Crossings

by Jon Kerstetter

  “How long before I can go back to work? I was planning on another deployment soon.”

  “We need to talk about that. Your stroke is going to prevent you from working until you recover. Your gait, your motor weakness, and your cognitive deficits—all added up means healing will take some time.”

  I had seen Dr. Leslie in clinical practice. She had the ability to talk with patients and their families in a way that encouraged calm understanding instead of panic or fear, even in the most critical of situations. That was how she was talking to me.

  “I know, but how long is that?”

  “I don’t know yet. What I do know is that you’ve had a multifocal stroke and some of your injuries will require a long course of therapy. Some of the deficits could be permanent, but it’s too early to tell. For now, I can only recommend that you remain on medical leave. You have to let yourself become a patient and let me be your doctor.”

  “I understand,” I said. As I replied, I knew I didn’t understand. Hearing Dr. Leslie say words like “permanent” and “long course” hit me hard. I knew that strokes were serious, but I wanted one that came with more options, ones that I could control.

  “Good. Now I need to talk to Collin and you together,” she announced.

  Collin joined us, and we sat side by side in the exam room on office chairs. She patted my leg a few times before Dr. Leslie started talking. Her touch conveyed to me that she knew, just as Dr. Leslie knew, that this was going to be one of those doctor-family meetings where we talked about a prognosis because we simply had to face it and that it would lay bare the things we feared the most. I felt the heaviness of becoming a long-term stroke patient whose career was at risk. It was a force like the weight of war. I wanted to resist it, get a do-over, repeat the surgery, consider one more opinion, but the doctor in me knew that the doctor before me was right and there was no need for anything further.

  “Will his symptoms get better?” Collin asked after Dr. Leslie had explained my stroke. Her question seemed to cling to the walls of the exam room. It was the core of all the questions she asked and I was afraid to ask. And she asked it with all the sincerity and concern that belied any assumptions that my recovery would be quick and easy.

  “It’s too early to tell. We’ll likely see some improvement, but it’s hard to predict how much function will be recovered and the time frame for recovery. We should know more as therapy proceeds.”

  “Is he at greater risk for another stroke?” Again, Collin was asking the same questions I wanted to ask but didn’t.

  “It depends on the underlying cause. If we find plaques in his aorta or carotid arteries or generalized arterial disease, then yes. High blood pressure adds to the risk. We need to complete our stroke workup before we know more.”

  There it was. I was a stroke patient. No equivocation. No bargaining. No way out. No time frame for recovery. Collin gave my arm a little squeeze and I choked up a bit and swallowed hard. I blinked back a few tears, because I was a soldier and a doctor and no goddamned stroke was going to do me in.

  Dr. Leslie had already discussed my case with a neurologist and had arranged for stroke rehabilitation at the University Hospital in the departments of physical therapy and neuropsychology. A physical therapist would work on my gait and physical deficits. A neuropsychologist would work on my cognitive deficits. She also prescribed a cane to help with my balance. That one small item, a cane, angered me, and I revolted in her office.

  “You can prescribe anything you want, and I honestly appreciate your help, but I’m not using a cane. No way. No how. I’m just not going to use it,” I protested.

  “Dr. Kerstetter, you know as well as I do the risk of falls after a stroke. Why are you resisting this? You’ve already fallen at home. Your balance and gait need attention.”

  “Well, I can walk just the way I walked in this office.”

  “You mean off balance and ataxic,” she replied with a clinical barb.

  I snarled. “I don’t want a cane, period.”

  “Why? Because you’re concerned with how people will see you, or because you don’t believe you need it?”

  “I just don’t want to feel like a stroke patient,” I said. I was stubborn, resistant, and in want of an exit. I wanted to go for a walk and smoke a cigar.

  “But you are a stroke patient. You have cerebellar and brainstem infarcts, along with the others. You’ve seen the MRI.”

  “But I don’t want to have this stroke.”

  “That’s not a choice you or I have, is it.”

