Neurology Intensive Care Unit Reflections

When I returned from Japan in early July, I spent July & August studying for Step 2 CK and CS, and I just completed my Sub-Internship ICU month in the NeuroICU this September. I flew to Philly this past weekend for a scholarship retreat, and I am currently in Boston for a stroke away rotation at Boston University Medical Center.

Residency applications were submitted on September 15, and we're in the process of hearing back from programs about interview invitations! It is both a nerve-wracking and exciting time.

NeuroICU reflections

I wanted to briefly recount a few interesting patient encounters I had while in the NeuroICU last month that taught me so much about the sacredness of life. (Personally identifying information and certain details of these encounters have been changed to protect the patients and their families. Real names have been changed).

Adam

Photo from here

Our team took care of a 35-year-old man (let's call him "Adam") who suffered a traumatic brain injury. He had fallen off a ladder and hit his head on the day that he was opening a new business. Shortly after the fall, he got into his car and began driving. He crashed the vehicle and was immediately brought to the emergency room by the police. Upon further investigation by the police, blood was found on the ground nearby the ladder at his new business. He likely suffered an epidural bleed into his brain. We assumed that he was driving to the emergency room but no one was with him when this happened, so no one knows if that was indeed where he was going. We also reasoned that the car accident resulted from loss of consciousness or a seizure. Unfortunately, the accident worsened the initial head injury that he suffered.

Not a day went by without a family member in Adam's room. They were religious and prayed regularly at his bedside. Unfortunately, Adam's condition did not improve significantly throughout the 3.5 weeks that he was in the ICU. All of the attendings did not think he was going to make it, but the family wanted us to move forward with every intervention indicated (including a feeding tube, breathing tube, etc). We found ourselves walking on tiptoes when speaking with the family, because for any extremely small improvement in the patient's condition (i.e. the presence of corneal reflexes or a gag reflex on neurologic exam) they believed that meant he was getting much better. He was not opening his eyes, following commands, or showing any sign that he could hear us, even after we minimized the sedation he was under. "Can we take out the breathing tube today?" "Does the corneal reflex mean he will open his eyes tomorrow?" "Is he getting better Doctor?" were questions we got every single day. We were very careful to not give false hope and instead emphasize that it may be a very long process before seeing any improvement, if any at all.

Adam has been transferred to another facility for further care. My heart goes out to him and his family. Who knows, maybe he will make a miraculous recovery and prove all of us wrong.

Walter

"Walter" was a 57-year-old man with a history of lung cancer who suffered a massive stroke. He had an 80-pack year smoking history (40 years x 2 packs/day) and was diagnosed with cancer only a few months before the stroke. The cause of the stroke was likely due to his lung cancer (hypercoagulable state of malignancy). It left him debilitated, completely aphasic (he couldn't speak at all), and unable to care for himself. I visited him every morning during pre-rounds and rounds, spoke with his family about his hospital course, and became very invested in his care. He did not understand what was going on around him (he had expressive and receptive aphasia, could not follow simple commands, and did not verbally respond to our questions). His ocean blue eyes simply stared at you. Our attending soon mentioned during rounds that it was important to have a serious discussion with the family about the very small chance of any meaningful recovery given the severity of Walter's stroke. I didn't know who Walter was before the stroke, but after hearing more about the person he was from his family during a Palliative Care meeting, it took a lot for me to hold back tears as they decided it would have been Walter's wish to transition to comfort care.

He loved life and experiencing new adventures. He was only 57-years-old!! He was nearly my own father's age. I couldn't imagine what his family was going through. It is so difficult to witness the death of patients we grow close to. I believe that it is okay for healthcare providers to get emotional and accept that sometimes things are completely out of our control. The best we can do is lend compassion and a listening ear to patients and their families during these times of immense pain and grief.

Brian

"Brian" is a 26-year-old guy who was hit in the head with a bowling ball. Yes, you read that correctly. A BOWLING BALL. This was such a jarring case. When I shared this story with my sister she scolded me for not leading with the fact that the patient recovered fully and did extremely well afterward. So there you go, I'm leading with that now. Brian did not die. He was in a bowling alley with friends and suddenly got into an altercation with another guy after they bumped into each other. I don't know the details, but shortly after the start of the altercation, the other guy grabbed a bowling ball, lifted it in the air, and brought it down with full force to Brian's head. Dear God. Yeah, that was my reaction too. Again, no one really knew the details of the fight, but NOTHING would warrant the blow to the head that Brian suffered. I believe that the idiot was caught and tried to the full extent of the law. 

When I went into Brian's room one morning during my pre-rounds, he was surrounded by scared family members, including his mother and sister who had a number of questions about his recovery. I gently explained the findings on his CT scan of the brain (he suffered a fracture and a little bit of bleeding below the skull), the medications he was receiving for pain control, and why we were monitoring him for seizure activity with an EEG (electroencephalogram). Just a couple of days into his stay in our ICU, Brian recovered tremendously and was able to walk around the unit with the physical therapist. I was so happy to see his improvement! He is doing well today.

~*~*~*~

Thanks for reading this entry! There will be more to come shortly, including updates on my stay in Boston and the Neurology residency interview trail :)