Reaching Down the Rabbit Hole Read Online Free PDF Page B

the nervous system. One of my professors used to say that the residents learn neurology stroke by stroke. But it is not a simple thing.
    Six thousand people have a stroke in the United States every day. The numbers are overwhelming. The country has a stroke belt which runs from North Carolina right through Oklahoma. There are genetic factors and dietary ones. Scandinavians have the fewest strokes, the Japanese have the most. There are at least three broad categories of stroke: one involving blocked blood vessels, another involving bleeding into the brain, and a third—an aneurysm—involving a ruptured bulge in a blood vessel. Although these are all called strokes, they are as different from each other as hepatitis is from gall bladder disease (both of which give you jaundice). And their treatments are entirely different.
    My experience told me that Arwen Cleary’s echocardiogram had missed something, not just once, but twice. I turned to Hannah after we had left the room, and asked her this crucial question: “Can you put your finger on what’s different in this case?” She replied that it was the angiogram, which showed the alarming number of constricted blood vessels and cutoffs in the cerebral arteries.
    “No,” I said. “It’s the recurrence of many, many small strokes over time . That’s what’s different. You have to think about what could cause this. There must be a cardiac source for the emboli. Do the echo over. It was wrong. If it doesn’t show something abnormal on one of her heart valves or in one of the chambers, I’ll eat my hat.”
    Medical textbooks teach you what tests to do to make a diagnosis, but they do not dwell on the simple reality that humans are interpretingthe tests. Hannah ordered the echocardiogram yet again. This would be the third one. The hospital would have to eat the cost. The cardiology fellows initially balked, but when we showed them the echocardiogram from the other hospital, they came around. It was incomplete. By way of proof, the repeat TEE showed a mass sitting on her mitral valve—a papillary fibroelastoma, the second most common benign tumor of the mitral valves, and one which took the shape, as I had predicted, of a peduncular (or branched) growth. I wasn’t entirely right. The cardiologists did not think it was consistent with an atrial myxoma, a very different kind of tumor, but at least I didn’t have to eat my hat.
    The course of treatment seemed clear to me: the tumor would have to be removed as soon as possible, before another stroke occurred, and her mitral valve would have to be replaced. Although this seemed to be an answer, when I ran it by the head of cardiothoracic surgery, he balked. “There’s too high a risk she’ll have a cerebral hemorrhage on the heart pump. We’ll have to wait six weeks so her last stroke won’t turn into a brain hemorrhage.”

    Alice in Wonderland is an absurdistan story. Beyond fantasy, it’s ridiculous. That’s neurology in a nutshell. Your patient disappears down a rabbit hole. You’ve got to do something. You can’t just sit there, so you go down the hole after the patient. Sometimes you can do it right away: you go to the gynecologist and say, “Take out her ovary,” and that gets her out of the hole. It may not get her back out the same hole she went in, but in a case like Cindy Song’s, it gets her out relatively quickly. Same with Vincent Talma. We brought him out, not quite as good as new, with a slight speech deficit that most people wouldn’t even notice, but we got him out. With Arwen Cleary it would be a longer journey. Although it went unmentioned at morning rounds, her case would offer a sobering reminder that there are significantlimits to our knowledge of diseases of the human nervous system. Anyone expecting a clean resolution and a quick turnaround was in for a disappointment.
    Arwen Cleary remained on the ward for five weeks. She did suffer a cerebral hemorrhage, but it resolved with almost no