The water was clear, and warm. I stripped off to just my shorts and put on my mask, snorkel and flippers. With a sack, I slipped over the side of the old 14-metre wooden launch Doris anchored over the scallop bed. The other four sat enjoying an interlude soaking up the balmy day. I hyper-ventilated for a while before diving straight down 8 or 9 metres to the bottom. Apart from collecting scallops I saw a small eagle ray, and a few fish. The activity came easy to me, despite being almost 60, as I had once been engaged commercially for many years fishing and diving for crayfish and paua. 

            We were about a kilometre from my home in Tryphena, Great Barrier Island. It was a bright sunny day, and yet, after a while, I found that I wasn’t feeling the best. I couldn’t put my finger on what was ailing me but I decided to end my diving early, having got three-quarters of my quota already.

            I climbed back aboard the Doris and sat and had a cup of coffee, but wished to get ashore and take a rest, which is eventually what happened.

            Next morning, I was down by the stream at the bottom of my small property giving my pet eel, Gertrude, the benefit of my shucked scallop shells when….my right hand started going numb.

            Unusual I thought. Serious I thought. So I made a very rare visit to the doctor. He checked me out and suggested it could be a migraine, which I’ve never suffered from before. Within a day, the numbness had gone.

            Five or six days later, I was a mile away giving a friend a hand doing some carpentry work on his property. I felt a bit dozy, and was slow in my thinking, and conversation, but I didn’t make an issue of it. In the late afternoon he dropped me off at my home and left. I went to walk down my driveway when suddenly the right side of my body became useless and I kept staggering into the rock wall. My thinking also went awry, but I realised something was seriously wrong and made a conscious effort to navigate the steps to get into my house and call 111. In a daze I made it inside, grabbed the phone, flopped to the floor and called 111 from there. After calling them and telling them what help I needed, I lay still and waited, trying to relax.

            Help came within about half an hour in the form of the local district nurse, who checked me out then got me to move. I was fine, with no paralysis. He suggested I see the doctor next morning. On seeing the doctor, he made arrangements to fly me to Mangere airport that same day where I was meant to be met by an ambulance coming directly alongside the plane. In the event, the ambulance was late, and the pilot was about to leave, so I walked across the tarmac into the airport lounge and out to the roadside where I eventually met it and was taken to Auckland Hospital. A couple of hours later I was eight floors up in ward 81, in pyjamas and in bed. Still showing no signs of paralysis, I was nevertheless more tired than usual. It was 10^th February, 2009. A couple of days later, and nothing untoward had happened to me. But sometime during the 13^th February, I had the full stroke.

 

            I am a European New Zealander, and was almost 60 at the time. I have spent a lifetime on or near the sea, commercial diving or fishing, was a fisheries officer for a while, but in later years was a gib-stopper and painter, while editing and authoring books, articles and doing early historical research. I smoked for 33 years until quitting seven years ago.

The last few years have seen my weight rise to 92 kg, 17 kg over my ideal weight. I became concerned about it a year ago and got down to 85 kg at the time I had the stroke, and am now, in July, 2009, 80kg and my ideal weight is 75kg for my 170cm frame. Six months before I had the stroke my total cholesterol was 5.8, including my LDL or the bad Low-Density-Lipoprotein cholesterol being at an equally dangerous 4.0.

            Blockages that cause strokes are the result of the breaking off of pieces of plaque built up on the artery walls, which in turn has been caused by low density lipoprotein levels being too high. Fifty percent of these blockages originate in the soft plaque that has built up on the walls of the carotid arteries. That was so in my case. My stroke was ultimately the result of my past ignorance. Belatedly, I am trying to change all that. Strokes also happen to 8000 other New Zealanders every year.

I don’t recollect the stroke happening. All I know in the days afterwards is that I had had a stroke. And I was very, very lucky to be in hospital when I had it, rather than out at the island. When the brain doesn’t get the sugar and oxygen it needs, the brain cells die. For every minute you wait, your chances of getting better from the treatment drop.

            On the 12^th February I was given a CT scan and this showed some possible trouble in my left carotid artery. On the 13^th, I had the full stroke. My right side was paralysed. I was urgently taken to the MRI scanner to establish whether I had had an ischaemic attack, ie a blockage, or a bleed, and the location. It is important to establish which type in order to give the right treatment. It turned out that I had had an ischaemic stroke in the territory of my left middle cerebral artery and originating from my left carotid artery. Because less than three hours had passed since my stroke, a valuable clot-thinning treatment called heparin could be started intravenously. An anti-coagulant treatment called warfarin was also started orally after which, once it started working, the heparin was stopped. I was to be on warfarin for three months before going onto aspirin. However, I continued to deteriorate until the 15^th when I had another CT scan. Over the next few days, I was stabilised, and a placement awaited at Rehab-Plus out at Point Chevalier, a suburb of Auckland. Rehab Plus reviewed my case and accepted me. It was noted that I also had hypertension and dyslipidaemia which means high blood pressure and high levels of low density lipoprotein cholesterol, both contributors to stroke..

