Sunday, January 16, 2022

Everyman

Ezel reached out to me. We had lunch.

He pulled a faded letter and envelope from his pocket, fingered it. I had written him from Prague. Ezel said his wife had died. He said she enjoyed reading my letter, as she was dying. It spoke of hope and love. Overcoming pain and fear. Ezel gave me the letter.

His voice was grave, eyes moist. I updated him.

It had been years.

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I lay on the operating table. I convulsed, vomited, full of New Year's booze. Pupils frozen. Ezel suctioned, wiped my vomit away.

#

I asked, "Did you actually touch my brain." Ezel nodded. "Yes."

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The morning traffic was stop and go. It was sunny. Two cars hit. The man and woman pulled aside and stepped out. They backed-up to inspect the dents. They were hit. Ambulances came. They closed the highway. A helicopter landed.

#

This was my second rotation at the Emergency Department at the level one trauma center. My prior study comprised 12 observations ranging from care for patients with significant hypertension, respiratory difficulty, muscle laceration, substance use disorder, cancer-related disability, syncope, and psychogenic issues: as well as procedures such as male personal care, cleaning medical equipment, electrocardiogram, ultrasound, and computerized axial tomography (CAT). My preceptor gave me high marks, but he apologized that the round was “not very exciting.”

For my second study, I arrived at 6:40 AM and was assigned to emergency room triage. The initial observed cases included leg joint swelling, abdominal pain (suspected early pregnancy), severed finger (construction accident), severe hypertension (blood pressure 294/179 with acute abdomen), and a cancer patient with tachycardia (pulse 200). At about 9:00 AM, we were notified of incoming code yellow and code blue vehicular trauma patients, transported by ambulance and air, respectively.

My preceptor assigned me to stand in a doorway between the two large ER patient care bays. Patient 1, the code yellow, arrived first, and was transferred to a bed in Bay 1. She was alert, responsive, and in severe pain. ER staff performed a rapid trauma assessment and identified probable pelvic fractures and lower abdominal injuries. The patient received x-rays in the bay and was to advance to CAT scan. Cervical spine immobilization and backboard techniques were used throughout patient care. She screamed repeatedly.

Patient 2, code blue, came from the helipad and was transferred to a bed in Bay 2. Patient 2 received a Glasgow Coma Scale rating of 4 at the accident scene and 3 in the ER. (GCS scores range from 3 to 15, with 3 being most severe. ) EMTs intubated the patient prior to arrival. Staff catheterized and gave the unresponsive patient intravenous fluids and medications. Rapid trauma assessment indicated no obvious trauma beyond ecchymosis and swelling about the left eye, and slowly reactive pupils. I helped transport the patient to CAT scan. I asked a few questions. A medical resident, previously an EMT-paramedic, instructed me to “follow [and observe] this patient all day.” (I had told him of my traumatic brain injury interest.) Imaging showed approximately 2-centimeter midline deviation of the cerebrum. This indicated cerebral hemorrhaging and swelling. The patient and trauma team returned to the ER bay where the patient received further medications. Staff performed various assessments, including deep foot stimulation. The patient remained unresponsive. He briefly seized, flouncing his upper limbs 30-degrees. I helped transport him to the Trauma Intensive Care Unit (TICU). A senior neurosurgeon evaluated the patient. A physician assistant drilled a hole in the patient’s skull and inserted a fiber optic intracranial pressure (ICP) monitor above the right brain ventricle. His position was shifted from Trendellenberg (feet elevated) to reverse Trendellenberg to observe ICP. ICP ranged as high as 85; normal is less than 15 mm Hg. He received additional medications, including mannitol (an osmotic diuretic to reduce intraocular and intracranial pressures). The patient appeared roused, moving all four limbs, and the resident worked to evoke a patient response by loudly calling the patient’s name, asking the patient to show two fingers, slapping the patient’s chest, and squeezing the patient’s hand and arm. The patient remained unresponsive.

I was an acute observer. I tied the undone shoelaces of the physician assistant who drilled the cranial hole.

ICP remained high. Medical staff inserted main-line IV routes for high-volume administration of medications in the patient’s chest and arms. I maintained traction on the patient's right arm to help manage swelling caused by the new line. Doctors decided that surgery was required. We took the patient for a further CAT scan in order to image current positioning of his brain. We transported the patient to an operating room. Because I was not wearing surgical garb, I remained in an outer hallway. The patient was prepped for surgery, head shaved, and orientation lines marked on his scalp (with lines indicating a left-superior cranial incision arc, from the top of the head to above the left ear). The resident returned from the OR, took me across the hall and gave me surgical garb — hat, mask, shirt, pants, and booties. I dressed. I put on sterile gloves when I stepped into the OR. There were about 12 staff in the OR, including the neurosurgeon and resident. I stood out of the way, six-to-twelve feet from the patient, observing medical procedure and asking infrequent questions. The resident cut a rounded triangular skin and tissue flap (approximately 10x15 centimeters) from the patient’s left superior cranium and pulled the flap back to expose the skull (cauterizing blood vessels and tissues in the process). He drilled six burr holes on the perimeter of the exposed skull area. (This procedure is termed craniotomy.) When the resident pierced the dura mater beneath the skull, cerebrospinal fluid and blood gushed from the openings. The resident connected the burr holes using a cutting tool and removed the patient’s skull segment, a chunk of bone. (This procedure is termed craniectomy.) The resident incised the dura mater. Upon broad opening of the dura mater, the brain herniated about 2-3 centimeters from the plane of the skull. This was dramatic. It looked like the patient’s brain leapt from its container. Several staff commented: “Did you see that? ... That’s not good.”

We looked side-to-side at one another, then focused on the open skull and erupted brain. Surgeons reattached the patient’s skin and tissue flap and conducted various closing and wound care activities. They bagged the skull segment for freezing (and potential later reattachment). I accompanied the patient back to TICU. The patient’s ICP was reduced, but he remained in critical condition. At 3:30 PM, I excused myself, returned surgical garb, met with my initial preceptor in ER triage, obtained sign-off, and returned home.

The patient later died and became an organ donor. 

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