  —

  The following week, cardiologists at the University Hospital performed trans-esophageal echocardiography (TEE) to look at my heart and aortic arch for evidence of atheromatous plaques that may have dislodged during surgery and caused my stroke. The results were normal, which meant my particular kind of stroke didn’t increase my risk of another stroke. That was something positive and I clung to it as if it were news of cancer in remission. After more follow-up appointments with Dr. Leslie for monitoring my blood pressure and adjusting my meds to keep it within a normal range, she asked me about my plans for the Army and for emergency medicine.

  “I suppose as soon as this is all over, I’ll return to duty and continue with ER medicine or teach in the flight surgeon academy at Fort Rucker,” I said.

  “Did you discuss this with your Army staff?”

  “Colonel Smith is informed. He said I had to stay on medical hold until rehab was finished.”

  “And that means no deployments, right?”

  “Right…for now.”

  Dr. Leslie looked at me and leaned forward in her chair. She waited until she had my attention. “Dr. Kerstetter,” she said with emphasis, “I want you to understand that your rehab is going to take longer than you expect and you need to be prepared for that. Your stroke is complicated because it affected so many different areas of your brain.”

  “Yes, I know.” I couldn’t think of anything else to say. No clinical insight. No comeback to question the validity of her counseling. Just a shallow consent, “I know,” like an impudent teenager being told about exercising proper safety while driving. Yes, I know, I know. I know how to drive. I’ll be safe. Dr. Leslie was right. My stroke was complicated. I was a doctor. I understood. I would do my time in therapy, recover, heal, six months max. That was the course set before me.

  —

  My first physical therapy appointment at the University Hospital was three weeks after surgery. The therapy rooms looked like large, open-spaced fitness centers sans bodybuilding weights and treadmills. Patients and therapists worked their sessions on mats and tables and exercise machines. My physical therapist, Peggy, who had been a physical therapist longer than I had been a doctor, introduced herself to Collin and me and told us that we would start with a baseline assessment. If quick, pressured action had characterized my practice style in the ER, then Peggy’s style was exactly the opposite. She exuded a calm and unhurried manner, a different kind of clinical control than I was used to.

  “There is a battery of short physical tests we need to do,” Peggy said to us. “It helps us evaluate and plan your motor recovery.” Her demeanor reminded me of Dr. Rhodes, my professor of pediatrics at Mayo. They both spoke with an unhurried wisdom that made me feel confident that I would learn something great if I would be patient and listen.

  “I didn’t know there were tests for that,” I said. “I just thought we did a bunch of balance exercises.” I wasn’t trying to belittle therapy; I truly didn’t know what would happen.

  “Well, exercises are an important part of the plan, but we also need to assess your starting point and set goals based on the specific motor injuries you have. Make sense?”

  It did make sense. And she explained things in a way that acknowledged my experience as a physician while at the same time bringing me up to speed with the nature of stroke rehabilitation. She talked as if therapy applied to both of us, to Collin as well as me, even though I was the one with
the stroke.

  “You both go through therapy,” Peggy explained. “What we do here affects you both and you will both have to learn new things and work together. Collin, I’ll give you instructions on how to continue therapy at home. Jon, you will have to remember that Collin is as much a part of your therapy as any physical therapist, and if you work together, you’ll have a better outcome.”

  Peggy led me through the assessment and scored it using some clinical rubric I was unfamiliar with. The whole idea, as I understood it, was to quantify each motor deficit and then design a custom physical therapy program based on the assessment. Gait and balance were my greatest physical deficits. Peggy explained how the stroke damaged the sensory and motor cortex controlling my right leg and arm, foot, and hand, and areas of the cerebellum responsible for coordination and balance. I also had issues with left-right discrimination and fine motor skills, particularly with my right hand and fingers.

