Police

You may not want to hear this, but ladies and gentlemen, it's about that time again.  No, not another insufferable, unreadable vaccine post (though as a fair warning a series of that is coming up soon).  Even though I talked about seat belts fairly recently, it's once again time to talk about . . .

Nutrition!

Just kidding, just kidding.  It's seat belts.  Oh be quiet, I can hear you groaning from all the way over here.  Yes, I realise I talk about them a lot, and you realise I talk about them a lot, and I realise that you realise that I talk about them a lot, and because I won't shut my damned mouth about them you therefore probably also realise just how important they are.  If you do, this post is not for you.  Instead this is directed to the people who still think seat belts are either A) not that important, or B) dangerous.

Something else (that ties into this story) that is even more important than seat belts is the police (the men and women who uphold the law, not the British rock band (though they were pretty damned cool too)).  I'm sure many people here, especially those who have ever been stopped for speeding, aren't such big fans of these folks.  Though I've been stopped a couple of times for speeding myself (though not in the last decade or two), and though I was admittedly righteously pissed off at the time, I only had myself and my stupid heavy foot to blame.  I now thoroughly respect the officers who were simply doing their job trying to protect me and the drivers around me.  As a trauma surgeon, this respect has only deepened.  It turns out that the people they deal with on a daily basis correlate quite nicely with my patient population.

But unfortunately police officers aren't perfect.  They are human, and they make mistakes.  Just like Colby (not his real name™).

When a group of police officers gathers outside my trauma bay, it can mean only one of two things: A) they are protecting everyone from the asshole they just brought to me, or B) one of their own was just brought in.  In Colby's case, it was the latter.  He was chasing a suspect at high speed in the rain when he hydroplaned and spun out.  This launched his car into the woods where he struck a tree and got knocked out.  When he came to, the medics were pulling him from the back seat of his cruiser.

At this point the clever readers are probably wondering, "Hey, how in the hell did he end up in the back seat if he was wearing his seat belt?"  Never fear, intrepid reader.  I'll get to that.

He arrived looking in not-too-bad shape, but his oxygen saturation was only 90%.  For a healthy (and very muscular) 25-year old kid, his oxygen level should have been no less than 98% unless something seriously wrong was seriously wrong.  I asked him what hurt, assuming it would be his chest.

"My chest, sir.  It's not so bad though, Doc."

Sir.  Heh.  I have to admit I thoroughly enjoy the "sir" whenever I hear it, which is almost never.  Getting "sir" from a patient is like eating filet mignon - something you experience very rarely but enjoy the hell out of it whenever you get the opportunity.

But why was he in the back seat, Doc?

Quiet, you.  I'm getting there.

A chest X-ray confirmed my suspicion - a couple of broken ribs, a lung contusion, and a pneumothorax big enough to require a chest tube.  Chest tubes are designed to evacuate the air (or fluid) that has accumulated around a punctured lung, allowing it to re-expand fully.  Colby wasn't enthralled with the idea of me shoving a tube the size of my thumb into his chest between his ribs, but he tolerated the procedure with hardly a grunt.  As soon as it was in, his oxygen level normalised and his shortness of breath disappeared.  A follow-up X-ray predictably showed that his lung was now fully inflated (HUZZAH!), so he was admitted and taken up to the trauma ward a short while later.

But Doc . . .

SHUSH.

The following day I went to see Colby, and he was doing very well and in rather high spirits.  He was a model patient - eager to get up and walk despite the large tube hanging out of his chest and the constant pain in it that stabbed him every time he coughed.  I decided this was the right time to get the answer to the question that everyone was asking: how did he end up in the back seat of the car if he was wearing his seat belt?

He gave me a rather abashed glance towards the floor as he gave me his a very simple explanation: he wasn't.  His colleague sitting in the chair next to him looked down and shook his head.

As he explained it, none of the officers in his district wears a seat belt.  He gave me some vague (read: bullshit) excuse about possibly maybe needing to jump out of the car suddenly and not wanting to risk getting ensnared in the seat belt or some crap.  I just gave him the look.  The Look.  You know, that look you give your kid when she tries to claim she didn't steal that last Oreo when you actually watched her do it five seconds ago.  Yeah, that look.

