was a terrible idea. There’s a reason people pull a nice bath, pour a bottle of wine and slit their wrists, and it isn’t because they’ve seen a vision of their girlfriend’s beautiful eyes while walking through a Scottish garden, and are desperate to live. No, if you pull out your arterial line, you can die. Fortunately for me, a nurse was standing over me when it happened and was able to immediately apply pressure. Maria had to do this for a full five minutes, praying that when she released her grip I wouldn’t bleed out. There was a lot of praying to be done in that time, not to mention time for the nurse to reflect that if she couldn’t stop the bleeding, I’d have suffered a fitting punishment for the shit she’d have to go through in the aftermath. Time to reflect that she didn’t really mean that. So she just continued to apply pressure, because only a minute had passed.

  Eventually a second minute passed. A third, finally. Another nurse came by, and Maria asked her to quickly bring a bandage. When the other nurse brought it, she gingerly eased off her grip and immediately applied the bandage, very ti
ghtly. When it was all done, she held my hand.

  ‘You’re a very lucky boy,’ she told me.

  I was certainly happy that the mosquitos had stopped and that someone was taking care of me, holding my hand. I even submitted to being remitted and wrapped in thick sleeve dressings.

  It was clearly way past time for me to be moved to Rusk, where they would have the time and skills to teach me to think straight again. Not that it would take me long to get put back on a 24-hour watch.

  4

  Frankenstorm

  My transfer to Rusk took place on a Wednesday, three and a half weeks after the stroke. It was an afternoon. Beth had come in to Methodist for her morning visit, and would come to see me in my new home in the evening. Having made a brief trip over, my father made a final visit the next day before heading back to Scotland on Friday. In one sense, the worst was over. In another, it was just beginning. My friends were concerned that the Ricky they knew was never coming back.

  Storm clouds were gathering over New York.

  The medical centres that make up the Rusk Institute are scattered around the city. An ambulance took me to the Hospital for Joint Diseases, or HJD, at Second Avenue and 17th Street in Manhattan. A grey monolith, its entrance was plunged into darkness by a canopy of blue plywood scaffolding. A large, silver truck would sit outside every day, unmoving, the doors to the main compartment plastered with ominous warning signs.

  Inside the hospital, the corridors of the ninth floor were lined by long, blue counters facing wards accommodating pairs of patients. Nurses sat facing the open doors of the wards so that the stroke patients and other victims of brain injuries who had somehow managed to avoid being put on 24-hour watch could still be monitored. The nurses were lovely, and their faces would burst into life when they were providing encouragement to patients. Unfortunately for them, they spent most of their days dealing with people who couldn’t understand what was going on, or what had happened to land them in this place. When you catch a glimpse of a nurse, unaware, at one of the long blue counters, you can see the toll it takes.