Reaching Down the Rabbit Hole (25 page)

Another anomaly was that in most cases the pus is concentrated in one area, so that the abscess is fairly restricted, usually to a few segments of the spinal column. In Harry’s case there was no clear point of origin. The infection was uniform along the entire length of the spinal canal, from the base of the brain all the way down to the tail-bone. The epidural space was bursting at the seams. There were pockets of pus from stem to stern, pockets between every rib. The diener didn’t have to lance them. The cord itself had been completely ravaged. Microbiologists have a healthy respect for bacterial infections because they move very quickly and do a lot of tissue damage, yet they are treatable. But it was clear that despite forty-eight hours of intensive antibiotics and a surgical draining, this was a very aggressive
staphylococcus aureus
, and we probably couldn’t have done much about it. That was the one finding that assuaged my guilt.

William Osler built his reputation on correlating what he had seen during the patient’s life with what he saw at the autopsy. He used to go down in his frock coat in midsummer into these hot basement rooms with his acolytes, and stand there while the organs were removed, and he would handle them, inspect them, and discuss what he had seen in his examination of the live patient, and how it related to what they now saw; what they had missed and, equally important, what they had gotten right. He would try to create a feedback loop that completed each patient’s story. That feedback loop has now been curtailed by imaging, the new pathobiology that, by default, has replaced the autopsy
with CT scans, MRIs, and ultrasounds. Before imaging and after Osler, it was considered the ultimate badge of a quality clinician to learn directly from the autopsy, which was the only way to look at the anatomical structures at that time. It meant you were willing to confront your mistakes. That was the classical approach.

Today, that approach has been compromised and compressed. In its place we have a Morbidity and Mortality conference every fourth Friday, in which the senior resident who has run the service, either in the ward or in the ICU, presents a synopsis of that month’s cases. By dictum of the Massachusetts Department of Public Health, these M&Ms are top-heavy on statistics: How many admissions? How many discharges? How many deaths? How many unexpected complications? How many patients who were discharged had to be transferred out or transferred back? Medicare and other agencies want to know these metrics, even though they have no pedagogical or practical value. After that, the senior resident presents her biggest cases and complications. Only then, and in less than five minutes, would a case like Harry Connaway’s be discussed. It is not a great opportunity for reflection.

I take some solace in the fact that four residents and a medical student got to experience the Oslerian perspective. That exercise, as much as any, is what will turn them into doctors instead of automatons. First, there’s a very intangible phenomenon of having seen a patient hours before when he was alive, and then seeing him dead, with the cause of death flayed out in front of you, knowing with precision how your involvement contributed to this result. Second, you will eternally cycle back to this possibility; it will be embedded in your memory in such a way that you will never miss it again. That was Osler’s innovation. And third, these students and residents didn’t have to read anything about epidural abscess because it was all there in plain sight: how the abscess affects the spinal cord, how it spreads up and down the spinal column, what its potential sources are, what effect it has on the neurological exam. An abstraction of that experience ends up in a textbook, but is no substitute for seeing it. Everyone
had studied it in medical school, it might even have shown up on board exams, but none of the residents had experienced it. They couldn’t have, because this case was one in a million, so extreme that it simulated another illness.

My sole consolation is that they will never through their careers miss another abscess. Nor again, I hope, will I.

12

The Eyes Have It

When is somebody not dead yet?

In Boston, during the interminable leafless months, there is a big difference between a day that feels cold and one that only looks cold. Given a choice, I’ll take the former. The latter just makes you shrivel. Driving to the hospital down Route 9, I could see obscenely large icicles suppurating from ice dams on eaves and dormers, frozen mist glaciating tree branches and power lines, and coagulating slush clotting sidewalks and sewers. My son, who was doing a surgical internship in Florida, had been beefing about the rainstorms down there, so I stopped the car along the Riverway and took a picture with my phone to reassure him he had the better deal. Down there, the rain quickly disappears down the storm drains, but way up north, in the slough of the Fenway, the ice which had overtaken the city was here to stay. By tomorrow’s inbound commute, it would produce my next patient.

It was a bad omen when my beeper went off the following morning at 6:10 as I warmed up my car in the garage. Trey, my senior ICU fellow, asked me to meet him in the emergency room to save time on an
admission. “A guy fell on Comm Ave this morning and cracked his head,” he informed me when I rang him back. “He’s got a big subdural, but the neurosurgeons don’t want him because he may be too far gone.”

Comm Ave is Commonwealth Avenue, and it snakes through Newton, past Boston College, then through Boston University, on down to the Public Garden. A
subdural
is short for a subdural hematoma, a brain hemorrhage typical of traumatic brain injuries, caused in this case when the skull hit the sidewalk and the brain caromed off the inside of the skull, in the process tearing veins that run across its surface.

