Life and Death as Seen Through the Eyes of a Neurosurgeon: My Typical Week of Trauma Call
By: Brian Hoeflinger, MD
Disclaimer: Opinions are my own. Not medical advice.
As neurosurgeons, trauma plays a significant role in our lives and our work routines. It is a necessity to have hospitals and doctors who can treat critically injured patients immediately and emergently if needed. Our society requires it. It can be a matter of Life or Death. Hence the multitude of hospitals around the country, and the world, that designate themselves as Trauma centers.
Hospital trauma centers are typically designated as Level I, Level 2, and Level 3. A Level 3 trauma center will typically see low acuity injuries such as simple bone fractures, mild head bumps, or body sprains. A Level 1 Trauma center will see more life-threatening injuries such as severe head, spine, or abdominal injuries. I work for a major healthcare system in Toledo, OH with a designated Level 1 trauma center.
One week a month, I am responsible for covering neurosurgical consultations and emergencies for our healthcare system. Any complicated cases or potentially life threatening injuries are transferred from a multitude of outlying “feeder” hospitals to our main hospital. People are brought by ground ambulance or by helicopter if required. The week of call is typically long and very busy.
Trauma call for us starts on Friday morning at 7 am and ends one week later at the same time the following Friday. During that week, I will typically see anywhere between 50 to 75 new patients with a wide variety of diagnoses and injuries. There is no predicting what may come in. Typical consults include people of all age groups and may include severe head injuries, skull and facial fractures, brain bleeds, brain tumors, broken necks, broken backs, tumors of the spine, spine infections, narrowing of the spinal canal or herniated discs causing pinching to the nerves and compression to the spinal cord often causing paralysis and the list goes on. Trauma call at a busy level 1 trauma center such as ours sets the stage for human drama both tragic and triumphant.
Let me give you a glimpse into my world as a trauma neurosurgeon. This is an all too common but tragic scenario that I often see while on call. The story begins with a young person being involved in a high speed car accident on a remote road. The person is trapped in the mangled car and it takes emergency responders over 30 minutes to free the barely breathing patient. A breathing tube is placed at the scene and CPR started. When the helicopter lands, the patient is carefully placed onto a stretcher and the stretcher loaded onto the helicopter. The Trauma center is notified of the incoming patient who is not responding. Upon arrival to the hospital, the patient is quickly transferred to the emergency department where the Trauma team is waiting to evaluate and stabilize the patient. The patient is resuscitated with IV fluids and medications. A thorough exam is performed by the trauma team and once stable enough, the patient undergoes extensive imaging of their body to determine the extent of the injuries. The patient undergoes CT scanning of almost the entire body and is found to have extensive swelling and bruising of the brain as well as a broken neck. No other significant injuries are found.
At this point, Neurosurgery is consulted emergently to evaluate the patient. Upon my arrival, the patient is comatose with minimal brain function. This person has suffered a very severe head injury. There are multiple neck fractures which appear stable. The rest of the spine is without injury. At the bedside, I drill a small hole through the skull and place a tube into the brain to monitor brain pressure. The brain pressures are moderately elevated. The patient is started on medication for brain swelling and monitored closely in the Intensive Care Unit (ICU).
In the meantime, the parents have arrived and know nothing other than their child has been involved in a bad car accident. What I am about to do next, no words can do justice. I sit the family down in a quiet conference room and I say those words that no parent ever wants to hear. Your son or daughter has been in a horrible car accident and has suffered life-threatening injuries including a severe head injury. I pause for a moment to give the parents a chance to absorb what I have just said. Their facial expressions immediately change and they look away from me. After moments, they look back up and make eye contact. I can see the fright and agony in their eyes. I can see them trying to brace themselves for what I’m about to say. As compassionate and honest as I can be, I tell them that their child has suffered a severe head injury with extensive bruising and swelling of the brain and currently has minimal brain function. At that moment, they both begin to cry as the pain that I have inflicted upon them in the middle of the night is unbearable. I indicate that we are doing everything that we can but there is no surgery that I can perform to reverse the injuries. We will need to watch and wait. That was enough for me to tell them for the night. I told them that we will monitor their child very closely in the ICU and I would talk to them further in the morning. I realize as the reader how dramatic this must sound but this is exactly what we must do as neurosurgeons.
The following morning, I begin rounds on the multitude of sick patients that we have been consulted on. Depending on the number of new consults and patients to be seen, rounding may take as long as 5 to 6 hours and that doesn’t include if an emergency surgery needs to be to be performed in the middle of rounds.
But back to our patient. I arrive in the ICU at the young man’s bedside. His parents are there next to him holding his hand. I ask them politely if I may have them go to the conference room while I examine their child and tell them that I will be out to talk to them after my exam. I then talk to the nursing staff to be updated on the patient’s condition. The pressure in the brain is gradually rising. I examine the patient. He remains in a deep coma with minimal brain responses. A follow head CT has been performed which I review. The bruising and swelling of the brain has markedly worsened. I now needed to let the parents know of this change. As a parent myself, I knew they were out there waiting and hoping that I would say that things are getting better and that everything will be okay. And yet, I had just the opposite to tell them. There is no easy way to have these conversations with family and as a physician, the conversation does not get easier with time. You just endure it and then place it in some remote corner of your brain where you store all the other tragedies that you have been involved in.
As I enter the quiet waiting room, a large group of family members and a few close family friends stand up and eagerly await what I am about to tell them. I ask everyone to sit down and I try to sit closer to the parents. I begin the conversation by actually asking them if they would like to ask any questions. It’s a way to break the all encompassing silence of the room. It is my way of trying to get a better understanding of where they are with things at that moment. I quickly gather that they know things are bad but do not understand exactly how bad. I indicate to them that I am going to be very upfront and honest so they, as a family, can make the best decisions regarding treatment moving forward. I go over my exam findings and review the results of the head CT. I tell them that the pressure in the brain is gradually rising and we may not be able to control it. I needed to let them know that his condition was worsening. A deafening silence ensues. I know that they don’t know what to say or think so I try and help prepare them for the worst. I then say those terrible words, “your child has suffered a horrible injury and may not survive”. Enough said for now.
I then continue with my rounds. Patient after patient we examine and talk to. Other families waiting to hear about their loved one. When you finish with one patient, you are consulted on a new patient with a new unexpected problem. Some patients you can help and can even be fixed or cured, and others cannot. Some patients decline rapidly requiring emergency surgery for life saving measures. And some patients are beyond helping and the most compassionate route is to do nothing and keep them comfortable. These are truly matters of life or death.
As the week nears its end, the young man’s condition has reached an end. Brain pressures have become uncontrollable and he has lost all brain activity. He is what you would call brain dead. For the family, it is a moment of finality where all hope is lost, and yet, it is a time of simple truth. No longer must the family wonder what will be. The agony of the unknown has come to a final conclusion and they may begin to seek a degree of closure. Now the last decision to be made here in the hospital. Would their child want to be an organ donor to help save the lives of others who may be waiting to die. It is one of the most selfless acts out there and the family must make this last decision. After learning more about organ donation from the Life Connection liaisons, the family consents and the process of organ donation is set into motion.
As the week comes to an end, I have touched upon the lives of 75 people. Two people that were able to live to see another day through emergency surgery and three people who could not be saved because of their injuries and condition. As neurosurgeons, Life and Death are an integral part of what we do. People look to us for hope and I have never taken that aspect of my job lightly. It is a privilege and a responsibility that will never leave me as long as I live.
Thank you for taking the time to read this newsletter and I hope by reading this that you have gained just a slightly better appreciation for your life and all that you have in it.
Best wishes,
Brian Hoeflinger
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