  Before the end of the one-hour session, we started my first exercise, a walk between parallel bars meant to test my compensated gait. As I walked between the bars, gait belt attached and Peggy near my side, I assumed my ultra-wide stance and began to walk. I shuffled, listing toward my right with my eyes tracking the position of my feet. The experience reminded me of a medical school clinical rotation in physical medicine. I observed patients learning to walk after brain injuries, and though it was interesting to watch, I always felt uncomfortable because they struggled so hard for so little gain. When I found myself between the bars, I felt that threatening sense of struggle. Would I stare at my feet forever?

  “Look up and straight ahead,” Peggy coached. “Hold the bars and steady yourself. Raise your chin. Look out across the room.”

  “If I look up, I’ll wobble and fall. I have to look at my feet to know where they are.”

  Peggy didn’t back down. She controlled the pace of the session—calmly, yet purposefully. “I understand, but let’s focus on a more natural gait and posture. Concentrate on your posture and let’s make some small corrections in your stance. Try again.”

  I started over. The length of the bars was no more than ten feet but it felt like ten yards, not because of pain, but because I couldn’t balance. Focus, I told myself as I set up my stance at the end of the bars. I started again without holding on and tried to bring my feet closer together. Before Peggy could stop me, I took two bold steps. Bang! I crashed against the right-side bar. Peggy grabbed the gait belt and kept me from falling. Collin watched from a chair across the room. She watched intently but didn’t say anything. I could tell she was scared. I was scared too, but I didn’t want to show it.

  “Use the bars to hold on,” Peggy insisted. “Lift your head. If you feel out of balance, stop and gain control. Pay attention so you don’t get hurt.”

  “I am paying attention.” When I said it, I knew we had different meanings. And with those floundering steps between the bars, I saw myself reduced to an infant learning to walk, so dependent on the steady encouragement of parents. I didn’t want to be that dependent kind of person, but I could hardly claim to be independent.

  “Start again. This time use the bars. Get your feet settled, find your balance, then take a step.”

  I stood with my hands gripping the bars, looked across the therapy room with my chin up, and took a step with my left foot. My right foot was slow to follow, but it did follow. I cheated and looked down to see where I had planted my feet. My left foot was just a toe ahead of the right, nothing close to a normal walking step. Peggy asked me to look up and said that was a good step.

  “Much better,” she said.” Let’s do another length and finish.”

  “That’s all?” I asked.

  “We had a good start. Let’s finish strong and we’ll go over your home exercises. I’ll see you back in two days.”

  Before she let us go, Peggy explained the testing and her findings. The tests related to central nervous system control over muscle groups and motor functions. Walking, she reminded us, took significant skill and control, and brain damage that interfered with that learned skill would manifest itself in the tests. Mine was not an unusual case—complicated, but not unusual in that motor, sensory, and cerebellar damage came from an embolic source of injury. She cautioned us that progress would take time.

  “This is one of those fields in medicine where progress is often measured in inches and months—not in all cases, but in many,” she said. “I suspect we’ll be working together for several months or longer. You will need to give yourself time and permission to heal.”

  Permission to heal. I had never heard that before. Time I understood. Permission I did not. I hadn’t given myself permission to have a stroke. Why would I need to give myself permission to heal? I said I understood and nodded my head, yes.

  —

  I scheduled sessions three times a week—Monday, Wednesday, and Friday—for the first few months, then two days a week, Monday and Thursday. On the calendar, I labeled the appointments “Stroke School.” The first weeks were hell. They were not as physically painful as I had predicted they would be, but they were painful emotionally and mentally. Every exercise reinforced that I had neurological deficits. Every session reminded me that I belonged to a special group of patients—stroke patients. And the reminder carried a clinical significance that was impossible to shake; that some deficits might remain forever.

  In addition to the gait training in the parallel bars, I walked on a blue taped line stuck on the floor, tandem walking. A physical therapy student helped. Peggy and the student gripped my gait belt as I brought my feet closer together and took a step on the tape. I never managed more than a single step before I fell off the line. The instant I brought my feet together, ataxia took control and the exercise degenerated into preventing a fall. If I was able to take a step, it was either off the line or crooked. I looked like I was taking a roadside sobriety test from a highway patrol officer. I was grateful that we spent only five minutes or so with that particular exercise.

