- Email: [email protected]
Life at the kerb
Perspectives
types of thrombolytic agents, such as desmoteplase, are also in clinical test. For a book dedicated to describing controversy, Zivin and Simmons overlook what is a key issue for me— namely, the way that some stroke experts have not contributed to recruitment in the IST-3 trial. If more of the stroke fraternity had joined this study we would have known some years ago whether to treat
patients older than 80 years, and those presenting up to 6 h after stroke onset. As it is, we will have to wait for the trial to report in 2012. This lack of cooperation is common in stroke research and it is vital that we, as trialists and investigators, take part in each other’s trials. So who is this book for? Stroke physicians, whether specialist or in training, will be curious about
reading this account of the story of tPA, as will those with an interest in medical history. But for me the book’s emphasis on the US aspects of the tPA controversy means this story remains incomplete. PB is a member of the IST-3 Data Monitoring Committee and uses tPA to treat stroke patients.
Philip Bath [email protected]
In brief DVD Life at the kerb
John Kawie: Brain Freeze Written and performed by John Kawie, directed by Mark Maxey. Big Round Records LLC, 2010. http://www.brainfreezedvd.com
1644
Stroke is not usually a laughing matter. Until, that is, New York stand-up comedian John Kawie resumes his career after a major stroke. This DVD of his comeback session offers something special for clinicians involved with stroke. From Kawie’s entrance—if bounding and hemiparetic can be contained in the same phrase—and his few prefatory curses that he has to climb stairs up to the stage, we are shocked out of our professional reserve, and challenged to rethink, and engage with, the individuality of our patients. Stroke medicine is overfixated with the acute at the expense of the chronic—a myopia neurovascularia whereby an intense focus on the acute hospital phase is followed by a loss of interest afterwards in the challenges patients face with the new ways of living that stroke demands. All great humour has the human condition at its heart and this is no exception, even if no aspect of human decency or reserve is spared from Kawie’s relentless dissection. Unsparing of a fellow-sufferer who has fallen into a self-pitying mode, complaining that he cannot hail a taxi from inside the lobby, Kawie’s response, that “life is at the kerb”, becomes a leitmotif for the engagement, recovery, and accommodation that underpin his return to public life.
Even the onset of his stroke has its tragi-comic hue: never has dysarthria been used to such comic effect, as he vainly tries to defend himself from accusations of being drunk (an experience not uncommon in young-onset stroke). Humour also provides a cheeky assertion of dignity in the face of the many indignities that come with personal care by others, particularly the stellar miscasting of personal care assistants at home. In a phenomenon recognised but poorly articulated in rehabilitation, Kawie provides a new variation to William Osler’s dictum on learning from patients: in this case, it is the other patients, rather than physicians, who are learning from each other. A friendship struck up with a braininjured patient, initiated through a shared admiration for the shapely posterior of one of the therapists, provides the spark for his realisation that his future lies in his own hands. Kawie’s key props are his residual deficits, from the difficulty of buttoning his coat with a hemiparesis to memory problems: he jokes about needing Post-Its to jog his memory, and then opens his coat to show his lining completely covered with the multicoloured reminder notes. His adventures with escalators in his beloved bookstore are excruciatingly funny, but his rejoinder to those who
suggest using the lift even more bracing: if they can have bungeejumping and other adventure sports, why can’t he have escalators? The dark and wildly funny heart of the performance is the group therapy session, where Kawie is given a glove puppet that gives him licence to express his savage rage and bile at oversimplifications, pat answers, and the expectations of conforming to certain “positive” patterns of recovery. At a deeper level it is a cry of anguish and anger at what he has lost, and an uncomfortable prompt to clinicians as to whether our processes allow for a therapeutic and individual venting of these losses. The chief casualties of Kawie’s remarkable performance in Brain Freeze are pity and professional complacency. He challenges us to replace pity with an identification of our shared destiny, fragility, and spirit. In turn, clinicians need to identify and struggle with what James Joyce termed the “hemiplegia of the will” that sometimes prevents us from seeing the bigger picture. Maybe, after recovering from our helpless laughter, we too might rouse ourselves to get out of our insitutionalised lobby and discover that at its best, stroke medicine, like life, is at the kerb.
