Witnesses said New Orleans native Paul “Eskimo” Clark (No, he’s NOT from Alaska!) passed out at the table three times during the 2007 World Series of Poker’s $2K stud/8 event. They said he was groggy and having trouble handling his chips. Paramedics, believing he was having “mini-strokes,” wanted to haul him off to the hospital, but he was chipleader and, supposedly, deeply in debt. Reportedly, he waved them off, lit up a cigarette, ordered some chicken wings and finished fourth.
So, what was really going on with Eskimo? Were these events really strokes? How do you know if you’re having a stroke and what should you do about it? The quick-reflex response to put down your chips and get help is just the beginning. If you’re truly having a stroke, you’re quickly going to be facing one of the most difficult and complex choices in all of medicine. I’m going to walk you through some of the basic math but, in the end, it’s you who might be called upon to make a life-altering decision from minimal information. Sounds a little like a WSOP final table, doesn’t it?
A relatively small number of strokes are caused by bleeding in the brain. These brain bleeds are usually terribly painful, dramatic and deadly. Not much decision-making here: operate, pray or pull the plug.
The more common variety of stroke is caused by a clot that breaks off and lodges in a blood vessel in the brain. The brain tissue downstream becomes starved of oxygen and quickly stops working. Headache is usually not the most obvious symptom. Usually an arm feels weak, a foot drags or a smile seems one-sided. Frequently, speech is involved. It’s slurred or maybe you know the word you want to say but you just can’t seem to get it from your brain to your mouth.
Pinpointing the exact time symptoms start is often difficult. If you were expertly shuffling your chips a few minutes ago and now you can’t lift your drink, OK, that’s your onset time. Stroke victims tend to wake up in the morning with a deficit and only notice it when they get out of bed. Was the onset one hour ago or eight? It makes a difference because timing is critical for the decision to come.
I’m going to apologize in advance to all the neurologists, interventional radiologists, stroke centers and researchers who will want to argue with the numbers that follow. Every month or two it seems another stroke study is published, statistics change, new miracle protocols are devised and new advancements are made. God bless you for the work you do. I’m not trying to nail down numbers so much as simply trying to give some insight into the kind of information a patient has to process quickly after arriving in an E.R. with a stroke. Poker players are used to thinking in terms of risk and benefit. In poker, it’s called expected value or EV. There’s a lot of that type of thinking in stroke decision-making.
Here’s the dilemma. There’s a drug available that dissolves clots. Unfortunately, it dissolves clots everywhere. Some people who get it will bleed uncontrollably from somewhere and die quickly and horribly. Most E.R. docs who have given clot-busters have seen it. I have and it’s not pretty. Let’s say the chance of death from the drug is about 1 in 16.
The risks of not treating the stroke aren’t good, either. Some small group will get better, but most suddenly cannot bathe or walk or communicate normally. Life quality and life expectancy plummet. The burden affects whole families as well as individuals.
So, take the risk and take the drug? If you don’t die, you get better right? Not so fast. Only about 30 percent get better. The others take the death risk and don’t improve. It’s an EV decision from hell.
Smart people with an affinity for statistics have spent countless hours churning numbers and have identified a group of patients for whom taking the clot-buster is a positive-EV decision. By that I mean the statistical benefits outweigh the statistical risk. That group has several well-defined characteristics.
First, their stroke is not so small as to be trivial. A right-handed 85-year-old might not want to risk death to restore some fine motor coordination in his left hand; while a 65-year-old who suddenly can’t speak, write or dress himself might feel differently. Second, if there has been recent surgery, or if the blood pressure is sky high or the stroke is “really big” (I won’t define that; there’s a complicated score for “really big.”) then the risk of bleeding goes up and the EV takes a nose-dive. On the value side of the equation, a delay of over three hours from the onset of symptoms drops the expected benefits into negative-EV territory. That’s why getting help NOW is more important than finishing fourth in a WSOP event.
There are all sorts of factors that can push that EV equation one way or another. Stroke centers lower risk and improve benefit. Fancy interventions expand the time window for treatment. New techniques and protocols are beginning to show real promise.
Here are the key points: Recognize the symptoms: one-sided weakness or numbness in an arm or leg, facial droop, confusion, speech difficulty, loss of balance. Don’t delay. The treatment window closes very rapidly. Anticipate that very soon after your arrival in the E.R., you will be presented with some critical decisions to make. Ask risk-benefit (EV) questions about the options immediately available. There is very little time for thoughtful detailed analysis. The clock has been called.
Eskimo Clark is a secretive kind of guy so we’ll probably never know if he really suffered a stroke. I would hope that most of you would place a higher value on your health than a WSOP bracelet.
— An avid poker player, Frank Toscano, M.D. is a board-certified emergency physician with more than 28 years of front-line experience. He’s medical
director for Red Bamboo Medi Spa in Clearwater, Fla. Email your poker-health
questions to firstname.lastname@example.org