Monday, September 13, 2010

NSICU begins...

I remember the first day that I spent on the neuroscience intensive care unit last term. The nurse that I was working with had just received a call from the ER announcing that she would be getting a trauma patient. From the brief report, we learned that he was a 28-year-old with a GCS of 4 and a self-inflicted gunshot wound to the head.

Moments later, I was pulling on gloves and helping to transfer this young man from the stretcher to the bed. Mr. W had three or four tattoos and a goatee; he looked healthy and normal, vaguely like a guy I could have dated in college, though this thought didn’t occur to me until later. He was intubated, wore an Aspen collar, and had large bore IVs in both arms. He also had a hole on the right side of his head, just behind his ear, where brain matter was oozing out onto the crisp white sheet.

We set up his blood pressure cuff and the nurse handed me a butterfly, which I pressed gently into his antecubital vein. We did constant neuro exams, monitoring his pupils, his cough and gag reflexes, his response to painful stimuli. While initially his pupils were fixed but not dilated and he had a cough reflex and showed decerebrate posturing, he had no Babinski sign and within the hour lost his cough reflex and stopped responding to pain. The CT scan showed that the bullet had crossed midline, and, as one of the neurosurgeons explained crassly, “bounced around,” though there was no exit wound. It was becoming readily clear that this young man had an unsurvivable brain injury. LifeNet had been triggered upon his arrival to the ER, and the goal was now to keep the chemicals in his body within the limits for organ donation. He had been given Mannitol, so we monitored his urine output and gave him fluids as appropriate. His vital signs were, for the moment, stable, and we drew blood gases and worked with the respiratory therapist to adjust the ventilator settings as needed.

His family had arrived and wanted to see him. His older brother, “J” came back first, with his girlfriend. I remember him wiping tears from behind his glasses, waiting for us to leave the room before he broke down. I closed the curtain and stood outside the room while he sobbed, telling his brother how much he loved him. “You don’t even know,” he yelled. “You don’t even know how much I love you.”

His mother and aunt came back to see him, crying quietly and staying only for a moment. His mom pulled the sheet up to his chest, worrying that he must be cold. J told us a little about his brother’s social history, explaining that this was not the first suicide attempt, that his brother was a heavy drug user and, on certain drugs, got very depressed. He told us that years ago they had been very close, but one night several years before, they had been arrested together. J straightened up and started his life over and his brother did not. When we explained the gravity of his brother’s situation, he asked us if you could donate organs if you had hepatitis C. Then he asked if there was a bar within walking distance; he needed a drink.

While his family was gone, his nurse and I began preparations for brain death testing. Mr. W initially failed the apnea test, as he was breathing over the vent which was set at a rate of 8 to level out his blood gases. This meant that he was not brain dead, so all further testing stopped. 30 minutes later, I stood holding his had while his brain herniated. His pupils were fixed and dilated, his blood pressure rose rapidly, and his heart rhythm was wide and bizarre. He had no cough, gag, corneal, pain, or Babinski reflex, no dolls eyes. He was no longer breathing over the ventilator. I remember that standing there watching it happen and not doing anything to stop it or fix him was extremely hard.

I went home that night and thought about what had happened and about how disconnected I felt from the whole experience. I thought about what we hadn’t done for him, if that was the right thing. I thought about movies and TV shows and how gunshots are portrayed and how different it was to be a part of it. I thought about what could hurt so terribly that you would rather put a gun to your head and pull the trigger. I didn’t cry that night, and I felt guilty about it. A few days later, after talking on the phone with one of my sisters, I cried hard for him and for his brother and his family and the pain that they had all felt and would feel for a long time. I thought about my own family, about my sisters, my parents, my friends.

I learned later that his brother had returned from the bar drunk and unwilling to discuss organ donation. Care was withdrawn the next morning.