skepticdoc
Critical Thinker
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Recent publication: http://www.peh-med.com/content/pdf/1747-5341-2-27.pdf
Brain Death determination
- Thread starter skepticdoc
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Deetee
Illuminator
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Don't fret - you are not alone.... Skeptidoc is also unlikely to ever master the field.*
*Evidence based on plentiful previous medical JREF correspondence.
So you're saying complete lack of blood flow to the brain, at least temporarily, and no response to stimuli of any kind and there's no apparent electrical activity in the brain, but the patient is not brain dead or somehow recovers to the point of not being brain dead?
You might want to consider extreme cases of hypothermia, especially in young children. Having extended periods without oxygen in such circumstances and having the brain function beyond what would normally be expected is highly unusual, but not unheard of.
drzeus99
Hellmouth Beastie
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SteveGrenard
Philosopher
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Karen Ann Quinlan was taken off the vent because without it she was expected to die but didn't.
More on the case at:
http://en.wikipedia.org/wiki/Karen_Ann_Quinlan
More on the case at:
http://en.wikipedia.org/wiki/Karen_Ann_Quinlan
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Alice Shortcake
Graduate Poster
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I'm reliably informed that in most UK hospitals the patient is always poked with a sharp stick before their life support system is turned off. 
Alice Shortcake
Graduate Poster
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Oops - double post
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I'm reliably informed that in most UK hospitals the patient is always poked with a sharp stick before their life support system is turned off.
Hmmm... always? Even if they don't need it anymore?
"Mister Johnson, I have some good news. It looks like your lungs are functioning well enough that we can take you off life support. But we'll keep an eye on you and let us know if you feel like you have trouble breathing when we disconnect this"
"HEY! What the hell was that for! You just poked me with a really sharp stick. That really hurt."
"Sorry that's procedure"
Two points:
(1) Brain death is a clinical diagnosis still. It requires two independent practitioners to confirm it. I took care of (in September) of a toddler in the PICU who was "brain dead", but did not meet clinical brain death criteria. He was accidentally strangled in a crib, and had a massive anoxic brain injury in spite of being resuscitated at an outside hospital and transferred to our facility for care. We did an MRI of his brain and he had absolutely no cerebral (telencephalic and diencephalic) brain function, which was clear on the MRI pictures. He was unresponsive to painful stimulus and did not have corneal reflexes. However, when we stopped the ventilator, he was able to continue an ataxic breathing pattern that would sustain his life. We kept him like this for 10 days and had serious discussions with the family. When it was clear to the family that he would never recover from this injury to lead a normal, meaningful existence (which had been immediately clear to us), they decided to extubate him and withdraw support. He died within an hour.
(2) I have participated in total circulatory arrest cases in the operating room, most recently this past weekend. The most recent scenario involved a 84-year-old gentleman who had a complete disruption of his ascending aorta secondary to a ruptured plaque. We circ-arrested him for only about 10 minutes, and maintained low cererbral blood flow for about two hours after that. The rest of his body got no blood flow during that time. We packed his head in ice and the perfusion pump was cooled. His core body temperature during this time was 18.1 celsius. Now, I'd talked to this man before the operation. He even signed his own consent form. After the surgery, it took him two full days to "wake up". I saw him on Tuesday of this week, and you could tell his mental status had changed. It was amazing enough that he was alive and talking after an injury that had predicted he'd never make it off of the table, but he will likely never be the same.
-----------------
What I have learned, as a clinician, can best be summed up by the thoughts of a neurosurgeon I've worked with, and it is a quite profound way to look at this problem. He told me once (and I'm paraphrasing), "Death is really a continuum. There's sometimes no really good way to determine in a catastrophic brain injury when the patient actually died." If you think about this, it makes sense. We know to remain "conscious" you need one of two hemispheres and an intact reticular activating system. If you blow out any of these things, are you still really alive? Certainly, your physiologic signs may say "yes" to that, but you've lost your "CPU" and you will never be able to process any input from that point forward on a conscious, meaningful level. And, with the advent of powerful drugs and mechanical devices as well as extreme surgical interventions, we've effectively blurred the line between what once would've been the natural terminal course of some conditions.