He gave me a sheepish smile and said, "I know, sir.  I know.  I'm sorry."

I gave him The Look again and asked him if he was going to give himself a ticket.  He chuckled as I reminded him that he was the one who needed to make sure that we wear out seat belts, and that in addition to protecting us, he needs to protect himself too.  It is his sworn duty to keep us safe, but a large part of that is setting a good example.  His colleague started nodding solemnly.

"Yes, sir.  If I had been wearing it, I probably wouldn't be here.  I mean, I'd be here, I just wouldn't be . . . you know, here . . . in this hospital, here.  I probably would've been fine and walked away.  I will from now on, sir."

Now that is what I was waiting to hear.

Coincidence vs fate

"Aren't you going to do something to help her?  Why aren't you helping her?!"

These were the very first words that Marilyn's grandmother yelled at me as I walked through the door of her ICU room before I even had a chance to introduce myself.  She was visibly shaking, Marilyn's mother's makeup was smeared down her cheeks, and her father was sitting quietly in the corner in stunned disbelief.  Meanwhile, Marilyn (not her real name™) was lying on the bed motionless, which is exactly the way she would stay. 

But I'm getting ahead of myself.  Let me start at the beginning. 

I don't really believe in fate or destiny.  The idea that everything is planned for us or that "everything happens for a reason" is something my sciencey brain can't seem to abide.  The Call Gods may disagree with me, but I prefer to think we're all in control of our own present and hence have control over our future as well, so anything chalked up to fate is simply a coincidence.

Enter Marilyn.

This particular Friday was nearly silent.  I sat around (not really) waiting all day (not really) for trauma patients to arrive, but none came.  At 2 AM that night (well, Saturday morning I suppose, but my brain doesn't give a shit about semantics at 2 AM) the Call Gods decided it was finally time to fuck with me as my pager told me I would be getting a Level 1 stabbing in five minutes.  That means wounds to the head, torso, or neck typically - you know, the type that can kill you.  I swept out of bed and power-walked (as fast as I can power-walk at 2 AM) down to the trauma bay where my team awaited the patient's arrival.  When he arrived 2 minutes later, I anticipated a long night ahead of me. 

Wait wait wait.  You said "When he arrived".  Marilyn isn't exactly a man's name.  Are you confused, Doc?  

Not at all, you're just jumping the gun.  This obviously was not Marilyn, who was not to arrive for a few more minutes.

As I was examining his stab wound to the left lower chest, one of the nurses ran in to the trauma bay to tell me that another Level 1 would be coming in 10 minutes, this one a car accident victim, stable vitals, but unresponsive.

Fabulous.  Just what I needed, two patients, at the same time, at 2 AM, both level 1s, after a quiet day.  What a strange coincidence.

Just before the new trauma arrived I was able to determine that the stab wound was superficial and threw some staples into the wound (perfectly straight, thank you very much).  When Marilyn rolled through the door, everyone in the room, from the nurses to the janitor, could immediately tell that something was seriously wrong.  Though her eyes were open, they had a vacant, dead look in them.

And she wasn't breathing.

The ABC's of trauma dictate securing an airway before anything else, so the anaesthesiologist inserted a breathing tube as I did a cursory evaluation.  There was a touch of blood on the back of her head, an abrasion on her great toe, and fixed, blown pupils.  SHIT SHIT SHIT.  That usually means one of two things: death or impending death.  The two immediate questions were 1) why, and 2) what can I do to stop it.  Starting with question number 1, I had absolutely no idea.  I usually have a suspicion why someone may be dying, but not with Marilyn.  She barely had a scratch on her.

Something didn't add up.

