Save vs. Death

So we’re coming up on the seventh anniversary of The Event, which should mean that we’re past the statutory seven-year bad luck period of whatever caused it, right? I don’t remember walking under any ladders or breaking any mirrors, but it’s possible that I opened an umbrella in the house or that I crossed paths with a black cat, most likely because I was trying to pet it.¹ But anyway, this isn’t a post about good luck or bad luck or even anniversaries, really. This is a post about saving throws.

I’m sure it comes as no surprise to anyone that back in the day I played a lot of AD&D, and after I got out of the hospital, one of my old friends and fellow players said something to the effect of I must have rolled a 20 on my saving throw to have come through my little health crisis as well as I did. I sort of filed that comment away for future reference and decided that “Annieversary” number seven was a good time to revisit it. But first, a little recap (or, for you non-RPG-playing-nerds, introduction) to saving throws, courtesy of Wikipedia:

[Saving throws] are used to represent the character’s ability to avoid or resist the threat, such as by dodging a trap, or being able to resist the effects of a poison. For this reason, they are often modified by appropriate attributes such as Dexterity, Constitution, Wisdom or Luck. … A successful saving throw typically either negates or reduces the effectiveness of what is being saved against.

Now unlike an RPG, where you might make one saving throw against the lightning bolt or fireball or hold person spell² that somebody lobbed at you, I would say that this was more a series of saving throws of various difficulty³, spaced out over the course of a month or so; but obviously the first and biggest saving throw would have been against the rupture itself, and I would call that one a Save vs. Death⁴.

1. Save vs. Death
2.6 × 3.5 mm irregular right ICA terminus aneurysm ruptures,
producing a substantial subarachnoid hemorrhage.
- Loss of consciousness at home, alone, except the cats and the dog.
- Blood in both Sylvian fissures, more prominently on the right.
- Angiography report says clinically Grade III, most likely Hunt and Hess III.
- "You had a LOT of blood in there." -- My neurosurgeon, about a month later.
THE ODDS:
According to the Cleveland Clinic, about 25% of people who experience a brain aneurysm
rupture die within 24 hours. Around 50% of people die within three months of the rupture
due to complications. Of those who survive, about 66% experience permanent brain damage.
Some people recover with little or no disability.

So obviously that’s the save upon which all the other saves were contingent; after the initial bleed failed to do me in, I had to, you know, wake up, call for help, and survive long enough to get emergency coiling surgery the next day, none of which was a given either. Time to roll the dice again.

2. INT Check: Correct Diagnosis
This check is made by the staff in the Emergency Department. Being diagnosed quickly and
correctly with a ruptured/leaking aneurysm and subarachnoid hemorrhage is extremely
important and by no means guaranteed. A failed check here could result in delayed treatment,
including being sent home with painkillers, with potentially catastrophic results.
THE ODDS
Studies have estimated missed diagnosis or misdiagnosis occurs in from 5%
to 12% of cases, although this varies across populations. Among patients who initially
presented with normal mental status, a missed diagnosis was associated with worse long-term
outcomes.

Despite the fact that aneurysms are relatively common (estimated to exist in perhaps 3% of
the population), most never cause symptoms and a subarachnoid hemorrhage from one remains
a bit of a zebra⁵. I haven’t found a lot of statistics about this, but what statistics there are are sobering. In one study, among patients who were misdiagnosed:

• 73% had not received a CT scan—the most common diagnostic error.
• 39% developed neurological complications before the correct diagnosis.
• 21% experienced rebleeding before diagnosis.
• Migraine or tension headache was the most common mistaken diagnosis.
• Among patients with relatively mild initial presentations (Hunt & Hess I–II), misdiagnosis was associated with 3.89 times the odds of a poor clinical outcome compared with correctly diagnosed patients.

So in a way, I was weirdly fortunate that mine hit me hard enough that, in modern D&D terms, we can say they made this check with Advantage (i.e., roll twice and take the higher result).