Who's right? I don't know. All I know is some of the brain bleeders I've seen and traumas and tumors and other conditions where you know that the person will never recover or even survive without intense critical life support is certainly not being "alive" to me, and is no way that I want to continue my existence if I'm ever unfortunate enough to be in that situation. We stumble through our ability to determine this as frail human beings trying to give the benefit of the doubt to the victim, and sometimes unexpected recoveries do occur (but usually only when the clinical diagnosis is uncertain). Protocols are blunt tools that assist us, but more often than not they cannot possibly mollify or assuage the wrenching decision to withdraw care on a family member. I can only imagine how hard that must be for the patient's family, because I know how hard it is for me as a practitioner. I've lived it, and that "gray" area is no fun place to be. Trust me.
-Dr. Imago
(1) Brain death is a clinical diagnosis still. It requires two independent practitioners to confirm it. I took care of (in September) of a toddler in the PICU who was "brain dead", but did not meet clinical brain death criteria. He was accidentally strangled in a crib, and had a massive anoxic brain injury in spite of being resuscitated at an outside hospital and transferred to our facility for care. We did an MRI of his brain and he had absolutely no cerebral (telencephalic and diencephalic) brain function, which was clear on the MRI pictures. He was unresponsive to painful stimulus and did not have corneal reflexes. However, when we stopped the ventilator, he was able to continue an ataxic breathing pattern that would sustain his life. We kept him like this for 10 days and had serious discussions with the family. When it was clear to the family that he would never recover from this injury to lead a normal, meaningful existence (which had been immediately clear to us), they decided to extubate him and withdraw support. He died within an hour.
(2) I have participated in total circulatory arrest cases in the operating room, most recently this past weekend. The most recent scenario involved a 84-year-old gentleman who had a complete disruption of his ascending aorta secondary to a ruptured plaque. We circ-arrested him for only about 10 minutes, and maintained low cererbral blood flow for about two hours after that. The rest of his body got no blood flow during that time. We packed his head in ice and the perfusion pump was cooled. His core body temperature during this time was 18.1 celsius. Now, I'd talked to this man before the operation. He even signed his own consent form. After the surgery, it took him two full days to "wake up". I saw him on Tuesday of this week, and you could tell his mental status had changed. It was amazing enough that he was alive and talking after an injury that had predicted he'd never make it off of the table, but he will likely never be the same.
-----------------
What I have learned, as a clinician, can best be summed up by the thoughts of a neurosurgeon I've worked with, and it is a quite profound way to look at this problem. He told me once (and I'm paraphrasing), "Death is really a continuum. There's sometimes no really good way to determine in a catastrophic brain injury when the patient actually died." If you think about this, it makes sense. We know to remain "conscious" you need one of two hemispheres and an intact reticular activating system. If you blow out any of these things, are you still really alive? Certainly, your physiologic signs may say "yes" to that, but you've lost your "CPU" and you will never be able to process any input from that point forward on a conscious, meaningful level. And, with the advent of powerful drugs and mechanical devices as well as extreme surgical interventions, we've effectively blurred the line between what once would've been the natural terminal course of some conditions.
Who's right? I don't know. All I know is some of the brain bleeders I've seen and traumas and tumors and other conditions where you know that the person will never recover or even survive without intense critical life support is certainly not being "alive" to me, and is no way that I want to continue my existence if I'm ever unfortunate enough to be in that situation. We stumble through our ability to determine this as frail human beings trying to give the benefit of the doubt to the victim, and sometimes unexpected recoveries do occur (but usually only when the clinical diagnosis is uncertain). Protocols are blunt tools that assist us, but more often than not they cannot possibly mollify or assuage the wrenching decision to withdraw care on a family member. I can only imagine how hard that must be for the patient's family, because I know how hard it is for me as a practitioner. I've lived it, and that "gray" area is no fun place to be. Trust me.
-Dr. Imago
That's why they say, "you're not dead until you're warm and dead."
Last night (well, actually this morning at 3:00 AM), I was present to provide "anesthesia support" for an organ procurement on a 2-year-old. Likely victim of shaken-baby syndrome. They took his liver and kidneys.
Sometimes my job is incredibly depressing.
-Dr. Imago
Sometimes my job is incredibly depressing.
-Dr. Imago