  I practiced walking through a slalom of tiny orange cones. The soft weave challenged my attention and balance. We alternated the slalom course with walking down a hallway with pictures hung every ten feet or so. When I got in rhythm and my gait actually moved me forward without weaving to either side, Peggy would ask me to look at a picture as I walked. My head always aimed straight ahead and tilted down so I could watch my foot placement. When I turned to look, my feet froze and my trunk wobbled in ataxic gyrations. I couldn’t do both. It was all or none, one or the other, walk or chew gum. We did that art walk every session for three months, and whenever I looked at a picture, my legs stopped working. Just for a change, Peggy would ask me a question as I walked. Same result.

  “So, tell me your name and address.”

  “Jon Kerstetter. Two-three-eight-eight…”

  And before the words left my mouth, as they were forming in my brain, my legs halted their staccato march down the hall and I would weave back and forth, stuck to the floor like a field mouse caught in a glue trap. Peggy got me to push through with my gait, but when I was able to do so, my words came out garbled or stuttered or I missed parts of my address. I spoke one word, took one step, stopped, spoke another word, then took one more step. All or none, sometimes both, but chopped into fragments of words and steps. Peggy said the choppiness was from brain neurons wiring a new connection for unattended gait, like when an infant learns to walk. I didn’t know about that, but what I did know was how much concentration it took to walk down a hallway without falling over, especially when it involved dividing my attention over two tasks at once. I got angry with myself and said “Shit” or “Dammit” when I couldn’t walk and talk. Peggy reminded me that I was making progress and needed to breathe when I walked and look up and not overthink it. “You’re being too hard on yourself,” she said. “Remember to give yourself permission to heal.”

  Despite the sort of droning pace of physical therapy, Peggy made it engaging and even fun at times. When I wal
ked the slalom cones, she asked me to pretend I was a race car driver or a skier. Sometimes she walked me into the large therapy room, where many therapists worked on patients in an open space. I saw other patients with injuries and strokes. Some, I could see, had deficits far greater than I had, and it made me grateful that my stroke was not worse.

  When Peggy wasn’t looking, I watched the clock in the therapy room. It always seemed stuck. I suspected that she had rigged it for longer sessions, but they always timed out after fifty minutes, after my mind was spent like a bullet fired on the range. At the end of each session, she offered me water and talked about my healing and my progress. I wasn’t always sure I believed her, but I kept going back for more. “See you in a few days,” she said as she reminded me to breathe. “Take a deep breath.”

  The same week I began physical therapy, I started cognitive therapy with a neuropsychology team just down the hall from Peggy’s office. Collin dropped me off and promised to pick me up afterward. The staff explained in the first session how they measured cognitive deficits and then worked to rebuild compensatory strategies and possibly new neural connections for patients with brain damage. It sounded like the same treatment philosophy as for physical therapy.

  In the first session, I completed a series of diagnostic tests and an interview with the neuropsychologist and therapist. The cognitive testing took hours. A neuropsych technician and a graduate student worked on my case. One tested me while the other scored the tests and made clinical notes. The technician asked me to remember and repeat words from a list that she read. “Ball, train, toy, apple, couch, book, banana…” She read until she finished a list of thirty or so words. As I concentrated on remembering, I repeated the words in my brain, the first word, then the second, and then the third. By the time she read the third or fourth word, I forgot the first word. When she read the fifth and sixth words, I had forgotten all the previous words. When asked to repeat them all back at the end, I struggled to remember any of the words and recalled only three or four. We repeated the process several times, same list, same sequence. Same recall phenomenon. The tech kept reading and I kept forgetting. After three trials I said, “I can’t remember shit.” The tech told me to do the best I could and not to worry about it. It was a diagnostic test and there were no right answers. But, for me, there were right answers, the answers that recalled all the words I was supposed to remember.