Dr. Rahul Jandial
I was 27 the first time I let someone die. Thirteen months after finishing medical school in the second year of an eight-year brain surgery residency at a major trauma center in Southern California, I was in charge of the neurosurgical intensive care unit. Before they taught you how to operate, you had to spend a few years mastering medical care of patients with brain injuries, so that’s what I was doing. This was one month into a year-long period of my career marked by 120-hour weeks, with three 36-hour shifts a week being the norm. (These work hours are now banned.)
The hospital “sleeping quarter” was a misnomer. We never slept. But on the sixth floor there was a room the size of a closet with a bunk bed and a telephone where you could at least get horizontal while you answered pages that came unrelentingly. I became accustomed to the beeps, but sometimes the room would shake—that meant the trauma helicopter was bringing someone in, and I would likely get a page.
On one Tuesday morning, I felt the room shake at 3 AM. My pager: Trauma Resus ETA 3 min. That meant I should be ready to receive a patient in three minutes, because the paramedics were bringing someone to the “bay”—the trauma bay—on the brink of death.
The paramedics in the helicopter let us know in advance that incoming was a “34F s/p MVA unresponsive with dilated pupil, scalp laceration, multiple orthopedic injuries,” meaning a 34-year-old woman who got in a car accident and wasn’t awake or responsive. Her heart was beating on its own, but they had to force air into her lungs by hand squeezing a balloon 20 times a minute, a process known as “bagging.” When the paramedics pulled her out of the car, they found broken bones and blood dripping from the top of her head. Most importantly, the black circles inside her two blue eyes were not equal in size; the “dilated pupil” was a telltale sign of severe brain injury and dangerously high intracranial pressures. That’s why neurosurgery was paged.
Exhausted but alert, I descended the stairs to the second floor. The trauma team was already assembled: surgeons, nurses, technicians, students. The paramedics rushed her gurney through two giant doors that automatically swung open. We all descended on her with defined roles and a cadence to our maneuvers. An anesthetist slipped a tube through her mouth and into her lungs so a ventilator could drive in air since her brain wasn’t triggering breaths. A series of images was taken confirming the broken bones, which weren’t immediately threatening. But her scans showed a damaged and swollen brain that needed emergency attention and intervention. The violent car crash had slammed her brain against the inside of her skull, and, just like any other tissue, brain tissue swells when hit.
I loaded a eighth-inch bit onto a hand drill and tightened it in place with an allen wrench. A quick stab incision got me to the skull.
Since the skull doesn’t stretch, I needed to make room for the swelling brain so it didn’t smash itself to death within its cranial confines. Luckily the brain is like a cantaloupe in that it has fluid chambers that can be accessed and drained to make room. So I loaded a eighth-inch bit onto a hand drill and tightened it in place with an allen wrench. A quick stab incision got me to the skull. My left hand held the drill steady and the right hand turned the handle. I made a hole and plunged a hollow catheter seven centimeters through her right frontal lobe and into the mysterious fluid lakes inside her brain. The pressure inside was already so high that clear brain fluid squirted out the end of the catheter into the air. Her injury was global so she wouldn’t need brain surgery, but she needed our intense management in the ICU. Two hours after she arrived in the bay, the ventilator and brain catheter stopped her spiral towards death. These steps and the ones to follow gave her about a 20 percent chance of living, we estimated.
She devoured my attention for the next four weeks. Using mannitol and other diuretics, I tried to dry out the boggy brain tissue and I tried to pull the reins on her brain swelling. When her arm veins were too thin to handle the volume of medicines, I punctured giant veins in her neck and slid in bigger catheters for better access. When her lung collapsed, I cut between her ribs and inserted a hose to vacuum up the lung. The brain swelling came in waves every 20 minutes, and during these surges the ICU nurse and I would time the delivery of various drugs—diuretics, sedatives, narcotics, paralytics—in hopes of preventing the intracranial pressure waves from cresting. Her fragility required so much minute-by-minute attention that the ICU nurse and I were by her bedside all night every other night.
Twenty-six days after she arrived at the hospital, her daily morning brain scan showed something that couldn’t be ignored, something for which surgeons will likely never have an answer. A certain part of her brain showed no blood flow and had the dark-gray color of dead brain tissue. She had a brainstem stroke. The brainstem is that deep part of brain that is rarely visualized. It’s the stalk of the mushroom, if you will, our reptilian brain, the master controller of our automatic functions. It allows you to breathe when you’re asleep and open your eyes when you wake up. The thinking brain (frontal lobe) is useless without its reptilian partner, and when the brainstem is injured the patient will never live off machines. Never breathe. Never wake up. Miracles don’t happen with this injury.
In crises people don’t understand your words—they feel your energy.
The complexity of what had happened is hard for even general doctors to understand, let alone traumatized family members. After four weeks, I had come to know this patient’s family well, but the emotional ether in that “family meeting” where I took away any and all hope of her surviving is hard to capture with written words. In crises people don’t understand your words—they feel your energy. They never fully understood, but they trusted me. The next day, they asked me to guide them through the process and steps of letting her die.
Before they came to see her one last time, I wanted her to look as close as possible to how her family remembered her, so I asked the nurse to help me. It was the ICU nurses who knew best what I had tried to do to save her, and how I had failed. I removed the cold sterile catheters and tubes from her neck, chest, and brain. To me, these were vestiges of a tattered parachute that failed. Only one catheter with morphine in the bend of her arm remained. I disconnected the ventilator and pulled the tube from her throat. The nurse combed her hair one last time and then we brought the family in to be with her. A few hours later, she finished the spiral that I delayed for 28 days.
We never met in the conventional sense; I never met her consciousness. My efforts left her with physical scars and she left me with emotional ones deep in the recesses of my mind. By the end of that year, I had let 24 other people die. Every family appreciated how hard I tried; many invited me to their funerals, and one time I went. But she was my first. I think about her nearly 20 years and thousands of patients later.To take care of the dying you have to become comfortable with death. I’m still not. But scar tissue is tough.
(The author is a dual-trained brain surgeon and neuroscientist)
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