Brain dead and bleeding

[bensonblues at comcast.net]

Ron,

Daily, neurosurgeons across the globe deide that patients unsalvigable and decline to operate. In that case as it was presented, I was left to assume that the surgeon was competent to make that decision. I fairly sure that I disagree with you, in that I do not believe that operating on a patient with known severe brain injury is a humane act. But, what is humane? If one of my closest friends, Ben the dog, was is the same situation, it would be considered humane to euthanize the animal. If a platoon is faced with leaving a severely injured Marine who cannot be evacuated to the whims of an advancing vicious enemy, or, shooting him in the head, most Marines that I know would suggest that the latter is the humane act. We all have different values, depending upon the situation, which are dictated by theological, legal, moral, and ethical standards which are culturally based that define what is humane. I am sure that we differ here, but probably only somewhat, and it does not make any on
e of us bad people.

Defining brain dead on-the-spot is not an easy clinical task, and is probably more philosophical as opposed to scientific. Those clinical standards on which we rely (persistent apnea and lack of responsiveness, fixed and dilated pupils, lack of cerebral blood flow, CT evidence of herniation, presence of gray-white on the stretcher, ad nauseum) are fairly succinct, however, subtler injury is not. Injury to neurons vulnerable to ischemia (CA1 pyramidal cell layer of the hippocampal gyrus, the Purkinje cell layer of the cerebellar cortex, and layer V of the sensorimotor cortex) will leave the patient mostly unresponsive, unable to care for self, but not apneic. We agree, I believe, that this is not brain dead. But, is it brain life? I suspect that we may have different views, but our disagreement here is purely philisophical.

As for anecdotes, we all have those. But, if I practiced that way, based upon anecdotes and my experience in the lab, I'd open the chest of everybody suffering a cardiac arrest, fill the area nursing homes with unfortunates, and wouldn't be able to sleep at night (not that I do, anyway).

So, allow me to rephrase: In my humane world, if I could not be restored to my family in a productive way, I would consider myself brain dead and would wish to die. That is not how I practice medicine, however, and I guarantee you that I give everybody the benefit of the doubt. That being said, I'm not sure if resuscitating a man with a known down time of 20 minutes is the right thing, I'm not sure if placing a high-spinal cord injury on a ventilator is the right thing, and I'm not sure if obtaining an operation for a patient who has evidence of brain injury is the right thing, but I do it. And I pray. I know that I've backed myself into a corner here: If I am allowed to define humane as what I would want for myself, then why don't I treat my patients the same? Again, I pray a lot.

I do believe that, if I am lucky, I won't die in a nursing home with brain injury. I also believe that if I am lucky, I will be able to buy you a tall pint of ale sometime and continue this discussion well into the night.

Merry Christmas

DB