"This is a pretty bad one."

“This is a pretty bad one.” “What’s the story.” “Post TPA bleed. They just transferred her from an another hospital.”

 As I walked into one of the resuscitation bays in the emergency department, I took notice of this middle aged woman. She seemed lifeless and intubated; a procedure performed at the outside facility after she lost the ability to protect her airway, a resulting problem from the ongoing bleeding in her brain. As the ventilator forced hyper-oxygenated air into her lungs, the neurosurgeon, already present in the emergency department, was setting up for an attempt at a heroic procedure to help reduce the pressure inside her skull. There was not time for pleasantries or move to the operating room, just a quick look between the neurosurgeon and myself. We both already knew the controversial clot-busting poison, TPA, circulating in her bloodstream gave her a poor prognosis in the face of her brain bleed, especially given the location of the bleed. As he performed the procedure, ventriculostomy, that would allow for relief of the elevated intracranial pressure, I reviewed the documentation from the outside facility. As I read, I became angry, very angry. In spite of hindsight being 20/20, this patient should never have received this controversial drug on at least three different major contraindications. In order to paint a better picture, the indications for use of this drug are so strict that there are clearly delineated guidelines and checklists for its use. Physicians are taught to never use this drug under nonchalant circumstances.

As her intracranial volume decompressed via the emergent procedure of placing an opening in her skull and now the ability to measure her intracranial pressure, we re-examined her and found no real change in her neurologic exam. Just a subtle response to pain, minimal central reflexes, and equal minimal responsive pupils. In the emergency department, she received blood product treatments that futilely attempted to reverse the bleeding process including a blood clotting factor just prior to heroic procedure. All we could do is helplessly watch and hope that her brain did not continue to bleed causing brain herniation and eventual death.

Eventually, the patient’s son arrived. He appeared shocked and bewildered. I honestly didn’t know where to begin, as he knew very little about the events that had transpired. So in the dimly lit room with the ongoing humdrum of the ventilator and occasional beep from the cardiac monitor, I told the family member everything I knew in an objective fashion. As I neared the end of the conversation where I described the prognosis, words became sparse, and my mouth became dry. I resisted the urge to became angry and tear. As the conversation concluded, he had no questions, which I expected. This news for far too deep-seated and shocking to allow for anything beyond breathing and otherwise paralysis. I fought through the piercing, utterly uncomfortable silence allowing the son a chance for any questions. The questions would come later. I left the room and went on to the next fire somewhere else in the intensive care unit.

As the night progressed into the early morning, she lost all reflexes and signs of life. Our fears were realized. Internally, I fumed in complete disgust of the complete incompetence of her prior caregivers. Their indiscretion directly resulted in her death. There was no way around this truth. This was not just a careless mistake or a quick life or death decision. There was time, and there was consultation with a so-called expert. Although I fully admit to not being witness to the initial patient encounter, the history of events and exam upon initial presentation were clearly described. By 8 a.m. with family present in the room, two physicians upon their own individual exam and evaluation, as per state law, declared her brain dead. The family allowed for discontinuation of mechanical ventilation.