The possibilities ran through my mind.  Internal decapitation . . . drug overdose . . . massive internal bleeding . . . alien mind abduction.  Admittedly some were more plausible than others.  A few minutes later her CT scans revealed the answers to both questions.  Question #1) Why was Marilyn dead or dying: bleeding in her brainstem.  A lot of it.  Bleeding on the brain itself can be drained and the cranium decompressed to reduce pressure.  But the brainstem is a different story.  In that location it doesn't take much to cause major problems, but there was enough that her brainstem was herniating through her foramen magnum.  And that detail answered question #2) What can I do to stop it: absolutely fucking nothing.  Though I couldn't confirm it yet, Marilyn was likely already brain dead, and there was nothing I (or anyone else) could do to help.

Her parents lived several hours away, and as I waited for them to arrive, yet more information came in from the lab, the police, and Marilyn's boyfriend.  As the police interviewed the boyfriend (who got there well ahead of Marilyn's parents), the seemingly endless stream of coincidences began stacking up.  Marilyn was 20 years old, healthy, no medical issues other than a history of drug abuse.  And her boyfriend had been driven to the hospital from the hospital by the police. 

Wait Doc, wait just a minute.  "To the hospital from the hospital"??  What the hell does that mean?  Are you confused again?

Yes, "from the hospital".  According to the police officer, Marilyn's boyfriend had been taken to Outside Hospital earlier in the evening after overdosing on heroin.  Not coincidentally, Marilyn had been on her way to Outside Hospital to pick him up when she veered over three lanes and was broadsided by a tractor trailer/semi/18-wheeler.  

I coincidentally was looking at her labs as the police officer was telling me all this.  Her blood alcohol level was 0, but not coincidentally her urine tox screen was positive for marijuana and heroin.

Indeed, Marilyn had been doing heroin with her boyfriend when he overdosed, and she hadn't yet come down when she got in the car to drive.

The aforementioned meeting with Marilyn's family came a few hours later after she had been moved to intensive care.  After I let Marilyn's grandmother scream at me and (finally) got a chance to introduce myself, I explained that A) this is a nearly universally fatal injury, B) the bleeding was not treatable due to its location, and C) Marilyn was not going to survive.  

That went over exactly as well as you would expect.  But after listening to the consulting neurosurgeon tell them the exact same thing, Marilyn's mother took a few minutes and several deep breaths before putting it in perspective: "I believe in God and I believe He has the power to heal, but if that's what He chose for her, then I'm sure He has a reason."

The following day an apnea test and cerebral angiogram both confirmed she was brain dead.  Marilyn's father gave me a firm handshake as he thanked me for being so kind and understanding, and her grandmother refused to look me in the eye.  I had the impression that she somehow thought it was my fault, that I had forced Marilyn to do heroin, get in her car, and crash into a vehicle 10 times larger than hers.  Her mother, as despondent as she was, was somehow much more forgiving in her grief.  Unlike other parents that we've discussed on this stupid blog, she opted to pursue organ donation.  

I have no idea how many lives Marilyn's tragedy was able to change for the better.  Was her death predetermined?  I don't know, but I somehow doubt it.  Maybe it was fate, or maybe it was just a series of bad circumstances combined with bad luck.  Regardless, I have no doubt that the recipients are more than grateful for their second chance at life.

Orlando

What can I really say.  I mean really, what can I say that hasn't already been said.  Though this tragedy was far from me, the impact is truly global.  Add Paris, Brussels, Tel Aviv, innumerable attacks in Iraq, Syria, Afghanistan, and Nigeria, and all the other recent (and not so recent) attacks, and it's enough to make me want to cry.

I've stayed notably silent through these tragedies.  What else can I do?  Offer prayers?  Say that my heart goes out to the victims?  Offer condolences to people I don't know?  Say that my thoughts are with them?  Change my Facebook profile picture?

Anyone can do those things, and none of them actually accomplishes anything.  Would I feel comforted by strangers offering me condolences if I were affected by such an event?  I don't know.  I honestly don't.  I hope I never discover the answer to that question.

