Tail Risk

1 July 2018

I'd clicked through the questionnaire on the NHS 111 site without much concern, hoping for some suggestions on pain management. Instead, it tells me to "CALL 999 FOR AN AMBULANCE".

I run through the whole test again and get the same response. Then I step through it with Amy, whispering through the pain of her headache in a darkened room. She cringes at the results page. She doesn't want to call 999 either - because that would mean accepting the reality where that call is necessary.

I am acutely aware of a forking path, right here, right now. I'd done a few minutes of googling between the first "call 999" result and the second, to try to figure out why such an extreme reaction was called for. Apparently, a severe ("worst of your life") headache that comes on "very suddenly" can be a symptom of a brain bleed. Amy is in so much pain that I have to make this decision alone - whatever I recommend, she will go with.

Very-low-probability-very-high-impact risks are hard to reason about.

If I choose to take action, and it's nothing - which it most likely is - then instead of waiting out her headache in a dark, quiet room, Amy will do it in a bright, loud A&E ward. It will be agonising, and terrifying.

If I choose to take no action, and it isn't nothing, we will miss our only chance at medical intervention.

I call 999. This is already starting to feel unreal. I'm outwardly cool and collected on the phone, but I forget Amy's date of birth. The operator says that paramedics are on the way but will take up to two hours. We don't have two hours - we've already wasted seven. I call an uber. The driver volunteers that the headache is probably just caused by the sun. We don't talk much. On the radio, he's playing - I kid you not - Staying Alive.

On the way, Dr Google fills in the rest of the details for me. Fifty percent of people with a subarachnoid haemorrhage die. Sixty percent of the rest are permanently affected. It is possible for a "thunderclap headache" to be triggered, instead, by coughing.

We check in at A&E. They don't say anything except "sit over there and wait". I have no idea whether this has been triaged as "headache" (bottom of the pile) or "suspected SAH" (minutes matter).

I am intensely calm. I'm planning the next actions - if this goes wrong, who do I need to call, and what do I need to tell them? If this wait gets longer, can and should I relocate us to a private hospital? I'm doing all of this like it's an interesting hypothetical, not something that I may need to actually execute on in the next 60 minutes.

I keep reminding myself that this is actually happening. It doesn't ever sink in for long. That's probably for the best.

We see a nurse who asks the same questions as 111 and 999 did. She sends us to another waiting room to wait on a neurological exam. I buy Amy some crisps from a vending machine. It feels weird.

A friend with a neurosurgeon connection is relaying information and reassurance over Messenger. She says that "even in the worst case scenarios, they are treatable". We both know that that's not true, but the doublethink is deliberate and useful.

Amy is asking me questions, but is in too much pain to fully process the answers. That might be for the best, too.

In the movie Signs, a particularly nasty car accident leaves the protagonist's wife able to talk lucidly for a few minutes - but they both know that it will be for the last time. I'm wondering if this is like that, listening to every word she says with intense focus. On one level I know that I tend to be overdramatic and that this is probably nothing - but on another, the symptoms are clear, and the statistics don't lie.

I'm reminded that Amy and I have spent far too much time and energy working. We've let months pass where, shortly, I might be in a situation where I'll beg for minutes. I make a helpless deal with myself that, if this turns out to be nothing, I'll ditch work and we'll go away together. (It does, but we're both too ill to go anywhere)

This is actually happening.

We advance to a treatment room where a doctor asks the same questions again, then runs through a neurological exam - follow my finger, touch your nose, can you feel this? He is completely calm and methodical. I'm wondering whether I need to insist on a CT scan like the internet says I do, and what "insisting" would even look like in this context. Am I going to risk my partner dying over a (very British) reluctance to cause a scene?

I'm helpless, utterly dependent. I ask some hesitant questions and the doctor takes the time to explain his reasoning. It turns on the definition of "sudden" - a severe headache that starts up over a minute or so is unusual but it doesn't indicate a SAH. One that starts up over the course of a split second, does. With no sign at all of neurological deterioration, he's confident that there's nothing to worry about.

The situation ends as quickly as it started. We step into the street and call another uber to get home. I can actually feel the switch from Emergency Mode ("is my partner about to die?") to the completely disjoint problems of Normal Mode ("I have a pitch due today.. can it wait until Monday?"). The other path, which never felt quite real in the first place, fades very rapidly into nothing.

But this is not going to be the last time that this happens. For people in less stable parts of the world - or for parents anywhere at all - I imagine that it's almost routine.

The world is an intensely scary place. Everything that you have can be taken from you, instantly and irretrievably. Being constantly aware of that awful truth would make normal functioning impossible.

But it might not be such a bad thing to be harmlessly reminded of it, every now and then.