Imagination in the Stroke Ward

“What mazes there are in this world. The branches of trees, the filigree of roots, the matrix of crystals, the streets her father recreated in his models… None more complicated than the human brain, Etienne would say, what may be the most complex object in existence; one wet kilogram within which spin universes.”

So writes Anthony Doerr in “All the Light We Cannot See,” a brilliant novel that won the 2015 Pulitzer Prize for fiction. It’s the book I’ve been reading this week and (sadly) the only novel I’ve read all year. Between my shifts at the hospital, I crack open the covers, unfurl the pages, and fall into the universe that Doerr spins with his sharp sentences. I follow two characters, two unusual children in extraordinary circumstances: Werner, a scrawny albino orphan prodigy conscripted by the Nazis for his mastery of radios and who fights to retain his humanity; and Marie-Laure, a blind French girl hiding in a walled seaside city who becomes a vulnerable courier and a dreamer.  For hours at a time, the book’s words transport me into the vividly bleak fictional realities of two children in the maelstrom of World War II.

But every night at midnight, I force myself to shut the book so that I can awaken punctually in my own reality. At 7 am, I become a medical student on the neurology stroke team at a metropolitan hospital, and I resume caring for patients whose brains have recently suffered catastrophes. Our job is to evaluate their deficits, localize them in the nervous system, coordinate scans and biopsies and vEEG brain monitorings, and begin their grueling treatment courses. All the while, in those crucial first days, we protect their bodies as their brains begin to mend themselves.

Most of our patients* we expect will survive, but they are enduring some harrowing disease processes: venous sinus thrombosis leading to ischemia in Wernicke’s area, perioperative embolic stroke, Guillain-Barré syndrome. As I learn about the proper workup and management of these conditions, my mind wanders away from the medicine to dive the minds of my patients. What does their world look like to them and their damaged brains?

Wernicke’s area is charged with comprehending language, and the woman who lost hers to a venous clot lies in her bed calm and unconfused, watching Netflix on her iPad. She can’t comprehend what the characters are saying, can’t read the text, and she resorts to answering our probing inquiries articularly but randomly. What is it like to be lost in a world once familiar but now encoded in gibberish? Why isn’t she panicked by the senselessness of it?

What about the young man who awoke from his minor vascular surgery to blurry eyes, uncoordinated fingers, and a sluggish tongue? He was told it was a harmless procedure and his disorientation was dismissed as the aftereffects of anesthesia. Only when his deficits persisted did he finally realize that his brain was accidentally carpet-bombed by a shower of dislodged plaque.

And the girl my age who worked through a mild stomach bug, then Guillain-Barré struck. Her immune system made a griveous error and gnawed away her nerve’s myelin sheath. A week later, she sensed a tingling in her feet, then a rising weakness, then a rising paralysis, and now she lies paralyzed in a bed, cross-eyed unable to close her eyelids, mute with her jaw lolling open, unreined heart racing, and with a machine breathing for her through a slit in her throat. All she can do is subtly nod when her mother points at letters on a chart to spell out messages letter by letter. We reassure her that she’ll slowly recover in a few months, but then we walk away and she stays there trapped in an her immobile body.

At 5 pm, and I go home, shed my white coat, and resume my life outside the hospital. I let the plight of our patients fade away and lose myself in other worlds instead.

“Toiling with your blood / I remember something
In B, un—rationed kissing on a night second to last
Finding both your hands / As second sun came past the glass
And oh, I know it felt right / And I had you in my grasp”

So writes Bon Iver/Justin Vernon on their/his third album “22, A Million” that was released this weekend after a 5-year silence. I’ve been listening to it on repeat, and it’s entrancing. It’s simultaneously electronic and rustic, pensive and lonely, chilly in timbre but warm in expression. Bon Iver’s music always reminds me of winter; his falsetto voice and enigmatic lyrics transports me to the isolated wood cabin in snowy Wisconsin where he creates his music. How privileged my mind is to be enriched by these artists’ creativity.

Of course, as a medical student, I must return to my scholastic duties. As I pore over my neurology books and lecture notes and to pack my brain with information, my mind still flits back to our patient with the Wernicke’s infarct who is currently incapable of language comprehension. As I teach my brain how to interpret MRIs and CTs, I’m reminded of our patient who is relearning to see anything at all. While scrolling through his slides on our digital lightboxes, I see the bright plumes of hyperintensity blooming in the dark folds of the brain that represent the lesions affecting his vision.

Honestly, brain imaging is close to magical. Doctors can scan straight through the skull into the internal structures of the brain, one step closer to peering into the minds of our patients. Unfortunately, as much as we can see, we don’t have the capacity to heal the brain’s microscopic complexity. All we can do is protect and wait.

For our patient with Guillain-Barré, we’ve tried IVIg and PLEX therapy, but she keeps on worsening. Every day, we reassure her that “it just takes time.” We moisturize her eyes that she can’t close, load her body with opioids to combat the myopathic pain, squeeze her calves to prevent clots, roll her around clean away her frequent diarrhea. Every day, we shut off the ventilator and ask her to exercise her lungs, even though she has barely any control over her breathing. Every day, we walk in and ask her to hang in there while her nerves mend themselves. Every day we have to walk out, powerless to help. I don’t know what runs through her mind when we leave, because she can’t really ask questions then and there. Maybe when she’s fully recovered next year, she can write a book about her poetically strange brush with Guillain-Barré and help us understand her vividly bleak reality.

It’s been a gloomy week. The spires of Manhattan’s skyscrapers are shrouded in clouds, and the sky is an blank gray canvas. Underneath them, I shed my white coat and shirt and run through the misty streets and the shadowless Central Park. My mind wanders, replaying Bon Iver’s frigid musical textures, envisioning the smell of Marie-Lauren’s ocean-scented shell collection, thinking about our patients on the stroke ward.

I hate that we have no disease-modifying interventions for them. When I’m out running, this troubling thought echoes in my oxygen-hungry brain. For our paralyzed patient who struggles to even breathe, I dash around outside on her behalf and train my lungs to withstand hours of strenuous exertion. For our patients staggering down the hallway on new wobbly legs, I strain my legs to propel me further and faster. Maybe that’s my way of trying to help from a distance.

Something about the stroke ward just draws me in closer than I should probably be. Imagination is the heart of compassion, but I haven’t found where one ends and the next begins.




*Patient details altered for privacy

PS. When all these things — the stroke ward, the book, the music, the weather — all came together, this post’s idea grew and wouldn’t go away. I feel it’s a promising idea that I wish I had time to write out, but I must set it aside and return to studying…

PPS. I later realized this turned out to be the spiritual sequel to the big post I wrote exactly a year ago about Brain and Mind.