All I can do is express my heartfelt gratitude to the trauma teams, each and every one of them.  I do not just mean the trauma surgeons, though we are the ones who tend to get what little thanks there is.  I'm also talking about the nurses, technicians, X-ray techs, orthopaedic surgeons, neurosurgeons, respiratory therapists, anaesthesiologists, radiologists, OR staff, recovery room staff, ward staff, physical therapists, and janitors whose job it is to clean up the mess that we make.  Every single person has a vital role whether they know it or not, whether they get acknowledged or not, and whether they get appreciated or not.  Ultimately it may be the trauma surgeon's name on the patient's chart, but we all have a role, and all of those roles are vital in some way.

Though my brain knows it will not be useful, my heart hurts, and I grieve.

I grieve.

Apnea test

NOTE: For the purposes of this post, I'll be using the American English spelling "apnea" rather than the British English spelling "apnoea". This is purely for clarity and search engine purposes. 

Thanks to vigilant readers of this and Thaddeus Pope's excellent and informative Medical Futility Blog, I've been alerted to several more brain death controversy cases in the news recently.  As was predicted during the Jahi McMath fiasco, more families are hopping on the "We don't believe in brain death" bandwagon.

The first (or next, as it were) is Mirranda Lawson, a 2-year-old girl who choked on a popcorn kernel on May 11, 2016.  She was taken to VCU hospital in Richmond, Virginia where doctors determined she was probably brain dead.  I say "probably" because nobody knows - her parents refused to allow the doctors to perform the apnea test that would either A) determine if she was brain dead or B) rule it out.  Mirranda's parents reportedly even went so far as to physically block doctors from performing the apnea test.  

Not surprisingly, one of this blog's best "friends", Dr. Paul Byrne, was brought in as an "expert".  Paul doubled down on his "brain death is a myth" stupidity by calling it "fake death" (what the hell is "fake death"?) and claiming Mirranda just needs thyroid and adrenal hormone.  “She needs them just like all of us need them," Byrne stupidly said.  Of course, a living brain has the ability to regulate both thyroid and adrenal hormones, something that Byrne either A) forgot (possible), B) never knew (unlikely), or C) lied about (most probable).

In a rare (it seems) victory for reason, yesterday a Virginia court denied her parents the ability to deny Mirranda's doctors the ability to do their damned jobs.  It is unclear if the hospital has performed the apnea test yet, and it is highly probable that her parents will appeal the ruling.

If that wasn't enough, another case popped up in (surprise!) California.  On June 3, 13-year-old Alex Pierce drowned at a celebratory party held at a high school swimming pool.  Despite the presence of adults and lifeguards, he remained submerged for 95 seconds (according to surveillance video) before being pulled out of the pool.  Tragically, no one performed CPR until paramedics arrived about 4 minutes later.  He was taken to a local hospital first before being moved to Loma Linda University Medical Center where it appears he met clinical brain death criteria.  In a move that will surprise no one here, his parents filed a temporary restraining order which prevent the doctors from performing the apnea test.

The wording of the petition itself is revealing.  In it they claim that Alex was responsive at the first hospital, opening his eyes and responding to voice.  He was then airlifted to Loma Linda where he began having seizures.  This is typical and not unexpected after drowning - as cerebral oedema (brain swelling) worsens, the patient's condition worsens, often including seizures.  Alex's doctors did the right thing by sedating him heavily, as this can both stop the seizures and reduce brain swelling.  Despite the doctors' best efforts, as the swelling worsened his overall condition worsened with it, and the following day doctors told Alex's parents of their plans to perform an apnea test.  This, according to the petition, would expose Alex "to dangerous levels of CO₂ in his blood, {and} could cause further injury to Alex's brain" (page 3 line 7).

I won't even comment on the very next line of the petition: 

"I am a Christian and believe in the healing powers of God."

Further down in the petition, the Jahi McMath and Aden Hailu cases are predictably brought up, as is a commentary by Dr. Cicero Coimbra, a Brazilian neurologist who (like our friend Paul Byrne) does not believe in brain death.  A 0.184-second Google search revealed a totally-and-seriously-not-biased-at-all-we-mean-it article titled "'Brain Death' Is Not Death!" (complete with super scientific exclamation point, of course) penned by . . . ready for it?  Paul Byrne and Cicero Coimbra! (super-sciency exclamation point).

