The Road Not Taken

 Joseph Gascho, MD, in the Journal of the American Medical Association - Neuology.

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I wonder if other people are like me: ponder in bed about what dire medical diagnosis they will receive, what will be the cause of their demise when they can’t sleep at 2 am. I am a cardiologist and I have had my own share of illnesses (coronary artery disease requiring a stent, aortic stenosis treated with a transcatheter aortic valve replacement) but strangely, it is not cardiac events that I consider. For me, it is cancer. If I have had vague abdominal discomfort the day before, in the middle of the night I worry, “Do I have pancreatic cancer?” I warn my patients, especially those with atrial fibrillation, about strokes, but a stroke was something I thought little about until recently.

Early one morning while on my daily walk, I suddenly lost my balance and almost fell. I sat on the curb for a few minutes. Stupidly, I did not call my wife, sat for a few minutes, staggered home, and called the emergency department and told the attending physician about my sudden lack of balance. It took him all of 5 seconds to tell me to get myself in to the emergency department. We were there in 10 minutes and I was witness to the stroke alert that I had read about when prepping for my Advanced Cardiac Life Support recertification. “Brain attack” sounded over the speakers. Three people took my history, started an intravenous catheter, and took blood samples within 3 minutes. My head was in the computed tomography scanner in 10 minutes. No bleed. “We want to give you a lytic.” It should have been a no-brainer, but I agonized, asked them to let me walk a bit to see if I was still ataxic (I was), and tried to reach my cardiologist (too early in the morning). The risk of bleeding into my head weighed on me. But wisely, with the urging of my wife and the emergency room physician, I agreed.

All went well. There were the hourly “Where are you? Who is the president? What day is it?” questions and blood pressure checks. Frequent finger-sticks for blood glucose testing. Finally, up and out of bed in 24 hours—and my gait was back to normal. Then next day, the magnetic resonance imaging that showed a small embolic stroke in an area of the brain that controlled balance.

And now, 1 month out, I still sometimes wake at 2 am and I reflect; part of me is ever so grateful. I am back to normal, whatever that is for me. Only a physician would do it. I get up and walk around the room, heel-to-toe. Then I put my feet together and close my eyes and feel reassured when I can keep my balance for 20 seconds without opening my eyes. But stroke is now on that list of “This could be the thing that takes you out,” and high on that list.

My mind is drawn to one of the books I frequently read at night, before falling asleep: a book of poetry by Robert Frost. My favorite poem is “The Road Not Taken.” Frost sat, debating, in his cart pulled by his faithful horse, about which road to take. I used to reflect on my own life, putting myself in that cart. I could have chosen the stay-on-the-farm road that my father would have liked. Or I could have ended up a certified public accountant or teaching biology at a university. But I chose medicine, and cardiology, instead. The poem comforted me. I was the one to make the decisions. I was in control (as much as a human can be in control).

But now I think of myself as a passive bystander, watching the cart. “Which path will it take?” I think about that nefarious clot, loosed from my atrium (or from who knows where), traveling north, not making a U-turn at the arch, heading to my brain, stopping at some point, trying to decide which artery to visit. Would it end up in the Broca area, or the frontal lobe where decisions are made, or the cerebellum? My clot took that last path. Even while I was stumbling around early that morning, grabbing at the walls to keep my balance, I could say the words I needed to say to my wife, I could opt for the right decisions. Why it took the road it took, I will never know. It could have been otherwise.

And then I break out in a cold sweat, knowing how day leads onto day. Is another path kept for another day?