STROKE OR NOT STROKE | Rebecca Ripperton
Years ago, I inherited a small, lapis-blue Dutch oven from my grandmother, chipped long before it came to me. Though the enamel is worn, I’ve carried it through countless moves. Soon after moving across the country to begin neurology residency, I stepped into an antique store to escape the sweltering July heat when a familiar shade of blue caught my eye. I eagerly turned over a bright, enameled pot, finding the elusive words Le Creuset stamped across the bottom – the larger sister of my grandmother’s Dutch oven. But as I looked more closely, both its heft and lettering seemed off. It was an imposter, I finally realized – a mimic. I set it back on the shelf. Not real.
In medicine, too, we are often asked to determine what is real and what is mimicry. But here the puzzles are harder, the stakes at times perilously high. Within the field of neurology, one urgent iteration of this question comes again and again: stroke or not stroke?
The first time an attending physician posed this question to me as a medical student in the hallway outside the CT scanner, I froze. For most of my clerkship year, my answer was nearly always the same: a stammered “I don’t know – I think so?” New aphasia, sudden weakness, unexplained sensory loss – each symptom alarmed me; each seemed to portend ischemia. Even when no stroke had occurred, these symptoms often looked close enough to the real thing to fool me.
During stroke codes, I marveled at neurologists who could calculate a patient’s NIH stroke scale rating from memory or scan through CT angiograms with the ease of scrolling through a camera roll. Most impressive were those who could pronounce “not a stroke” or “large vessel occlusion – call the thrombectomy suite” long before imaging had been completed. Over time, I’ve begun to develop my own degrees of concern for stroke. But as I first learned years ago, some cases leave no doubt.
On a sub-internship in my final year of medical school, an alert from the labor and delivery unit sent those of us on the stroke team sprinting across the hospital one morning. A young woman had suddenly become unresponsive at the end of her labor. When we came into the room, it was as though we had stepped into an El Greco painting: the daylight was darkened and the patient’s eyes were rolled over and transfixed to one side. In another corner, the stunned new father held his infant, wrapped in a white hospital blanket. He too was wordless, his speechlessness born of shock rather than stroke. “I’m so sorry. And congratulations,” our attending physician told him as we left to take the patient for urgent imaging.
No one asked me “stroke or not stroke?” that morning.
The CT scan confirmed what we already knew: this stroke was all too real. Blood had already begun to pool in one of the language-rich areas of her brain. I quickly learned that the satisfaction of playing and winning the “stroke or not stroke” game is erased whenever the answer is “stroke.”
For once I had been right, even down to the exact location of the injury. But neither diagnostic accuracy nor precise localization could offer any comfort to our patient or her family in that moment. In her room, our medical knowledge felt wholly inadequate. What seemed to matter more were the spaces the stroke revealed: the chasm between our patient’s expectation of motherhood and the reality, the sudden collapse of language between her and her family.
In time the blood would be reabsorbed and we would see on imaging whatever damage remained. In time, too, we would better be able to define her lasting motor and language deficits. But for the present the course of her recovery was unknown. Their small family had come into the hospital expecting one life to begin, and a new life had indeed begun. Though not the one any of us would have imagined.
How I wished I could say “not real” and undo her stroke with the ease of replacing a piece of cookware on a shelf. To restore order in her brain by returning just a few milliliters of blood to its vessel.
* * *
Months later, back on the stroke service again – this time as a neurology resident – I was helping a medical student examine a patient in the ICU who had suffered a series of catastrophic strokes only days before. The patient’s brain imaging had shown massive swelling and herniation and we were now evaluating her for brain death. She, too, had pools of blood scattered throughout her brain.
It was our student’s first coma exam and, though at times clumsy, he was careful and did well. For him, we had replaced the terrible game of stroke or not stroke with still harder questions: irreversible loss of brainstem reflexes or not? Brain death or not? After we finished, I asked the student to speak to our patient, even though she was sedated and comatose: “Just tell her where she is and what’s been happening.” His speech was halting at first, and in it I recognized the same mix of trepidation and earnestness that had overwhelmed me in similar situations as a student. But in a soft voice, he told her she was in the ICU and reassured her we were doing our best to care for her.
The next morning in the neurology workroom before rounds, I overheard him admitting to a classmate, “I didn’t think I would be so affected by doing that exam, but I was.” His comment gave me pause. He, too, was learning to carry the weight of what we do not want but cannot return or undo.
Listening to our medical student reflect reminded me that our responsibilities do not grow lighter with time; we only grow steadier in carrying them. I recalled my own first day as a student in the ICU with the neurology service. Before entering the room to see the first patient on our list, the attending physician had turned to me and asked, “what is the first step in a coma exam?”
“Pupillary response,” I answered confidently.
“Introduce yourself,” he corrected me. “Talk to your patient as if they were awake in the room with you.”
After my initial attempt, the attending chuckled and said, “Good work. Next time use shorter sentences – ones someone who isn’t a doctor might understand.”
Although the ritual of the stroke code remains the same, much has changed since I first stammered “I don’t know” outside the CT scanner as a medical student. I am more confident in predicting “stroke” or “not stroke” and less easily shaken in high acuity situations. Too often, though, I catch myself poring over imaging on a computer screen then glancing down at my rounding list to make sure I say the right words when I walk into the room, at times more certain of the contours of a patient’s carotid vasculature than of their age or name. So, the physical exam becomes an opportunity to slow down, to be present with a patient. To remember their humanity and my own. And to accept that it’s right to be affected by what we see, especially when the findings are devastating.
Now, even when the only other sound in the room is the mechanical breathing of a ventilator, I try to follow the example of my first teacher, who would take his intubated patients’ hands in his own as he spoke to them in their coma – his work an exercise in perpetual hopefulness. At the same time, I feel ever more keenly what I cannot do for these patients: return blood to vessels, make dying brain tissue grow again. There are many order sets in Epic, but not one for this. And so, though he never said so, I have come to realize that when we take the hands of our sickest patients, it is as much for us as for them.
* * *
Months after moving, my grandmother’s lapis-blue pot continues to serve me well, though I have yet to find its mate. For now, there is a quiet pleasure in setting aside what I do not want, simply because I can. In medicine there is no shelf, no return; only the responsibility of carrying what is real and learning, slowly, how to bear its weight.
Rebecca Ripperton is a neurology resident at Beth Israel Deaconess Medical Center in Boston. She received her medical degree from the University of Colorado School of Medicine and her undergraduate degree from St. John’s College in Annapolis, Maryland. Her interests include medical education, narrative medicine, the humanities, and improving care for patients in carceral settings.