A Stroke and the Accident and Emergency Department of Raigmore Hospital

ACCIDENT AND EMERGENCY

Soon we were being rushed through the doors into the casualty department and I was whisked into a curtained area where blood pressure and other tests were carried out. There were also blood tests taken, including a diabetes test.

I was still trying to come to terms with what had happened to me. The casualty department seemed very busy and there was a young woman or girl screaming somewhere off stage.

A tall young Irish doctor came to see me and performed the same tests as before, checking each of my limbs, smile, grinning teeth etc. and then Wendy arrived in the casualty cubicle.

A short Asian doctor also came to see me and I had to get Wendy to explain to both of them that although my poor speech had deteriorated in casualty, I could really understand everything they were saying.

The doctors had explained to her that a new drug, Alteplase, was available and that if my stroke were of the ischemic type, caused by a clot preventing the blood supply reaching part of the brain, rather than a hemorrhagic stroke caused by a bleeding blood vessel, then it may be possible to use the drug to break up the clot.

There were risks attached to it however. There was a chance that the drug could cause the condition to worsen, but it was important that the drug was delivered within three hours of the stroke occurring.

Wendy asked them to explain this again, but to me and she assured them I could understand everything that was being said.

I asked about the risk factor and was told that problems could occur in about 3% of cases. The Asian doctor went off to check this and came back with a problem rate of possibly 6%. I was also told that only fifteen previous stroke patients in the Highlands had had the opportunity to take advantage of this treatment. I gave a thumbs-up sign.

One of the reasons so few people have been treated is that most stroke victims are not admitted within the magic three hour period. This can be down to a number of factors. For instance it is essential that a CAT scanner is available as it must be positively confirmed that the stroke is not hemorrhagic as Alteplase would be likely to cause the bleeding to worsen, even causing death. With Raigmore Hospital, Inverness, having the only CAT scanner in the Highlands of Scotland, the physical distances can prevent the admission within the three hour window. Another factor, I later discovered, is that many strokes occur while the patient is asleep and so the window of opportunity is already gone before the stroke is diagnosed or even suspected. Further to this many foolish people fail to appreciate the seriousness of a stroke and leave the reporting until the next day, or until they can visit their general practitioner.

I nodded to Wendy that I thought the risk was sensible and the doctor disappeared.

I seem to remember that this was the point where I changed into a hospital gown. Why the devil are they so dreadful? Surely there could be something less obnoxious for patients whose symptoms are unlikely to need their bums to be permanently visible to all and sundry!

Then, for a time I was just held in the casualty area. I didn’t realise at this time that much was going on behind the scenes and a call was being put out for an on-call CAT scanner operator to come into the hospital.

After what seemed a fair while, but was probably only ten minutes or so a porter, together with a casualty nurse took me off along the hospital corridors towards the CAT scanner with the Asian doctor trotting ahead of us. After a short distance he had vanished from view completely and the porter said to the nurse, “I don’t see why he’s in such a hurry, it will take them at least ten minutes to get the scanner working.”

The two of them seemed to be under the impression that I could neither hear nor comprehend them.

I can’t remember the exact words used, but my impression of the conversation follows:

Nurse, “Yes, I did tell him that.”

Porter, “So we’re all rushed off our feet in casualty and instead of spending ten minutes there, we’re going to be twiddling our thumbs at the scanner.”

Nurse, “I’m thinking of emigrating.”

Porter, “Oh, where to?”

“Australia”

“How old are you then?”

“Forty-two.”

“Should be OK then.”

“It would be nice to be somewhere where you feel valued. Since the changes this has been too hectic. Not enough staff. All trying to do too much.”

When you are lying on a stretcher admiring the cleanliness of the fluorescent fittings on the corridor ceilings while actually contemplating whether or not your life may end at any minute, you tend to rather absorb things which are going on around you and the above is probably pretty accurate as far as I can remember.

I was surprised at the tone of this conversation as my recent encounters with the hospital had all been good. Staff in the clinics and physiotherapy and occupational therapy sections had spoken very positively of the hospital over the last few years. I’d been told wages had risen and working hours and conditions had improved. Why should the casualty department be different? Perhaps it was just general grumbles, but it certainly seemed more than that at the time.

I managed, by great force of will, to get the following to emerge from my lips, “I thought things were better here these days?”

My asking the question shocked them into realising that I was quite cognisant and there was a sort of light hearted change in the chat. Sadly we were just approaching the scanner and so I never found out what the answer to my question may have been.

In through the double doors to the scanner section where my Asian doctor was already deep in conversation with a young woman, who looked somewhat dishevelled after her rushing into the hospital to do the scan … and how desperately thankful I am to her for getting there so quickly!

She came through and had me lifted on to her scanner trolley and then I was placed in the mouth of the scanner. The doctor instructed the casualty nurse to have a drip ready for me so that if the Alteplase were to be applied, it could be put straight into the drip as soon as the all clear was given.

I must say that from the moment of entering the scanner, there had been no delays and so the porter’s concerns that they were being rushed for no reason was not apparently correct. Maybe he did not realise how tight the treatment window was. Should there be more communication in casualty on such things. He obviously felt that ten minutes was neither here nor there.

Today I know that the drug was applied just two hours and fifty-five minutes after my stroke. Every single minute was absolutely vital and I thank that Asian doctor so sincerely for forcing the speed of action.

I was told to hold myself as still as possible as I was taken into the scanner and then more slowly back out, with Star Trek style lights whirring around the machine as I was scanned.

I came out of the scanner and was placed back on my hospital trolley while the doctor and the scanner operator were poring over the displays behind the operator’s glass shield.

Two or three minutes passed, maybe more. This was vital time as they had to be one hundred percent certain that my stroke was not the hemorrhagic type.

The doctor came out of the viewing area and said to the nurse, “Right, 25ml of Alteplase over the next sixty minutes.”

“Don’t you mean 0.25ml the nurse asked?”

Such a query is somewhat worrying to the person lying prone with bags of fluid attached to him as you may imagine.

Somewhat impatiently, “No twenty-five millilitres.”

“Are you sure?”

A few seconds passed, “Yes, look.”, obviously showing something to the nurse.

“Oh, right, sorry.”, and she proceeded to put the drug into the drip (I think) and adjusted the flow.

While all of this may cause concern to the patient at the time, at least, in retrospect, you realise that everything was being double checked.

I was then taken to the Coronary Care Unit where they could monitor my ECG. It was after ten o’clock when I arrived here and so the three hours had well and truly expired.