3. Save vs. Death/Incapacitation
Remaining alive and stable until the aneurysm could be repaired.
Surviving the initial hemorrhage, ambulance transport, emergency evaluation, 
angiography, and the wait until the following day's coiling.
THE ODDS
Contemporary research estimates that approximately 3–6% of patients experience 
rebleeding within the first 24 hours. Rebleeding substantially increases the 
risk of death or poor neurological outcome.

My memory of this period is a little fuzzy but I’m pretty sure they did tell us about the possibility of rebleeding, and they were very, very keen to get the coils in before that happened. There was a clock, and it was ticking. Interestingly, that ties into the next saving throw, which wasn’t one I made; the medical team did.

4.  DEX Check: Surgery
Successful coil embolization
This is the medical team's ability check. The angiogram documented a favorable aneurysm
neck, approximately a 2:1 ratio, making it suitable for endovascular treatment.
THE ODDS
Securing a ruptured aneurysm promptly is one of the most important interventions for
preventing rebleeding.

In my case, my surgeon later told me my artery had a “weird little jog”⁶ in it that had made getting to the aneurysm somewhat more challenging than had been expected, hence why it’s a Dexterity check⁷, which — spoiler alert! — they pulled off. Of course, securing the aneurysm was hardly the end of the story, because it was still not clear what kind of long-term damage might have been done. I was pretty much asleep all the time so it was hard for anyone to tell for sure.

5. Save vs. Permanent Brain Injury
Surviving the hemorrhage with cognitive abilities substantially intact.
This is distinct from surviving the initial bleeding. The large blood burden, loss of 
consciousness, and clinical Grade III all establish a serious neurological event.
THE ODDS
Long-term cognitive, behavioral, and quality-of-life problems are common among SAH
survivors, including some who achieve good physical recovery. 

I was ultimately able to return to my previous job, return to driving, grocery shopping, hobbies like ballroom dancing, etc. Finishing a novel, on the other hand, seems to be another matter, although I am thinking about giving that another shot next year. I also spent years not remembering a single dream, and when I finally did start to remember them they were super boring, which was a big and unwelcome change from how they used to be. I continue to have some difficulty in overstimulating environments, especially unfamiliar ones with a lot of light and sound, such as the last room at the Beyond Van Gogh exhibit where music plays while you’re surrounded by swirling animated Van Gogh paintings on the walls, floor, and ceiling; I got super, super edgy in there and had to step outside for a while to compose myself.⁸ I also have lingering occasional (though diminishing) bouts of what I call “the weird anxiety” and what appears to be a permanently exaggerated startle reflex⁹, and I feel like I tend to drop things a little more often now.¹⁰ There’s also the whole medical PTSD thing, which I finally got some help for over the past year or so. So lest one think all these successful saving throws mean I got off scot-free, think again; I may have saved against the primary attack, but it still inflicted conditions.

6. Save vs. Stroke
Delayed vasospasm and cerebral ischemia.
Vasospasm is a well-known and dangerous complication of subarachnoid hemorrhage which
can inflict further damage via ischemic stroke, by causing arteries to spasm and constrict.
THE ODDS
Angiographic vasospasm is reported in roughly 30–70% of SAH patients, depending on how 
it is defined and detected. Delayed cerebral ischemia occurs in a smaller proportion, 
often estimated around 20–30%. Vasospasm does not automatically mean stroke, but 
greater subarachnoid blood burden is associated with increased risk.

Although they did tell me I was showing signs of vasospasm at one point, I never developed noticeable symptoms. They kept a very close eye on me the whole time with transcranial Dopplers, one of the many technological innovations I had never heard of before this all happened.

7. Save vs. Disease
I developed a Klebsiella oxytoca urinary tract infection with a fever reaching 
approximately 103°F, adding a systemic complication to an already dangerous 
hospitalization.
THE ODDS
Medical complications after SAH are associated with worse outcomes, which is why 
specialized neurocritical care is so important.