So with all this hubbub about the apnea test, I believe it's high time some of these myths and lies were put to bed.  And who better to do it than me.  Sigh. 

The central questions on this issue are: 1) What the hell is the apnea test?  2) How is it done?  3) What does it mean?  4) Is this related to sleep apnea, and if so how is this related to brain death? 

And the answer is I'M NOT YOUR MOTHER!  DO YOUR OWN RESEARCH!

Oh sorry, I forgot I'm not a pseudoscientist.  Fortunately I've done the research for you.

The apnea test (full description here) is an important part of the assessment of brain death, in which the brain dies in response to a lack of oxygen and all brainstem reflexes are lost.  A portion of the brainstem controls the ability to breathe spontaneously in response to rising carbon dioxide levels, so when that portion of the brainstem dies, the ability to take a breath dies with it.  Note that low oxygen levels are not involved in the reflex to take a breath, only high CO₂ levels.  When the test is performed, the patient's vital parameters are normalized (temperature, fluid balance, and blood pressure must be normal, and the patient cannot be on any sedating or paralysing medications).  The patient is then pre-oxygenated, and blood is drawn to ensure that arterial CO₂ is normal and O₂ is normal or high.

When this is all done (and only after this is all done), the ventilator is turned off.  Oxygen can be passively administered to the patient by blowing it into the breathing tube, though this is not necessary.  The patient is then watched closely for any respiratory effort.  If the patient takes a breath (or even tries to), the test is aborted and declared negative - not brain dead.  However, if the arterial CO₂ level reaches 60 mm Hg or if it rises by at least 20 mm Hg from baseline (as determined by further blood tests) with no respiratory effort, the test is positive, and the patient can be declared brain dead.  If at any time the patient's blood pressure drops or if the oxygen saturation drops to below normal, the test is aborted.

While there are some risks associated with the test (including pneumothorax, asystole, and acidosis), these are very rare, and with the right technique the test is considered safe, even according to Calixto Machado (who wrote the article above describing the apnea test and whose name will sound familiar to those who followed the Jahi McMath saga).

At no time during the test is the oxygen level dangerously low.  If drops below normal, the test is aborted and the result is not considered.  And though the carbon dioxide level can certainly rise, it is not allowed to rise to dangerous levels, and once the ventilator is turned back on the excess CO₂ is released rapidly.

In his testimony to the Virginia court, Paul said this about the apnea test: 

"It's a test where they take the ventilator away for 10 minutes, which suffocates the patient, makes the carbon dioxide go up. When the carbon dioxide goes up, their brain swells, and they get worse... and they want to do this to Mirranda."

As usual, Paul distorts the truth (ie lies).  The test does not suffocate the patient, and the CO₂ levels are not allowed to get to the point where brain swelling can worsen.  Again, I wonder if Paul is simply ignoring his decades of medical knowledge or simply telling lies because they sound scary to the public and fit his agenda.

I am in no way saying that the apnea test is perfect, because clearly it is not.  A perfect test would be one that is completely non-invasive, 100% accurate, and 100% safe.  But that describes the perfect test for anything, and as everyone in medicine knows, that test simply does not exist.  An EEG can be used to confirm, but not diagnose, brain death.  There are other newer techniques for confirming brain death, including CT cerebral angiography and the cerebral scintigraphy, but at this point both of these remain confirmatory studies rather than primary studies.  Other studies, such as transcranial dopplers, somatosensory evoked potentials, and bispectral indices, have insufficient evidence to be recommended so far.  There is an excellent review here of the current evidence for brain death and its evaluation written by Dr. Eelco Wijdicks, who says:

"Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing. There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain."

It is important to note that Dr. Wijdicks is not only the editor-in-chief of Neurocritical Care but is also an editorial board member of Clinical Neurology and Neurosurgery and Journal of Clinical Neurology.  In other words, he  knows his shit a lot better than you or I or Paul Byrne.

