His CT scan looks worse than this one. And it's on the other side. The 'hypodense' areas on scan are dead or dying brain, the fluid build-up from a massive stroke.
Down the middle you can see the ventricles on the left side of the image, which is the right side of the head. Not only are his ventricles effaced on one side as here, but the midline is being pushed into the other side of his skull--or, at least, it was, until the neurosurgeons took the skull off. That's the treatment of choice. Brain swelling from a massive stroke, young, 'juicy' brain (said with a straight face, it's not derogatory), and a young guy has 80 plus-percent mortality with medical treatment alone, cut to between 47 and 53 percent with the removal of the skull piece.
His family has camped out in the elevator lobby between two units; there are constantly ten to fifteen people there, men women and children, with air mattresses, portable DVD players.
On day 4 after surgery, a repeat CT is, unfortunately, even worse; in addition to the right-sided lesion, there are new, bilateral, occipital lesions. He's now likely blind; the area at the back of the skull processes vision.
The walls are plastered with pictures of the patient and his wife, who is seven months pregnant, on an ATV, dressed up at their wedding. Their three year-old daughter with straw-colored hair, who, when I first see the patient, is standing next to the bed, looking up at the parade of coats; she can't even see her dad from the floor, the bed is too high.
He had a headache. He went to the chiropractor. His headache got worse. Then he lost consciousness. That's it. Done.
Should he come back? His vitals have leveled off, temp is stable, BP is controllable, ICP (the pressures in his head) are low, which is a good indication that the swelling is down. But his brain is jelly. Or, at least, half of it. Paralysis, loss of sensation, slurred speech, blindness. Neglect. Not of his children; of half of his reality. Since it's in the half of his brain that's likely non-dominant for language, he won't be able to put his world together. If you show him his left arm, he won't know that it's his own arm. But he won't be able to move it anyway. Does that mean they cancel out?
There's a steel of spirit needed to even enter the room that becomes second-nature to clinicians for defensive reasons. If you allowed these cases to get all the way into your head right away, you'd just cry in the broad, antiseptic hallway and then leave for the day, desperate to return to fresh air, movement, life. Within that context there is a feeling of helplessness, a knowledge that we've built to acquire that tells us how long the road to recovery will be, and how incomplete his return will be. He has truly put one foot in the grave, and I'm not sure if he can come back.
The family wants him back. Of course. But do they want him back? I don't know, I've never been the caretaker for a massive stroke victim. The question is worth asking. Death is not always the worst option, is it?
Every morning, we go in and push on the beds of his fingernails to see if he withdraws to pain, pull open his eyelids and shine lights in, rock his head back and forth gently to check for eye movement, try and decide if his periodic writhing movements are purposeful or stereotyped and primitive. Primitive because they come from a part of the brain that predates the concept of history. That breathes for us, sets heart beat, controls the myriad of daily control tasks, provides basal input into the motor system so we don't have to coordinate the thousands of muscle motor units involved in every single action.
He's me. Thirty. Kids. Healthy. He wasn't being risky, wasn't skydiving, wasn't drinking. Just got a headache.
The leading cause of death I have to worry about is still trauma, and yet I manage to ride my bike to work every day. But sometimes patients get to me not just because they are suffering, sick, and beautiful, but because it's so easy to put myself in their shoes--or, more accurately, in their compression stockings and compression devices, balloons that inflate rhythmically from the bottom up around each leg to ward off clots.
Grief wells up like air underwater which I cannot breathe.