Over to You

NEUROSURGICAL NAUSEA

It feels indescribably horrible when a human life is slipping away

MARK BERNSTEIN October 20 2003
Over to You

NEUROSURGICAL NAUSEA

It feels indescribably horrible when a human life is slipping away

MARK BERNSTEIN October 20 2003

NEUROSURGICAL NAUSEA

Over to You

MARK BERNSTEIN

It feels indescribably horrible when a human life is slipping away

ANOTHER WEEKEND on call started inauspiciously. Toronto Western Hospital, where I’m a neurosurgeon, is a regional referral centre, so I got a seemingly endless stream of calls about cases at other hospitals. As well, I had to perform a number of surgeries. Then, late on the Saturday evening, another call came, this time from the neurosurgical resident in the emergency room. A 70-year-old man had been found by his family in the street near their home, apparently the victim of an assault. He had a deep cut on his head, was very

drowsy and vomiting profusely. A CT scan showed bleeding inside the brain and in the space between the brain and skull.

Life-saving surgery was needed. I told the family how serious it was and they wished me Godspeed. The operating room was quickly set up, the patient anaesthetized, and my resident and I cut skin by midnight. We peeled a large scalp flap off the skull behind the eye and above the ear. We used an airpowered saw to remove a piece of bone the size of a hand. The leathery covering of the brain, the dura, was taut and discoloured blue from the blood bulging tensely beneath it.

We opened the dura and saw a huge pancake of semi-clotted blood. We removed it, exposing the badly bruised brain. We then cut into the frontal lobe to remove a large blood clot the CT scan had showed there. Everything was going well and we had been fast, too—it was only about 1:15 a.m.

Then we noticed a steady rivulet of blood running down the surgical drapes and puddling on the floor. The anaesthetist told us the patient’s blood pressure was dropping rapidly, and she gave him a blood transfusion. The resident and I cauterized any visible bleeding points with special coagulating forceps and placed synthetic materials designed to promote clotting where the cauterization technique failed. Still the blood was pouring from everywhere, like water off a roof in a rainstorm. The patient’s heartbeat became irregular. The resident and I chattered nervously, but then the cruel reality hit me: the patient had developed an uncommon blood-clotting disorder called disseminated intravascular

coagulation. It can be caused by a number of conditions, severe head injury among them. With the disorder, the blood loses its ability to clot so that thousands of tiny open veins and capillaries in skin and muscle leak blood. In this case, even his brain was oozing.

The man, who was very ill before surgery but potentially could be saved, was likely going to die right there in the operating room. I started to sweat from every pore and was overcome with nausea. My throat was so dry I couldn’t swallow. Filled with horror, I had that sinking feeling that things were not going to be alright. Even in neurosurgery, it is rare to lose a patient on the table. I wished I had become a truck driver

instead of a brain surgeon.

The nurses were running around for blood products from the blood bank and for various things we surgeons needed. The anaesthetist and her resident were also a blur of activity. I heard myself saying to my resident: “I think God wants this chap and I think he’s going to get him today.” He nodded, his eyes wide with fear, but he was too numb to speak. Drawing on my experience, we decided to put two big drainage tubes in and close as

quickly as possible. Perhaps the closed scalp would help staunch the flow of blood. We had to leave the bone flap out because the brain had now swollen well above the edges of the skull.

The patient’s blood pressure was barely registering when the resident put the head dressing on and we wheeled him to the intensive care unit. I told his oldest daughter, the spokesperson for the family, what had happened and that it was possible her father would not survive the day. She was shocked and upset but thanked us with the reassurance that she was sure we had done everything we could.

It was 4:30 a.m. I was dead tired, stunk of tension, and was profoundly shaken and depressed by what had happened. It wasn’t our fault, but that didn’t matter. The feeling of being there while a human life is slipping away is something you can never make anyone else understand.

After a few minutes of sitting in stunned silence in the ICU, I walked to the patient’s bedside with my head hung low, avoiding everyone’s gaze. To my amazement he was waking up and moving both arms and legs. His blood pressure was stable. A CT scan showed that the blood clots had been successfully removed and no new ones had formed. The patient went on to make a good recovery.

The resident later described it as “horrific ordeal” and a defining moment in his career and his life. When he is a practising neurosurgeon in another city in 10 years, and we bump into each other at a conference, we will likely relive that night’s events. We had been part of something indescribable and powerful together.

A few months later, as I recall the experience to write about it, I am still overcome with nausea. 171

Mark Bernstein is a Toronto neurosurgeon.

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