Last night was the most difficult and trying night of the month, maybe of my career. He was a young race car driver. Last night he was in a race at a local track when he flipped his car over and was trapped underneath. the car behind him ran into him at 100 mph. Local ground crew brought him to our emergency departement where he was seen by the trauma team. A cat scan of his head showed that his brain had swollen to the point where there was absolutely no room left for expansion. The ventricles in the brain, which normally contain spinal fluid, had been completely compressed. His brain was starting to herniate down through the opening of the skull where the spinal cord emerges. His right pupil was dilated, an ominus sign.
He was brought directly to our ICU where I began the process of admitting him. Naturally, I had a lot of help, the entire trauma team was there, the neurosurgeon showed up shortly afterwards and drilled through his skull to place a pressure transducer. Normally, if there were a collection of blood to be drained, or if there was still fluid in the ventricles, the neurosurgeon would drain it, but in this patient, there was nothing but swollen brain. Nothing to remove or drain. Our only option was to try and prevent further damage to his brain…but the initial damage had already been done and everyone knew it.
For hours I sat by his bedside, watching the pressure inside his skull climb higher and higher. I made small adjustments to IV meds to try to increase his blood pressure so that his heart could still pump oxygen carrying blood to his brain. Eventually, his injuries won out. His Intracranial pressure skyrocketed to a level higher than any one in the unit had ever seen before. His other pupil blew, his corneal reflexes were gone, and ice cold water squirted into his ear canals failed to produce the expected reflex jerking movement of his eyes. He was dying right in front of me and there was nothing we could do. We turned off the ventilater to see whether or not his brain still had the most primitive of reflexes remaining…spontaneous breathing. After one minute of his chest being completely still except for the beating of his heart, he took a breath. He was still alive and yet all of his brain function was long since gone.
His family was traumatized and stunned. He came from a racing family. His uncle and grandfather had both died from racing accidents, and now, the family was losing another. His body didn’t have a scratch on it, not a single scrape or bruise, and his helmet was intact. Throughout the night, his nurse and I were able to be lighthearted and objective in his management. But when mornign rounds arrived and I had to update the attendings and remainder of the ICU team on his case, I felt sick to my stomach. During mornign rounds, there is frequently debate and inturruptions as all the members of the patient care team make suggestions on cases. But this morning, I presented my young, dying race care driver without a single inturruption, the remainder of the room completely silent, and I’m sure, feeling some of the same overwhelming grief and sadness I had been supressing all night.