When I arrived at the Emergency Department, I found the poor guy—a very thin, elfin-looking man, with pallid skin and short, whitish, sparse hair—breathing on a ventilator. According to his driver’s license, his name was Mike Kavanagh, and he was an organ donor. A huge gash decorated his scalp, with dry-crusted blood cascading onto the bedsheets like a frozen brackish waterfall. His neck was wrapped in a leather Miami J collar that made him look like a gaunt, yoked horse.

“He was intubated in the field with a GCS of five,” Trey dourly pronounced, as if that would capture everything about the case. It rarely does. The Glasgow Coma Scale was devised as an assessment of consciousness, especially for the use of first responders in cases of head trauma. It runs from a high value of 15 for a normal person, down to 3, indicating deep coma. “The EMTs said he slipped on the ice,” Trey continued. “Someone saw it and told them that.”

“Let’s see what we have,” I replied.

When I pulled back the sheets I saw Mike’s thin frame: short, maybe five feet four inches, small-boned, tautly muscled, almost anorexic. He could have been a jockey. His skin was blanch white, with a fair number of age spots but also a farrago of freckles on his cheeks and upper back. His hair, even whiter, accented rather than covered his gouged scalp. Definitely Irish. If his name wasn’t a giveaway, the Sinn Féin tattoos on his deltoids were. No outward sign of life other than the rising and falling of his chest with the ventilator breaths.

A few days earlier, my colleague, Martin Samuels, the head of the neurology department, had given a lunchtime lecture on consciousness, coma, and death by brain criteria. Here, I thought, was the poster boy for the third part of that talk. Marty prepares all of his talks, no matter the audience, as though he were addressing the annual meeting of the American Academy of Neurology, leavening insight with humor and technical minutia with lively anecdotes. Trey had been at the talk, and even though I had heard it before, I had tagged along, not just for the free lunch, but because I enjoy the way Marty launches into the topic:

Imagine two scenarios. In one, the viewer, perhaps yourself, sees a dog being hit by a car, being thrown thirty feet to the side of the road, where it lies motionless, probably dead. In the other, you watch a fly land on a countertop, where it is swatted and effectively crushed. Most definitely dead. Why do we agonize over the dog but not the fly? The philosopher says, “Because the dog is conscious and the fly is not.” How do we know? Because the dog has eyes that look at you. The secret to consciousness is in the eyes. If the creature has humanoid eyes and it looks at you, then it is conscious. And if it doesn’t, it isn’t. The compound eyes of the fly do not convey any feeling to us of consciousness. Same with the worm. Philosophers and neurologists have come to the same conclusion with regard to consciousness, and that is that the secret to consciousness is in the eyes. If you understand the eyes, you will understand a lot about consciousness. In fact if you know a lot about the eyes—in great detail—then you’re practically a neurologist. This is not chance.

“Dr. Ropper, are you going to put gloves on?” The nurses always have to ask me this because I am obdurately inclined to forget. Gloves are a modern and quite sensible innovation, but I have always had trouble finding size sevens for my smallish hands. The cheaper size S
gloves that come in boxes are too small, and the Ms make me fumbly. I grabbed a pair of Ms to set a good example to the junior residents. No need to worry about fumbling with this patient. The moment I pulled Mike’s lids up to check the reaction of his pupils to my flashlight, I knew that he was dead. No tone, no resistance in his eyelids, well beyond the sleeplike state of coma.

Remember, an overdose of barbiturates will make you look absolutely dead—no pupils, no eye movement, no vestibular ocular reflex, no calorics, no EEG, nothing—until you crawl out of the grave. So until you know with reasonable certainty that there are no drugs, that there has not been any severe hypothermia, and the criteria are fulfilled, don’t pronounce anyone dead.

“Has he gotten paralytic drugs or sedation from the ED guys?” I did not want to be fooled by an artificial death created by the medications that doctors use to facilitate intubation.

“Nope.” Trey was rhythmically shifting his considerable weight from side to side, making me nervous. Trey is at least six feet six inches, a recognizable cell tower even when spotted from a great distance. We had twenty-two patients to round on upstairs in the neuro-ICU, and at the moment there were no beds for the thin man. Not only would Trey have to clean up all the medical problems from the overnight shift, but one of us (him) would be stuck making calls all morning, putting the squeeze on our colleagues upstairs to send one of their patients from the ICU to the ward in order to free up a bed. Shifting your weight is something you do when the worst part of your day is ahead of you rather than behind you. I tried to recall whom I had done a favor for in the past week, who might oblige me with a move. I also wondered if there was any point to it, whether Mike was already gone and we could simply house him on the ward.

“Look, Trey, maybe he’s brain dead, and we can dispense with the ICU bed.”

“Yeah, but the ward team won’t take him on a ventilator.”

Mike’s pupils were enlarged, without a hint of constriction. I went right up against his face, the ventilator tubing digging into my neck, looking for even a glimmer of movement as I swung the flashlight in and out of his eye.

“Nothing on the other side, either.”

Don’t let yourself be forced to pronounce death by brain criteria until you’re ready, no matter what they try to do. The neurology service is put in the middle here, in the Emergency Department and the Intensive Care Units, for various reasons, some of which have to do with organ transplantation, some of them with family pressure, some with the anxiety of caregivers (that is, other doctors).

