All quiet on the transplant front again. Seems like as soon as I come near the service the operations disappear.

Which leaves time to study for the ABSITE, a good thing since the test is coming up in. . . 8 days. I got to the neurosurgery part of the review book, and had a flashback to my neurosurgery rotation.

It was far enough in to the month that I was holding the call pager by myself most days. I got called to see a lady in the ER. She’d had a headache for a few days, but that day it was much worse, and her son had finally forced her to come to the ER. Her history of severe, poorly controlled hypertension was a red flag, and the ER doctors got a CT scan. By the time it was done, and they had recognized the subarachnoid hemorrhage, her mental status was deteriorating to the point that, while still fairly alert, she could no longer answer questions coherently. I didn’t waste much time on exam, just verified that her pupils were still equal and reactive, and there were no other gross neurological deficits yet (neurosurgery physical exam is the most abrupt and pointed of any specialty), then called the resident. He concluded that her worsening symptoms were due to a still-active aneurysm, and arranged for her to be taken to radiology for an emergent cerebral angiogram and coiling of the aneurysm. I saw her off, then tried to tackle some of the other pages that had been accumulating (hypotensive post-op patient; tachypneic patient failing a vent wean; rising ICP; hyponatremia in a trauma patient).

About half an hour later I got a stat page from radiology: “Your patient just had a bradycardic arrest on the table, maybe you should come down here.” I asked the nurse to please page my resident as he was the only really useful person, and then ran down the stairs.

I arrived (with the resident soon on my heels) to find that the report was very slightly exaggerated. She hadn’t completely arrested, just become so bradycardic that there had been several 20-second pauses between heartbeats. That had improved with atropine, and she was now awake. So awake, in fact, that she was insisting on leaving AMA.

Which posed a problem, since her vital signs were a classic case of Cushing’s triad, found in impending brain stem herniation: bradycardia, hypertension, and slow respirations. Well, actually, she was breathing just fine, since she was loudly insisting that we let go of her, give her clothes back, and let her leave.

The resident announced that he needed to put in a ventriculostomy drain now – right there, in the middle of the angio suite. He started finding the supplies – some of which had to be brought down from the neuro ICU. I was left to deal with the matter of consent. The patient herself was very dramatically not consenting. By now, it was taking the efforts of two nurses to keep her lying down (which of course wasn’t doing any good for her blood pressure or her intracranial pressure, which was what we intended to relieve by placing a drain). Her son, whom we knew to be somewhere in the hospital, had disappeared: either he was trying to get a bite of lunch, or the move to the maze in the depths of the radiology department had lost him. So when the supplies were assembled, we decided to proceed with the drain as an emergent procedure – no consent required.

Despite all of us knowing quite well that the patient’s protests were further evidence of altered mental status and injury from the blood now surrounding her brain, it was no fun to perform an invasive procedure on patient who spent the entire time protesting that we were kidnapping and abusing her, and who had to be held down by several staff members. Once the drain was placed, we ended up intubating her right there as well, as her level of consciousness continued to decline.

So by the time her son caught up with us, in the neuro ICU, we had the job of explaining that his mother had gotten significantly worse, and was now on a ventilator.

It was all downhill from there. Everything that can go wrong with subarachnoids went wrong with her: her ICP stayed up despite all measures to lower it; she had surgery to remove the aneurysm, but with no improvement; she remained in persistent vasospasm, despite every single treatment in the book being tried; she developed diabetes insipidus (seen in brain injured-patients when the hypothalamus stops producing anti-diuretic hormone, needed for the kidney to concentrate urine). After two weeks in the ICU, she died. So the last her son saw of her, conscious, was in the ER; and the last time any of us had talked to her had been while we were wrestling with her in radiology.

That’s why I hate dealing with subarachnoid hemorrhages, and I could never imagine being a neurosurgeon. Within twenty minutes she went from a pleasant lady with a headache to being delirious, then intubated and critically ill; and nothing we did could help at all.

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