Bardos

Buddhism has this concept of transitions, or bardos, transitions between one state and the next. When a practitioner is prepared, they can be opportunities for enlightenment; for the unprepared, they can be terrifying. Buddhism captures the same fears and opportunities many religions do about death, just in a different framework. The picture is the 'big buddha' on Lantau island off of Hong Kong, which I saw in college--although my favorite was the tiny stone buddha in an alleyway in Kathmandu.

When I saw those buddhas and read about bardos I had never seen people die. From my perspective they really do withdraw; wikipedia above describes all these stages of the bardo of death--final breath, lucidity after the final breath, then the space until the next life. I feel as though my whole service right now is in that state--some stage on their way out. Three brain-dead patients between yesterday and today, two donating organs, preserved for now. I joked I was the angel of death. Now, I think not so much. That's too stereotyped, co-opted by the halloween crowd. Bardos are more my style. They're more real, too. Death can be terrifying, but maybe, if we prepare ourselves, it might be a transition to something else? I hope?

Old School

When my hands ache from four central lines and an arterial line, and I laugh inappropriately at the MRSA swab on the brain dead 20-year old overdose admission because I'm too tired to care about hiding my derision...

When my boss tells me to go upstairs and talk to the overdose girl's family and it's just me and two parents who have lost a daughter and the nurse...

When it gets to be one in the morning and I haven't even started my documentation for the three afternoon transfers...

When these shifts come along, they make us doctors.

For The Love of God, Wear a HELMET

Natasha Richardson's death is tragic and sad. No one is prepared for such an event, and the mysteries surrouding her case have prompted a rash of articles on traumatic brain injury on CNN and in the New York Times.

With the exception, finally, of this article on CNN, which actually advises people to wear helmets, gasp, everyone has been discussing imaging and neurosurgery. It was noted that the initial hospital didn't have an MRI scanner, as if that would've been used. It was noted that she could've had a carotid or vertebral artery dissection that would've required special imaging, and then 'months' in the NICU, as if the best imaging and the best critical care was what she was missing. Perhaps she needed a craniotomy, or better yet, a hemicraniectomy where half her skull was removed. Then, in a one-liner at the bottom of the article, we get, 'it might've helped to wear a helmet'. Maybe.

The autopsy report showed an epidural hematoma according to the AP. The ONLY WAY to get an epidural hematoma is by TRAUMA. Not some rare neck artery dissection, not some wierd syndrome, or Moya Moya, or an aneurysm.

I have some bad news for the public. If you get this injury, we can do virtually nothing to reverse the damage to your actual grey matter if it has already occured. Yes, you can get a CT scan and then a hole in your skull or your skull removed and we can reverse any coagulopathy and we can monitor you in a beautiful ICU and control your blood pressure to within strict parameters and monitor your blood sugar and correct your electrolytes and prevent clots and use new, fancy drugs, and protect your airway and eat for you and pee for you and poop for you and then give you the best in long, slow, painful rehabilitation...

Or you can WEAR A HELMET!!!

This post does not in any way disrespect the tragedy that befell Ms. Richardson. But, why, by all that is holy, in that aftermath, wouldn't you advise people to wear helmets strongly? Another ABC article starts with a debate over whether acute care would've made a difference, and on page 3 says, well, she should wear a helmet but 'there's little evidence' that a helmet would've helped. Well, shoot, let me go out and conduct a randomized controlled trial on helmet use. We'll put half our people in helmets, half not, and then ram them all into a snowbank and see what happens. Heaven forbid we advise safety precautions before we have 'good evidence'.

Everyone should wear helmets. They're warm, they're stylish, they have ports for headphones, and, contrary to some asinine contentions on CNN and other major media outlets, they don't restrict your peripheral vision or encourage reckless skiing. Please. Please. Wear one.

Scary

Room 1 is an 84-year old stroke, clotted off her whole left carotid. We had to place a central line. Her BP is supposed to be like, 220.

Room 2 is a forty-something with c-spine surgery that lead to fulminant meningitis on the ventilator.

Room 3 is a COPD-er who is breathing 30-40 and dropping his saturations to the low nineties on BiPAP who we are giving one last shot at breathing because if we tube him he will never breathe without help again.

Room 4 is an intubated subarachnoid hemorrhage who moves her feet, sometimes, and blinks.

Room 5 got tPA today and was bleeding from her IV, her ET tube, her NG tube, and her eyeballs when she arrived. Her blood pressure is supposed to be low. Pray I don't mix room 1 and 5 up.