By the time we could move a post-op patient to free up a room for Irish Mike Kavanagh, it was easily 10 a.m., and I was mad at myself for not doing a better exam in the ED to see if our guy was truly brain dead. That diagnosis is transformative. The same warm body from ten seconds ago undergoes a state change, much like the transition of a liquid into a solid, and once pronounced officially dead, is entitled to all the rights and privileges thereof, which is to say, none whatsoever. When you are dead you cease to be a person, and you become an object. You no longer have possessions, a future, even a present, only a past. But Mike was not dead yet, not legally, not biologically, not until we said he was. He was still warm, still breathing (with assistance), still digesting his last meal.

With a bed now ready, we swung the gurney onto the service elevator, trailed by a respiratory therapist and an ED nurse, both pushing rolling IV poles, and looking like two subway straphangers on the ride upstairs. Whenever I feel I haven’t wrangled myself into enough exercise in the previous few days, I look for opportunities to join in physical tasks around the unit. Transferring an unresponsive patient
from the gurney to the bed is just such a ritualistic dance: turn the body away from the bed up on its side, slip a varnished board with a cutout handle on one end under him (
Why only one handle?
I always think), roll him back onto the board, grab the sheets from the opposite side of the bed, wait for someone to count “one-two-three,” and pull the sheet across the board and onto the bed with the body.

As we shifted him, I perceived an all-too-familiar feeling of “dead weight” that gave further credence to my initial impression of death.

The cranial nerves are key because they come out of the brain stem segmentally, and the big question is: is the brain stem involved? That’s why we begin with the eyes. The eyes are the secret to unconsciousness. We can’t test smell in these patients because that requires cooperation. Remember that smelling salts do not test smell; they test pain, the fifth cranial nerve. You can test everything else, but do you? You don’t have to. The eyes include cranial nerves 2, 3, 4, and 6, so you can go from 2 to 6 just by looking at the eyes. Whether the person gags or swallows when you move the tube depends on the level of anesthetic and many other functions.

“Watch the vent, dammit!” Trey shouted at the nurses. “It’s pulling the endotracheal tube out.”

What I noticed, and what I’m sure the others occupied in the dance did not, was the complete lack of a cough, a grunt, or even a quickening of breath coming from the patient. Sliding a tube up and down the trachea is one of the most noxious stimuli that can be applied to any live body, so noxious that it stimulates certain obligatory reactions. Awake but paralyzed persons tear profusely. Comatose people flinch and cough weakly. The dead are dead to it, and our guy hadn’t even flinched.

Once we had him situated in the bed, it was time for a curious piece of neurology: the brain death exam. This involves a sequence of
tests designed to confirm a suspicion that the brain is not working on any level. There are five features that confirm a diagnosis of death by brain criteria, a few surrogate features that accomplish the same task, and a few that exclude the diagnosis. If you get a perfect score on the brain-death examination—five yeses—you can officially pronounce the patient as dead as Jacob Marley: as dead as a doornail. There is no other neurologic situation in which you would push a body to the extremes that these tests require, in particular, shutting off the ventilator to see whether someone can breathe on their own. It could kill someone who wasn’t already dead.

We don’t call it “brain death.” We call it “death by brain criteria.” To use the term “brain dead” confuses the public because they ask the question: “If it’s only brain death, what is alive? Are the kidneys alive?” I don’t use the term
alive
with regard to the kidneys or the skin. The person is in the brain, and virtually everybody in every culture agrees with that. It’s death, just like death by cardiac criteria. Our job is to make sure that people don’t abuse it.

In the United States and most European countries, the brain-death exam has become a generally agreed-upon series of bedside clinical tests that start at the top of brain, the cerebral hemispheres, and sequentially test the function of each part below: the midbrain, the pons, and finally, the medulla. While a dead brain is one thing, and a fairly easy thing to confirm, a dead person is another thing, and Marty was indulging in a bit of oversimplification when he said that “the person is in the brain, and virtually everybody in every culture agrees with that.” It would be more accurate to say that the medical establishment, via the medical schools, agrees with that. But the question hangs out there like a Cadillac on cinderblocks: What does it mean to be brain dead? Is that really the same as being just plain old dead?

Here was Mike Kavanagh, a warm body, chest rising and falling
rhythmically, oxygenated blood coursing through his arteries, fingernails growing, facial hair still sprouting, digestive tract still sending nutrients into his bloodstream, all of his vital organs save one most definitely alive. But both Trey and I were sure that he was in fact dead, or, more to the point, that after due process we would be signing a certificate that established not just the “fact” of his death, but the precise moment of it. The inherent absurdity in such cases is that whatever had happened to Mike out on Comm Ave, and whatever was happening inside his body and inside his skull right at that moment, his death and the instant of its occurrence were up to us. According to Catholic doctrine, Trey and I had the power and the duty to decide when to release the soul of Michael Joseph James Kavanagh unto his Maker.