Neurocritical Care

Today was the last day of my 4 week neurocritical care rotation.  Every morning I woke up at 4:45AM and worked from 6AM - 6PM, 6 days a week with one 25 hour overnight call shift a week.  I am physically and emotionally exhausted.  My nickname for the neuroscience ICU is the vegetable ICU.  Patients who have sufferred devastating hemorrhagic strokes spend weeks in the ICU.  Often their strokes are caused by uncontrolled hypertension. Less commonly they are caused by arteriovascular malformations, tumors, or intrinsic arterial disease such as cerebral amyloid angiopathy. The blood thinners they were taking to prevent clot propogation/ischemic stroke ironically can indirectly cause a more devastating bleeding stroke. Trauma and aneurysm rupture are also common causes of bleeding strokes.

As a neurology resident, most of my effort and attention goes into the first 24-48 hours of a stroke.  What caused the stroke? What can be done to keep the stroke from worsening?  What are these patients' neurologic status? Can they protect their airway? Does they to be intubated and connected to a breathing machine?  Are they awake? How impaired are their abilities to follow commands and speak? Are they plegic on one side of their body, are they neglecting one half of their environment?

Patient's who have a poor exam and a CT scan which suggests they have or soon will develop elevated intracranial pressure will come to the neuro ICU.  Here they will be connected to a breathing machine if they cannot protect their airway or breath spontaneously. Their blood pressure will be monitored closely and they will receivce continuous infusions of calcium channel blockers if needed. If their neurologic exam or head CT show elevated intracranial pressure, they may need emergent craniectomies to remove parts of the skull to allow the brain to swell. Often the neurosurgery residents will drill a hole in their skull at the bedside and place a catheter into their brains to drain fluid and monitor intracranial pressure.  But if the patient's neurologic status is poor enough, the decision can be made early that all of these interventions are futile as the damage has already been done and their is nothing left to save.

Some of the younger and middle aged patients do well with early interventions. Patients with subarachnoid hemorrhages from ruptured aneurysms will get their aneurysm clipped or coiled surgically, and they are watched closely for signs of elevated intracranial pressure and vasospasm for at least 2 weeks.

Then there are the patients who are vegetables. These are the people who already had any combination of  multiple forms of high grade cancer, heart failure, end stage renal disease, and are also unfortunate enough to suffer a devastating hemorrhagic stroke. They become comatose, and are hooked up to a breathing machine. Often the only signs of life they show is the ability to locate painful/noxious stimuli with their limb that is not weak.  Somedays family members feel they are tracking and regarding them with purposeful eye movements; this can be equivocal.  They are mute, they are fed through a tube.  Days go by and they don't wake up. Often continuous EEG monitoring ("EKGs of the brain") are used to see if there are underlying seizures causing the poor mental status.

In situations like this, physicians turn to family members, the next of kin, to make decisions when a patient cannot communicate his own wishes.  This typically would be a spouse, parent, son/daughter in that order. Would the patient want his/her life prolonged in a situation like this?  In the foreseeable future there is no reason to believe the patient will walk, talk, or eat again.  Families ask will their loved one wake up, what are the chances that they will get better? The truth is there is very little data to definitively answer these questions.  To say that these vegetables will never regain any further signs of life with 100% certainty is often incorrect.

But it always baffles my mind why care is not withdrawn in patients like this. The right thing to do is to talk to families, show them all of the brain scans which explain why their loved ones are comatose, and then start the patient on a morphine drip so they can pass.  Sometimes this does not happen because families hold on to hope that their loved ones will get better and walk out of the hospital. Even if these patients didn't have strokes, they often have other serious underlying medical problems which cannot be fixed such as cancer, heart failure, or advanced underlying dementia such as alzheimers disease.  Sometimes care is not withdrawn because physicians are intentionally misleading about prognosis. No matter how sick patients are, modern medicine can keep them alive indefinitely. We have machines that can act as a patient's lungs, heart, and kidneys. Nutrition can be delievered through gastric feeding tubes. But there is no machine that can replace a damaged brain.

Sometimes extensive measures have previously been made to keep patients alive, whether it be kidney transplants, pacemaker placements, coronary artery bypass grafts, or decompressive craniectomies. I feel physicians often don't want to withdraw care because it admits defeat. Instead modern medicine is abused and patients are kept alive on life support indefinitely and sent to long term care facilities; out of sight and out of mind. And what happens to these vegetables after they leave the hospital? I don't know, I never see them again. Our residency doesn't focus on how to manage these patients, and frankly the physical act of transporting these immobile patients on mechanical ventilation is so difficult that they will never leave the long term care facility they go to, so they never come back to the hospital or clinic.

 

These experiences made neurocritical care the most difficult rotation for me thus far in my second year of residency. Maybe my feelings of disillusionment are amplified by the negative feedback I received for constantly being uninformed on the ventilator settings my patients are on or the rate of their IV infusions.  None of these things matterred to me because it doesn't change the fact that the patient is a vegetable and will continue to be for the foreseeable future.  But, for every vegetable who spends weeks in the ICU and gets shipped to a long term care facility, there are many other patients who have done well from neurosurgical intervention and close monitoring in the neuroscience ICU. However, I feel that too often uninformed decisions are made to prolong the life of patients who have sufferred severe irreversible brain damage by both family members and physicians. Few people would want to continue a life where they are unable to walk, talk, or eat.