When emergency physician Michael J. Jarosick, DO, decided to go for a mountain bike ride in Ohio’s Mohican State Park on Aug. 20, 2013, he didn’t expect to end up as a patient in the emergency department—or know that his decision to ride with two friends, Rabbit and Jamieson, instead of riding solo would be a critical one. During the ride, he experienced a subarachnoid hemorrhage.

Dr. Jarosick, currently a physician at a privately owned urgent care and occupational medicine clinic in Findlay, Ohio, recently sat down with ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, to talk about his experience diagnosing his own medical situation and being on the receiving end of lifesaving emergency care.

KK: What were you doing that day?

MJ: I was mountain biking. I was preparing for a trip to Washington State to stay with a friend and do some mountain biking out there with him. I had all of my stuff packed. I was busy all day tying up loose ends before I was going to leave town for a week and knew that I wanted to get in one more ride.

KK: Was this was an average training day, and did you feel normal?

MJ: I was going to ride by myself, like I often do. I thought at the last minute, “Why don’t I call my one friend Rabbit and see if he wants to ride?”

KK: When did you know that something was not right?

MJ: We were about an hour into the ride, starting to do this one hill climb, when I noticed my neck was a bit sore and I was getting pressure in the temples. I thought, “This is my backup helmet, and I can never get it adjusted just right.” This built for about 20 minutes gradually. The thing about [feeling a] thunderclap coming from out of nowhere? Not really.

KK: Your first response, just like every good patient, was denial of your symptoms?

MJ: Yes, but then I looked at my buddies and said, “I’m having a subarachnoid hemorrhage.”

KK: Are they physicians?

MJ: No. One guy is a total layman, and the other one is an athletic trainer. They said, “You’re having a what?” I said, “A blood vessel broke in my brain, and it’s bleeding.” Within a matter of minutes, we shifted into rescue mode. I was overcome with pain right there. The nuchal rigidity was unbelievable. I tried to sit down, but any little movement of my head when I was seated upright was too much pain for me to take. It was nuchal rigidity as I imagined it would be.

KK: Absolutely. Did you have any of the classic symptoms like photosensitivity, nausea, or vomiting?

MJ: I did get some nausea, and I vomited once.

KK: When this happened, how far away from civilization were you?

MJ: We would have had to go at least two miles in either direction to get to one of the main roads.

Dr. Jarosick on a bike ride.

KK: Were you going to try to ride out, or were you going to have someone come up and get you?

MJ: They asked me, “Can you ride out of here?” and I said, “No, there’s no way I can do that.” It just so happened that we were at a junction in the trail that crosses a hiking trail. I knew that if they could just get me up to that parking lot, I’m basically at the ambulance.

KK: Did you experience any fear or other emotions?

MJ: I saw myself as patient and rescuer at the same time. I couldn’t effect the rescue by myself, but I had to participate in it. I was in a survival mode.

KK: What kind of thoughts were you having? Were you starting to think about how bad this would be? What if you didn’t make it out?

MJ: I stayed pretty positive because I’m thinking I’ve seen some subarachnoid hemorrhages in the ED; they get treatment, and some of them do all right. I used to never carry a cellphone because I believed in rugged self-reliance. I always carry a cellphone now. Between the three of us, one guy had a cellphone. There are valleys there where you really can’t get a signal. My friend Jamieson, the athletic trainer, rode up that trail to the open parking lot, and he was able to call 911.

KK: Did they transport you by ground, or did they fly you?

MJ: I was in the submissive baboon position with my butt in the air, my hands on the ground, and my head in my hands. It was the most comfortable for my neck. As I was in that position, the paramedic [Tom Gallagher] walked up to me and said, “We have the stretcher and the rig. Want us to go get it?” I said, “Can you carry me out in this position?” I knew I didn’t want to lie on my back. He said, “No, we’d have to lay you on your back.” So I said, “Get me up, and let’s see if I can walk out of here.” At that moment, I had to push the guy away so I didn’t puke on his shoes.

KK: Were you a good patient and let them do their work? Or did you tell them exactly what was going on and exactly what you wanted done?

MJ: I was a good patient. I certainly would have put up a fight if I disagreed with them, but I didn’t have to because they had it under control. There was a well-intentioned nurse who walked in and said, “I heard you have a bad headache.” I replied, “It’s a subarachnoid hemorrhage.” That really threw her off guard. She said, “Do you have a history of migraines?” and I said, “No, and this is a subarachnoid hemorrhage.”

