A walk after hemiplegia
It was an early Saturday morning in the Himalayan kingdom after a hectic week of service as an intensivist. I was still asleep when I was startled by a loud voice full of agony: “please hurry... mom has suddenly stopped responding.” The housemaid came running to knock on the door of my bedroom. Before making sure it was not just a bad nightmare, I ran to my mom’s room and found her unresponsive. The housemaid uttered:“she was talking and walking just a few minutes back.” I trembled for a while and shouted for help, but neither I nor the housemaid knew who to call for help. We do not have effective emergency response systems.
She was not breathing and her carotids were not palpable. As a mere reflex response, I put her flat on the bed and started chest compressions and delivered a few rescue breaths. The fear of losing her was growing stronger. Suddenly she started to moan. I shouted: “mom... are you okay?” She nodded and slowly mumbled: “yes....” I could see her breathing again. I ran to dial for an ambulance, which arrived after about 10 min. Together with the help of some of my friends, we took her to the nearest hospital. In the emergency department, we found her vital parameters to be normal and she was responding to verbal commands. What a miracle. But the happiness was very much short lived. I quickly noticed that she was not moving the left half of her body and she had distinct facial deviation. She was quickly taken to the CT scanner. Except for the early features of ischemia, she had no infarction and no intracranial bleed on the head CT. The contraindications for thrombolysis were quickly ruled out. It was just 45 min since she collapsed at home. She was obviously in the window of thrombolysis. I started to call my neurology and radiology colleagues, but as expected, it would need some time for them to arrive. Most of the hospitals here do not have in-house specialists. The clock was ticking and the neurons were dying every second. Even in the capital of Nepal, none of the hospitals have well-established stroke teams or stroke management protocols. Alteplase is available only in 3–4 hospitals in the capital. A 50-mg vial would cost around USD 650. She was a suitable candidate for thrombolysis and it would potentially help her. My mother was a tiny lady weighing just 35 kg. A 50-mg vial would be enough for her. My friends ran around and were able to gather the Nepalese equivalent of USD 650 in just 10 min. I ran to the closet center that would dispense alteplase. It was early Saturday morning with very sparse traffic. I could get her the drug over the next 30 min. Within 90 min of her collapse, alteplase was administered. Over the following hours, she progressively improved and regained normal motor power. Her facial deviation resolved and she stayed responsive and oriented. A CT of the head at 24 h after the incidence showed a small infarct in the right sensory cortex. The motor cortex and the internal capsule were spared. The next day, she walked without support in the intensive care unit.
Watching my mom walk after hemiplegia brought tears of happiness to my eyes. This was an extremely rare occurrence in the capital of the Himalayan kingdom. Lack of public awareness about stroke and its potentially treatable nature, absence of effective emergency response system, lack of stroke team and stroke center, limited availability of alteplase, cost of the drug, lack of health insurance system, and the significant time lag during transportation of the stroke patients have been the key barriers for effective early stroke management and thrombolysis.
The friends, relatives, and moreover the health care workers and doctors started to praise a brave son for making this miracle a reality. However, I could not stop asking myself a series of questions. Would not every son or daughter want their parent be managed as recommended by international guidelines? Why have the guideline recommendations remained applicable only to a limited proportion of the global population residing in the western world? Is it a misfortune to be born and to reside in a resource-poor country? Is it a miracle or a right? Don’t we all live under the same sun and walk under the same moon?
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Conflicts of interest
I declare that I have no conflicts of interest.