            What seemed like a three-day stay in Auckland hospital, I see from records, was actually two weeks. I remember very little about my time there, apart from fleeting memories of seeing familiar faces and the doctor and his team. I have a single note which I can’t remember making, that I’d made on 17^th February, - “Today-slight headache in morn. Waiting for Rehab date to Carrington. Docs in morn. - sombre mood, foot movement poor, arm worse. Pills for headache.”

 

 

            Rehab Plus is located on Carrington Road at Point Chevalier opposite Unitec on a sprawling piece of slightly rolling land. It is mostly single-storied with ample parking for visitors. These characteristics are important for the types of patients that Rehab Plus deal with. These could be patients suffering from traumatic brain injury, stroke, orthopaedic injury, amputation, multi-trauma, and other neurological conditions or brain injuries. The organisation offers intensive and comprehensive rehabilitation following moderate to severe illness or injury. Because of the limited mobility of many patients the lack of stairs is an advantage. The ease with which visitors can come and go is helped in a big way by the easy parking. This facilitates the support and encouragement of relatives and friends of the patients, which in turn has a vital and positive effect on their recovery. These were important factors in the creation of the separate facilities to the usual multi-storey hospital with its less convenient parking arrangements, although it still remains part of the Auckland District Health Board. For instance, hot meals (lunches and dinners) are still made at the main hospital and transported to the patients at Rehab Plus. Rehab Plus admits public as well as insured and private patients. The criteria for admission to Rehab Plus are that the patient must be between 16 and 64 years of age, living in the North Health region (includes the areas covered by the Waitemata, Auckland and Counties Manukau District Health Boards), and be New Zealand residents. As well, the patient must previously have been admitted to Auckland acute services for treatment following an accident or illness, have prolonged or persistent cognitive and or physical effects following illness or injury, for whom specialist rehabilitation will promote a faster return to their former level of function in various roles, and are able and willing to participate in rehabilitation programmes. To service the range of patients that Rehab Plus must deal with, the organisation has both an holistic approach to health and provides an interdisciplinary team to service, and enhance co-ordination, of all the rehabilitation programmes. The services include clinical psychology, recreation co-ordination, neuropsychology, neuropsychiatry, dietician, occupational therapy, physiotherapy, rehabilitation medicine, rehabilitation nursing, social work, specialist medical services, and speech and language training.

  

            In the week or two after I arrived at Rehab Plus I started becoming more aware of my situation. I concluded that there was nothing for it but to have a positive attitude because I was there to be repaired. Despite that, it was hard keeping up my spirits as I was intensely tired, and easily fatigued, which is a characteristic of brain-injured victims. The brain is less efficient and has to work harder to do everyday things, either mental or physical. I slept long hours, which is part of the recovery, - a time when the brain is healing itself. I started off rehabilitation gently, with plenty of sleep for a start.   

 

            After a few days, I became aware of a routine. There was the meal times, and at these there were perhaps a dozen to twenty patients seated there all in various states of mobility, injury, communication and ability to feed oneself. Breakfasts were available from fridges and cupboards every morning, while lunches and dinners were delivered hot from Auckland hospital. The default diet was a varied but not particularly targeted dietary meal. There was the choice however to have a healthy meal order and I later ordered it on the advice of the dietician. One could come in anytime and grab a coffee or tea. Nurses floated around ensuring everyone who needed to was fed. There were forms to fill in to order from a menu. The variety of drugs one was on were mostly given out during meal times.  Apart from the meals, the regular daily routine things going on were the frequent taking of blood pressure, and the rosters put up on the wall of the main concourse during the night or early morning showing the patients down one side and the time across the top with the various activities that each patient was destined to do that day at a specific time. As well, patients would receive a sheet of paper on which was written their activities for the next week. The beds were made by the time one got back from breakfast.  By 8-30am the first of the days various activities started and had finished usually by 4pm. Weekends of course were free of organised activities. There was always the TV room, easy chairs to relax in, and outside the dormitories, tables and chairs.