I’m active in a few different aneurysm groups and I like to tell people in them about neurogenic fever, because it doesn’t seem to get talked about very much and, in addition to being potentially dangerous in and of itself, it can cause you to ignore high temperatures that are actual fevers. In my case, I had been routinely spiking temperatures of up to around 102°F, and it wasn’t until somebody else told me how warm I felt that we decided that maybe this time I should go get looked at. Good thing, too, because this one was higher than that, and once the good folks at the Emergency Department figured out what was going on they gave me an almost comically massive dose of IV antibiotics and a course of pills to take home to knock down the infection.

8. Save vs. Lasting Disability
Recovery, rehabilitation, and adapting to life afterward, with help from others.
Discharged from intensive care, recovered physically, returned to work and other pursuits,
and eventually began addressing the psychological aftermath through EMDR.
THE ODDS
Functional recovery varies enormously according to initial neurological grade, 
complications, age, treatment, and rehabilitation. Importantly, a good functional 
outcome does not necessarily mean a complete absence of fatigue, emotional changes, 
sensory difficulties, or trauma-related symptoms.

The key here is “with help from others” which, sadly, a lot of people end up not having. I have seen many, many accounts of people who have lost contact with friends and family after something like this. It takes a toll on everyone around, not just the patient; between personality changes wrought by brain injuries, economic pressure (many SAH survivors are unable to return to work), the burden of aftercare, paperwork, and so on, it can be challenging to maintain the relationships you need to navigate something like this. In fact this last one might be better thought of as a series of rolls by the patient and everyone around them, against a variety of attributes, not just Constitution, but if I could write that rulebook I would probably be on the lecture circuit right now instead of typing a blog post on my computer.¹¹

This series of saving throws is just a thought experiment from somebody who has spent a lot of time rolling funny-shaped dice both IRL and virtually, but I found it a useful way to gain perspective on what happened in the fall of 2019. Between the chances of dying in the initial rupture, from a rebleed, from complications such as vasospasm and infection, plus the chance of serious neurological damage that can impair one’s ability to function, the odds of this kind of outcome ― back to work with computers, back to driving, dancing, shopping, cooking; you know, mundane things that you never really think about before something like this happens ― are not great¹². But for now the campaign continues, and to anyone who has read this far, I would like to offer this: May you never need to make so many rolls in a row, but if you do, may they all succeed.

1. “Crossing paths with a black cat is not bad luck! Black cats bring good luck! LIKE NINJAS!” ― Oona, probably. ↩︎
2. But not Magic Missile, which always hits. ↩︎
3. I had ChatGPT help with the difficulty levels, by looking at the statistics for various situations I encountered during my hospital stay and have previously documented here. Probably in excessive detail. ↩︎
4. Obviously none of this has any basis in science or medicine; no doctor is going to congratulate you in ICU for succeeding in your Save vs. Death. But it would be kinda cool if they did. ↩︎
5. When you hear hoofbeats … ↩︎
6. Technical term. ↩︎
7. Back when I was playing tabletop AD&D, you didn’t save or check vs. ability scores, you saved vs. what was being thrown at you, according to values in a table. It wasn’t until I started playing Baldur’s Gate 3 that I discovered all these ability checks, not to mention that all of a sudden higher armor classes are better than lower ones. What ever happened to THAC0?! But I digress. ↩︎
8. This has left me quite wary of things like rock concerts, despite the fact that my faves Metric keep coming to town. ↩︎
9. No more haunted houses for me! ↩︎
10. My wife claims that this is just my own perception and isn’t true, but when we needed to carry her serger ― a sewing machine type thing that we would be unable to replace ― around the corner to show it to our friends, she opted to carry it herself instead of letting me do it, even though it’s pretty heavy. So you do the math. ↩︎
11. No I wouldn’t. Standing up and talking in front of a bunch of people is just about the last thing I would want to make a career out of doing. ↩︎
12. Another technical term. ↩︎