Room 7 is a poor guy who got mugged for three dollars after his car skidded into a ditch and the person who offered to help him beat him up. He only moves half his body.

Room 8 is bleeding from her tracheostomy, has renal failure, and can't move because she's been here so long. She's having trouble breathing.

I'm the only white coat here.

Only six more hours until the others return.

Only five hours, fifty-nine minutes until the others return.

And so on.

Statins Updated

A poster posited a link between Parkinson's Disease (PD) and Statin use, which led me to an article in Movement Disorders, 2006 (PubMed ID 17177184) that points out, in a retrospective study, a strong link between low LDL and Parkinson's incidence. The lower the LDL, the more people had PD: up to 3 times as often with an LDL below 93.

However, that same article seemed to find a 'neuroprotective' effect for statins. The poster obviously knew more biochemistry than me, so I'm not incredulous, that's just what I found in an admittedly quick search. Updated articles are welcome. It certainly did confirm a link between low LDL and Parkinson's, from which I can infer that LDL is perhaps not entirely deserving of the pejorative 'bad' cholesterol label.

A Google search on statins, however, on the broader issue of Number Needed to Treat analysis, showed very high NNTs, like 33 here, based on a 2003 Lancet article. I'm not sure how reliable that is. However, with an NNT of 33 in people with diabetes, I suppose there is good reason to question statin use given the lack of mortality benefit, and given the serious side-effects; I'm not sure about PD, but pancreatitis and rhabdomyolysis are no picnic.

Just don't ask what the NNT is for epinephrine in out-of-hospital resuscitation. The evidence for a lot of our critical situation algorithms seems a bit thin from podcasts I listen to. Just a tad bit hard to study.

Can't Escape the Psych

'I don't know. I can't localize his lesion; he's had three episodes of left-sided weakness, he says it came on suddenly followed by headache, and he had pins and needles on both sides. So, if we were to go with one lesion, motor only, let's say, that could be his right internal capsule...but to have three episodes that resolve completely and last for days?'

Dr. S strokes his beard, says a non-commital 'yes', which means, 'I'm thinking of how to tell you what I think', and says, 'I don't think he's had a stroke. At this point, I'm hesitant to call it conversion disorder...there's always a kernel of truth to these. And, just because this isn't, quote-unquote, real, doesn't mean he can't have a real stroke'.

'What about the one-sided migraines that affect 0.00005% of the population?'

'Well, it doesn't fit the onset...and before you really go and lay your nickel down and say, 'I think it's migraine', we would need to rule everything else out...'

Conversion. As in conversion from the brain to the body, crossing the border, if there is one. Conversion disorder occurs most in young women with other psychiatric diagnoses. As in, 27-yo female w/hx of OCD presents with acute onset of bilateral pins and needles in hands along with right-handed weakness, worse in her fingers than wrist. Oh, BTW, she just had a huge fight with her boyfriend and he's moving out. There's no explanation for her neurological complaint. None. You can't put it anywhere in the CNS. So the patient 'converts' their emotional stress into a syndrome that fits their own idea of illness, and makes it real. The opposite of self-help.

Or, factitious disorder. The patient fakes it, but in order to take on the role of the patient, be cared about, get tests, perhaps in an attempt to compensate for some loneliness curled around their heart. We look at their hearts, often, with sound waves, with dye. We don't see the loneliness.

At extremes, people may contaminate their own surgical wounds, give themselves thyroid hormone. An historical precursor was named after a German baron, Munchausen, who told amazing tall tales upon returning from a war with the Turks.

That's him. But the idea that these patients are making up their lesions is somewhat more sinister than his tall tales of riding on a cannonball, or pulling himself out of quicksand by his beard. I've blogged about one before, the patient below who would put her head in the pillow to drop her O2 saturation. Perhaps not faking, but on a spectrum from the professional patient to Munchausen's.

Or, most distasteful, described in my lifetime, Munchausen's by proxy, in which a parent, usually a mother, makes their child sick deliberately in order to receive care for themselves. Perhaps I won't say any more about that.

These people are included with malingering in some articles, people who are faking pain, for example, in order to obtain narcotics. But I don't see them in the same spectrum. Imagine being so lonely that the attention of a stress test relieves some need; that the clustering of your family in a tiny room, with the gentle beeps of IV monitors to guide you, starts to feel more familiar and comfortable than home, or what passes for it. That seems worse than wanting narcs bad enough to complain about abdominal pain, a lot.

My world tilts a bit more towards the bizarre; or, more likely, I see a bit more of what's real. I still can't let go if the idea that he has the migraines that cause paralysis, and that's he's in that 0.00005%.

That's Me

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.