The Greatest Gift

She was already dead when I came in to work. Blunt head trauma sustained during a common winter activity. Not breathing, and intubated on scene by paramedics. Despite two emergent neurosurgeries, there were no signs of improvement. The day before she had failed neurologic and apnea testing.

For some reason, the weekend team did not want to declare her brain dead the day before, so we waited, as a re-evaluation by neurosurgery had been promised. When I first examined the patient that morning, her family members were yelling at her nurse for not supporting their hopes that she would wake up. I just quietly listened to the patient, and did a quick neuro exam and let them be.

When we rounded as a team, the child's father told us that they were waiting for a miracle. He said that he believed in the Bible and there were cases where people had been brought back from the dead. He didn't believe that God would allow his daughter to survive the accident only to die now. My attending said that he believes in miracles, but that from his exam, the child was clinically brain dead. He apologized to her father, but said that in his opinion, their daughter did not survive the accident. He told them that they should talk to only the loved ones whose opinions they valued. They would have some decisions to make, including possible organ donation, if the child was confirmed brain dead by neurosurgery later as he suspected.

Neurosurgery finally came back to the bedside and the same tests from the day before were repeated. Again, there were no signs of brainstem functioning or breathing. Time of death was declared, and the family was given time to talk with their pastor and social workers.

It was an awkward situation for us to walk into that morning, having not met the family beforehand, but I think that my attending handled it pretty well. I believe in miracles, too. I would have also added that miracles and unexpected outcomes happen in spite of what we do. As a physician, there is nothing that I can do to stop one of God's miracles from happening. Some people recover in spite of showing up late in their disease, while others seek treatment immediately, get treated aggressively, and still die. Life is unpredictable. While I have not seen anyone declared brain dead recover, I have seen a patient recover from removal of life support when it was expected to be a terminal wean. Maybe that's how I rationalize dealing with my own values though, when sometimes families and powers of attorney make different decisions than what I would do. However, at the same time, I think that saying something like that also helps the family to move through their grief. To the family members, there is never going to be an acceptable time to remove life support. They will wait, day in and day out for weeks, and even months. It's horrible to watch families camp out in hospitals, losing sleep and sometimes risking their jobs to be at the bedside of a loved one non-stop, especially when there is not expected to be any recovery.

In the end, the patient's family decided to donate her organs. An organ transplant service was contacted, and they set out immediately looking for matches across the country. Things got a little hairy while we waited as the patient developed renal failure, had great swings in blood pressure and glucose levels, and lost the ability to concentrate her urine (likely due to pituitary infarction). It took about 36 hours of constant work to arrange, but three separate surgical teams were flown in and coordinated to harvest her heart, lungs, kidneys, pancreas, small intestine, corneas, bone, and skin. In the end, she helped about 50 people, a significant number of which were probably children.

I think that this child was part of a miracle, it just wasn't one for her family. It was amazing that she was able to help so many others, and that her family was able to make the decision to donate in spite of the shock of an unexpected death.

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For the last couple of weeks, "Grey's Anatomy" has been focused on a small boy needing organ donation. However, in their scenario, the surgeons are running all over the hospital testing critically ill patients to look for a match, and pressuring their family members to donate. In reality, this is prevented by the use of independent organ donation teams. Once we find a donor (typically emergency and ICU patients), the procurement team is contacted and they come in and run the show as far as looking for matches on the national database.

While it makes for good drama on TV, there are obvious ethical concerns about having the same doctor caring for a potential donor and a potential recipient. We can't randomly test people for matching a recipient without their knowledge, and have no control in regards to what order on a recipient list a patient is. So get it together, TV writers, that was just ridiculous-- I'm not running a chop shop here!

Running Late

Usually, I get to work about 15 minutes before I'm supposed to start so I can kind of get a grip on my surroundings or spend a few minutes chatting with someone in the locker room without being frantic about getting somewhere.

On Monday, the first patient that I met was a 13 year-old boy. He was unresponsive. He had been in the car with his dad when their tire blew out and they flipped upside-down into the frozen waters of a nearby creek. His father died that night. The boy was taken to our hospital, and several tests had shown that there was no brain activity. His mother, who had not been in the car that night, made the tough decision to stop all medical interventions, including fluids and nutrition. As he was seizing uncontrollably, there was little hope of him regaining any function. Over the weekend, one of the nurses had an issue with fluids being withdrawn, and decided to restart his IV without having an order to do so. I don't know how that issue was handled, but this is what I walked into. I briefly met the mother, examined the patient, and continued on with my list of patients. Fluids were again withdrawn. Tuesday I had off, and Wednesday was a conference day so I was excused.

Today, as I walked in, I was told that the patient had just died. I think that I have never been so thankful to be running late in my life. By the time I got there, he had already been pronounced, and the poor overnight resident had to stay late finishing up the paperwork. I don't know exactly what I'm learning about medicine this month, but I am certainly getting a crash course in ethics.

My next patient was the opposite end of the spectrum. The resident from last night had been taking care of her so I hadn't really known much about her case. She was doing well enough after her surgery to be transferred to the rehab floor, so getting that accomplished was my goal for the morning. As I sat down to read her chart, I was surprised by what I found: this girl was from Iraq. She had been a very sickly child, who was having fainting spells that were getting worse. It turned out that she had a large defect in the wall of her heart that separates the two ventricles. Her oxygenated blood was mixing with her deoxygenated blood to the point that her body wasn't getting the oxygen that it needed. She had seen doctors in Baghdad for this, but after keeping her on medication for a year, they had stopped all treatment and told her family that the condition was inoperable.

And that's when the miracle took place. Somehow her path was crossed by a U.S. soldier who brought her here. To sum the story up, last month she got a patch placed over the defect in heart. She developed a fatal arrhythmia in the operating room, and a pacemaker was immediately inserted. Her left side is weak, and the head CT I ordered this morning explains the weakness as there is evidence of an old stroke. However, today she has a chance. Her life will never be that of a normal 9 year-old, but with therapy and some medications, she should do well. I tend to not make political comments because in general I have nothing nice to say, but today I was proud of my country.

It kind of reminded me of that tale about the starfish, where the old man is on the beach throwing the starfish he finds back into the ocean. A young man points out how they will keep washing ashore and there's no way to save them all. The old man keeps at his work, and says something like "well, it makes a difference to this one."