Mondays were different for two reasons, the early morning probes to sample bodies for infections that might invade the wards, and the visits to the doctor and his team. At these visits one was interviewed, records consulted, questions asked and decisions made then and there about one’s treatment for the next week or more. Whether one was infected or not decided where one was put up, in an isolation ward or not, for infection control was taken very seriously, and although I never had any infection then or afterwards, I was lucky not to have contracted one while there. The main infections, against which few antibiotics continue to work, were methicillin resistant Staphylococcus aureus, otherwise known as MRSA, and ESBL, otherwise known as extended spectrum beta lactamase-produning bacteria, usually carried in the bowel, but if it crosses into the bloodstream can be fatal.

About twice a week I would have my blood taken to monitor the level of warfarin which was required to be kept within a narrow range. There was a BBQ every second Wednesday instead of the traditional lunchtime fare. Patients would be encouraged to help out, and relatives and friends were welcome. Also every two weeks the field officer would visit from the Stroke Foundation, whose mission is “to reduce the incidence of stroke and to gain and provide the greatest benefits for the stroke affected community to improve their quality of life.” This organisation is a very useful one to know about over the long-term.

            There was a chaplain I spotted at times visiting various patients and posting papers around advertising various meetings. Once a week on a Wednesday there was a meeting run by the social worker to hear any grievances or concerns the patients might have. I mentioned the variety of different times showing on the clocks spread about the place making it hard to keep to schedules, and lo and behold, the handyman was straight on to righting things.

 

            Within a week after I arrived, and to get a measure of my disability, the 9-hole peg test was carried out on 2^nd March by the occupational therapist. A simple board with 9 pegs in it was spilled out on the table and I was timed on how long it took to put all the pegs back in their holes. With my left hand I took 26 seconds and with my disabled right hand I took a minute and 42 seconds. It would be interesting to see how much I improved by the time of my discharge. The activities which I was involved with varied over time as my state of health improved. In the beginning, as I said previously, there was more rest and less activity. But those I did do were physiotherapy sessions where my right leg and right arm and hand were exercised in many different ways, to regain better use of nerves that control various muscles. I carried on with these exercises throughout my time at Rehab Plus, progressing eventually to a motorised walking machine. After the first few weeks I was involved with hydrotherapy where on most days of the working week I spent an hour in the heated pool with staff members and patients doing various exercises. Speech and language therapy sessions where various puzzles, problems, games, were thrown at me all with the intent of exercising my mind. There was an upper limb group where patients came together to test their arms out using a large variety of tools. The activity circuit was a fearsome round of pure physical exercise designed to give a well-rounded and challenging test of bodies by carrying out eight different activities for four minutes at a time. It was a relief to finish. The various activities increased in frequency over time as my condition improved.

 

            Starting on 10^th March, and every second week, I had been having goal-setting meetings with all the staff responsible for my welfare. Included was my sister to encourage a family dimension. For instance, the discussion for the first meeting included the various staff reporting progress - the physiotherapist that I was progressing well-walking without supervision-leg strength improved, arm strength is returning, no pain, good sensation. The speech and language therapist reported high level language assessment completed-decreased speed on word finding but achieved good scores-improved processing time of inferential information-continue with high level language tasks with improved speed and accuracy. The occupational therapist reported that she had assessed thinking skills, concentration and memory skills-divided attention being focussed on in therapy. And a combination of the occupational therapist and the speech and language therapist reported that the brain injury education and fatigue was to begin. The goal-setting included short term objectives along with who was to oversee me and the specific task. For instance, short term objectives from the 10^th March meeting was to answer questions relating to inferential pieces of information, and to increase the processing speed of word finding tasks, and the task was taken on by the speech and language therapist, and specifically the tasks involved me in doing summarising and comprehension activities, and for me to measure my processing time of word finding tasks and complete word finding activities. Some other objectives were that I should have independent mobility outdoors, to be able to lift and carry objects to enable me to do this at home, and that I will be able to understand and recall information around my brain injury and the impact on my functioning, all with the goal of going home. These goal setting meetings were part of a rehabilitation plan for me, and to which I agreed to and signed off.

            I also became part of a research project funded by the Health Research Council conducted in four rehabilitation wards around the North Island. It’s aim was to gather information on goal-setting in rehabilitation. “After a stroke, people’s views about the goals of rehabilitation should be taken into account when planning therapy. Unfortunately, it is not known what would be the best way to do this, or even if it really makes much difference to people’s well-being. This study aims to gather more information about a particular method of establishing goals during stroke rehabilitation. It might not tell us all we need to know but the results should enable a more conclusive study to be designed properly.” I was chosen because I was recently arrived, could speak English, and didn’t have significant memory problems or severe language problems.