KK: The nurse was your first contact when you came in.

MJ: Yes. She was doing what she was supposed to do. I was just a little ahead of her.

KK: Did you have a CT scan or lumbar puncture?

MJ: The doc walked into the room, and I basically told him the short version of what happened. I don’t remember the exact words of the conversation, but he did a very appropriate 30-second exam. Why spend more time? He gave me something for pain and ordered the CT, just like that.

KK: So the CT was positive. How did he deliver that information to you?

MJ: He came in and said, “Your CT scan shows subarachnoid hemorrhage,” matter-of-factly. He already had a plan, which was good. We did have a very good neurosurgeon there at the hospital, Boh Chopko. He said, “I called Chopko, and he’s only going to be here for another week and doesn’t think he should be involved in your care since he’s not going to be here to finish it,” so I was transferred.

KK: How did they fix you? What did they do?

MJ: The very next day, they did an angiogram and saw that there was no aneurysm. There was nothing to fix. It’s what they call a perimesencephalic subarachnoid hemorrhage, also known as a prepontine, which are venous leaks in the brain stem. It often happens to young, healthy folks who are exercising, but they don’t say that exercise caused it, if that makes sense. I saw the attending neurosurgeon the next morning, and I was feeling a lot better. I was thinking, “I’ve got this thing beat. I was looking down the barrel of the gun last night, and now I’m just going to have to hang around the hospital for a couple of weeks.” Then things changed. I got a very severe headache that night. It was 24 hours later. That’s when I was really scared. I was a lot more scared than when it first happened. Knowing that I don’t have an aneurysm, there’s nothing to fix. If the return of my severe headache meant that I was bleeding again, now what was going to happen? What were they doing to do? I was much more scared than when it happened originally.

KK: What did they do next?

Tom Gallagher, the paramedic/fire chief who met Dr. Jarosick in the park and initially assessed his condition.
PHOTO: Michael Jarosick

MJ: They ran me down for an emergency CT and showed that there was no more bleeding. That was all I needed to know. The explanation that I was satisfied with is, “This is just a process. You’re going to have bad headaches for a while.” As long as I knew I wasn’t bleeding and wasn’t going to die, I was OK. They had to keep me in for two weeks because there’s a danger period of arterial vasospasm that lasts two weeks from the initial bleed. I was treated with nimodipine. One of the things they did for me, which ate up a lot of the two weeks, was to perform arterial dopplers every day for a week. They would take a ratio of the velocity in my carotid and one of the cerebral arteries. If the ratio of the cerebral to carotid was too high, high velocity in the cerebral circulation, it was an indication that the artery was narrowing down a bit. They were using that monitoring technique to determine how long to have me on hyperhydration therapy. The theory was if you keep an artery stuffed full of fluid, it can’t close down. They started off with saline. Then they moved up to albumin. I was having these incredibly wild vivid hallucinations. It took me a couple of days to figure it out. I was sitting there going, “Steroid psychosis! I remember hearing about that.” They had me on high-dose Decadron for the inflammatory changes, which were presumably making my headache worse. That was my diagnosis, and I was right. They stopped the steroid, and the hallucinations went away.

KK: Any long-term sequelae?

MJ: It took me several months to realize it, but I have a bit of fine-motor left-right confusion that only manifests with quick fine-motor skills. The only time I notice it is when I type. Examples: typing “fro” when I try to type “for” and “sympotms” when I try to type “symptoms” and “dya” when I try to type “day.” If you look at a keyboard, you can see that the transposed letters are always opposing sides of the left/right finger position. I am usually immediately aware of the error when I make it, but I can’t stop it from happening.

KK: How long did it take you to recover?

MJ: I was on a mission to feel normal again, and I wanted to prove to myself that I was normal. I went home and started mountain biking the next day. I got myself back in shape. My goal was to ride a 100 km mountain bike race within a year of the event. There was a race I’d done once a couple of years previously in New Hampshire called the Hampshire 100, so that’s the one I aimed for. Nearly a year after my subarachnoid hemorrhage, I finished the race going hard, and I’d like to think of it as a punctuation of my recovery. It was a wonderful day.