Desmond O’Neill [email protected]
www.thelancet.com Vol 377 May 14, 2011
types of thrombolytic agents, such as desmoteplase, are also in clinical test. For a book dedicated to describing controversy, Zivin and Simmons overlook what is a key issue for me— namely, the way that some stroke experts have not contributed to recruitment in the IST-3 trial. If more of the stroke fraternity had joined this study we would have known some years ago whether to treat
patients older than 80 years, and those presenting up to 6 h after stroke onset. As it is, we will have to wait for the trial to report in 2012. This lack of cooperation is common in stroke research and it is vital that we, as trialists and investigators, take part in each other’s trials. So who is this book for? Stroke physicians, whether specialist or in training, will be curious about
reading this account of the story of tPA, as will those with an interest in medical history. But for me the book’s emphasis on the US aspects of the tPA controversy means this story remains incomplete. PB is a member of the IST-3 Data Monitoring Committee and uses tPA to treat stroke patients.
Philip Bath [email protected]
In brief DVD Life at the kerb
John Kawie: Brain Freeze Written and performed by John Kawie, directed by Mark Maxey. Big Round Records LLC, 2010. http://www.brainfreezedvd.com
1644
Stroke is not usually a laughing matter. Until, that is, New York stand-up comedian John Kawie resumes his career after a major stroke. This DVD of his comeback session offers something special for clinicians involved with stroke. From Kawie’s entrance—if bounding and hemiparetic can be contained in the same phrase—and his few prefatory curses that he has to climb stairs up to the stage, we are shocked out of our professional reserve, and challenged to rethink, and engage with, the individuality of our patients. Stroke medicine is overfixated with the acute at the expense of the chronic—a myopia neurovascularia whereby an intense focus on the acute hospital phase is followed by a loss of interest afterwards in the challenges patients face with the new ways of living that stroke demands. All great humour has the human condition at its heart and this is no exception, even if no aspect of human decency or reserve is spared from Kawie’s relentless dissection. Unsparing of a fellow-sufferer who has fallen into a self-pitying mode, complaining that he cannot hail a taxi from inside the lobby, Kawie’s response, that “life is at the kerb”, becomes a leitmotif for the engagement, recovery, and accommodation that underpin his return to public life.
Even the onset of his stroke has its tragi-comic hue: never has dysarthria been used to such comic effect, as he vainly tries to defend himself from accusations of being drunk (an experience not uncommon in young-onset stroke). Humour also provides a cheeky assertion of dignity in the face of the many indignities that come with personal care by others, particularly the stellar miscasting of personal care assistants at home. In a phenomenon recognised but poorly articulated in rehabilitation, Kawie provides a new variation to William Osler’s dictum on learning from patients: in this case, it is the other patients, rather than physicians, who are learning from each other. A friendship struck up with a braininjured patient, initiated through a shared admiration for the shapely posterior of one of the therapists, provides the spark for his realisation that his future lies in his own hands. Kawie’s key props are his residual deficits, from the difficulty of buttoning his coat with a hemiparesis to memory problems: he jokes about needing Post-Its to jog his memory, and then opens his coat to show his lining completely covered with the multicoloured reminder notes. His adventures with escalators in his beloved bookstore are excruciatingly funny, but his rejoinder to those who
suggest using the lift even more bracing: if they can have bungeejumping and other adventure sports, why can’t he have escalators? The dark and wildly funny heart of the performance is the group therapy session, where Kawie is given a glove puppet that gives him licence to express his savage rage and bile at oversimplifications, pat answers, and the expectations of conforming to certain “positive” patterns of recovery. At a deeper level it is a cry of anguish and anger at what he has lost, and an uncomfortable prompt to clinicians as to whether our processes allow for a therapeutic and individual venting of these losses. The chief casualties of Kawie’s remarkable performance in Brain Freeze are pity and professional complacency. He challenges us to replace pity with an identification of our shared destiny, fragility, and spirit. In turn, clinicians need to identify and struggle with what James Joyce termed the “hemiplegia of the will” that sometimes prevents us from seeing the bigger picture. Maybe, after recovering from our helpless laughter, we too might rouse ourselves to get out of our insitutionalised lobby and discover that at its best, stroke medicine, like life, is at the kerb.
Desmond O’Neill [email protected]
www.thelancet.com Vol 377 May 14, 2011