 

            I found out ways to accomplish some things more easily, such as instead of wearing shoes with shoe laces I got crocs. I wore shorts and t-shirts instead of long trousers and long-sleeved shirts to avoid the difficulties of working the buttons and zips and belts, and, I’m sorry to admit, left off wearing underpants,- one less difficult manoeuvre to accomplish. I’d hobble along to the showers most mornings around 7 or 7-30am, but sometimes later, after going to bed around 9 pm. I started taking more notice of taking off weight in conjunction with getting control of my blood pressure by asking about medication and exercising on my own by walking increasingly long distances. The dietician advised me on cholesterol and the healthy eating option with meal ordering, and gave me literature on eating for a healthy heart and losing weight. The subject of cholesterol I am still learning about, but it all makes sense. I just wish that I had taken notice of it years ago.

            As I gained confidence that I was making significant improvements, I went on my first long walk outside the hospital up to the library at Point Chevalier and came home exhausted but satisfied I had made progress. I tried not to drag my right foot. Friends from Whangarei came to visit and took me to the zoo. I got half way round it but had to cut the visit short, but again it was an advance. I had a steady stream of visitors. Mostly they were welcome, except when I was chronically tired- then I found it a trial. Overall, it was good to see them. I found that the visitors had to learn to visit outside my scheduled activity periods or I would have my program of rehabilitation compromised. I went on weekend home stays with my family members. I checked my email but didn’t reply or send any to maintain my focus on getting well rather than re-engaging in communication. Besides, it was an effort to think.

           

            The longer I was at Rehab Plus, I got to see the difference between the often broken condition of the recently-arrived patient and how he or she mostly improves over time. Also I noticed the overall impression of Rehab Plus being a processing facility, where broken people come in one end and go out the other in various states of repair and this process is going on all the time. And the staff are mostly female, of all ages, from all parts of the world - Brazil, China, India, Sri Lanka, Samoa, England, Ireland, etc., and without exception are interesting and engaging people to know and interact with..

 

            Because I was being prepared for going home and looking after myself the staff had to ensure I would be successful. I wanted to go to my home at Great Barrier Island rather than stay on in Auckland and become an out-patient. To achieve this, Sutherland transitional house was available. This was a normal house set apart on the grounds of Rehab Plus where I could live normally by myself for a weekend, have visitors, watch TV, cook meals, sleep etc etc. I was taken to a supermarket and went through the exercise of buying my own food. I was also taken up and down steep slopes outside and up and down steps to ensure I could manage the steep parts of the land and steps of my own property. I had got a friend at the Barrier to go around and photograph the property so my carers could see what I was facing.

            The time came when a time was set for my discharge. In the run-up to discharge I was given a few tests to illuminate the before and after state of my body and mind. One was the 9-hole peg test that I had first taken on the 2nd of March, (left 26 seconds, right one minute 42 seconds). On the 7^th April the result was left hand 22 seconds, right 35 seconds - a huge improvement, and a high five from the occupational therapist. The occupational therapist also gave me a folder to accumulate all the literature that I had been given and had acquired and which I have used extensively for this article. The person doing the survey came and interviewed me just before I left for the second of the three hour-long interviews, the last to be conducted within three months of discharge to my own home.

I was finally given the chance to visit the workshop to test out my ability to use various tools. I partially took apart a petrol motor, and helped use drills to screw in desktops from underneath for the renovations then going on in the hospital. I seemed to cope allright.

 

            I can’t say enough about the care and attention I received at both Auckland Hospital and Rehab Plus. The staff were at all times professional and friendly. I just thank my lucky stars that I happen to live in New Zealand and not some other countries where I may not have received any treatment at all.

 

            On the day of my discharge, 15^th April, I was given a Discharge Report, and my medication.

I flew home three days later and made contact with the local doctor in order that my warfarin levels were continually monitored by blood samples being taken.

 

            I found the property overgrown, and the garden out of control. I attempted to used the weed-eater and found I had all sorts of difficulties just starting it, apart from the short period of time I could spend using it before I became exhausted, and my clumsiness. Starting the diesel generator was also beyond me until I could work out a new way to do it. I retrieved tools out of the creek at the bottom of my property which were taken away in a flood after I had gone to hospital. The electric water pump had also been in the flood and no longer worked.  And the water levels in my battery that stores the electricity from my solar-electric panels were way down. But that was all a small price to pay for returning home in a reasonable condition, or even returning home at all.

            The NZ Transport Agency required that I consult a doctor as a first step to a return to driving. The doctor determined that I was fit enough to drive and so I am back driving and have been driving to different locations to go for walks to maintain my fitness and mobility while varying the locale. The person doing the survey phoned me the other day to do the third and final interview. Otherwise, I’m getting on okay, considering. Social welfare have come to the rescue with the help of the social welfare person at the hospital.  

            My life has changed forever.

 

Don Armitage © 2009 (Version September)

Not finalised.