I hope that clears up any misinformation that may be circulating about the apnea test.  Perhaps this post will come across the screens of the lawyers representing VCU and Loma Linda hospitals and will help them.  Perhaps some grieving parents who are trying to figure out why a hospital would perform an apnea test on their child will come across it, read it, and understand a little better.  The sad fact remains that each one of these cases is sadder than the previous, only because each one further proves the point that too many people continue not to get it.

With that all said, I'm sure this will clear up any and all confusion surrounding brain death, this will be the last we hear of any controversy, we will see no more of these nebulous brain death cases, and Dr. Byrne will call me to offer his sincere apology.  

Seriously Paul - call me.

PS Sleep apnea (temporary cessation of breathing while asleep) has nothing to do with the apnea test.  Thanks, Ugi. 

Fast food

I feel I must start by making a confession: I love fast food.  I know it's terrible for me, but I love fast food.  Hamburgers, hot dogs, chips/fries/frites, tacos, burritos, pizza, fried chicken.  I'm a total sucker for it - all of it.  If I have the choice of eating a very-good-for-me grilled chicken salad versus a very-not-so-good-for-me pizza, I will go for the pizza every single time.  I never feel particularly good about myself after eating it, but despite years of practice, I've still never quite perfected the art of avoiding it.

But there has been a serious emphasis put on nutrition and healthful foods these days (yes, "healthful", not "healthy"), and I've seriously cut back on my fast food intake.  I will still indulge from time to time, but it has become an anomaly in my life rather than a regular thing (and I still enjoy my Coke too).  But considering the GMO/organic/gluten-free discussions being bandied about, I decided it's high time I weighed in on the subject.

Weighed in.  Har dee fucking har.

Stupid (and obvious) puns aside, a recent interaction with Tim (not his real name™) illustrated just how dangerous fast food can be.  Sort of.

Tim was eating at a fast food restaurant (whose name does not start with M or S) when he suddenly became unresponsive and collapsed.  Instead of making sure he wasn't choking, his friends first took pictures of him on the ground, and then (after posting them to Facebook/Instagram/Twitter, presumably) called an ambulance.  (Before you ask, no I don't have any of the pictures, and even if I did I wouldn't put them here, you sick people.)  The crew found him completely unconscious, and they brought him to me as a high-level trauma.

Now those of you who know the world of trauma (you know who you are) may be thinking, "But Doc, choking is not classified as trauma!  Why did they bring him to you?"

Shush, you.  Don't ruin the story for everyone else.  There's a reason.  In my stories there is always a reason.

The first thing I do for most new trauma patients is lean over their faces to make a quick evaluation for any head trauma, as well as to make sure they have a patent airway and are breathing.  In trauma, Airway and Breathing are considered Very Important Things.  Tim had some minor abrasions to his scalp and was definitely breathing (and therefore not choking), but I believe his exhaust fumes were comprised mainly of ethanol rather than nitrogen, oxygen, and carbon dioxide.  

And there is the reason you've been waiting for.  The medics confirmed my suspicions.

"Good afternoon Doc, this is Tim.  Tim was drinking whiskey with his buddies at Fast Food Restaurant (not their real name™).  I guess he'd had enough, because he fell off his bench and hit his head.  He's just starting to come around now."

Uh huh.  In case you're wondering, no, that particular establishment does not serve whiskey.

The rest of my assessment was unremarkable, and all of his scans and x-rays were shockingly normal.  His bloodwork, on the other hand, was more revealing: though his chemistry and blood counts were totally normal, his blood alcohol level was just over five times the legal limit.  Even with aggressive IV fluids, it still took him nearly 12 hours to sober and wake up completely.  Once he did, I re-evaluated him.  Finding no serious injuries on him (other than wounded pride and a Facebook page full of rather crude comments), I sent him home.

The remainder of my day was filled with old ladies falling (4 of them), drunk drivers, drunk passengers, and one multiple gunshot victim who came in dead and stayed dead.  Fortunately everyone else survived.  To celebrate, I stopped at Fast Food Restaurant on my way home for a delicious and thoroughly-bad-for-me meal.  As usual I still felt terrible about myself for eating it, but for the 2,706th time in a row, I forgave myself.

Until next time, hamburger.  Until next time.