Yesterday, Monday July 11, 2016, at 8:43 am, an unfortunate young man was declared dead.
His heart was still pulsing blood to the rest of his body, but he had actually been dead by neurologic criteria for a while. In morning rounds, the attending doctor demonstrated a lack of brainstem activity. No response to stimuli including pain, no pupillary, corneal, oculocephalic, oculovestibular, gag, cough reflexes. He was disconnected from the ventilator for 10 minutes and there was no spontaneous breathing. Therefore, his brain was dead. Therefore, he was dead.
He was a young guy, not much older than me, who took a tumble down the stairs when he was drunk a few days ago. His family put him to bed to sleep off his stupor, but when they checked back hours later he was even less responsive. Little did they know that he had bled massively into his skull — a subarachnoid hemorrhage — which pressed again his brain structures, cut off blood flow, and destroyed his brain. They rushed him to the hospital where he received a prompt medical workup. They cracked open his skull to drain the blood and release the pressure, but the damage was irreversible and he was already comatose.
There’s something about death by neurologic criteria that makes it feel almost incomplete, especially when compared to the other legal definitions of death: asystole (no heartbeat) and decapitation. The resident working the SICU (surgical intensive care unit) had been diligently drawing labs extremely often at every 3 hours and keeping his vital signs and labs within normal limits using aggressive IV fluids and medications. There was a feeling of frustration and futility when she gave her report, rattling off the progression of his lab values and responses to interventions, but then the attending cut her off with “the guy came in with a Glascow Coma Scale of 4, right? Like solidly comatose. Don’t be surprised he’s not doing well.” She sighed in resignation and listened along blankly as the attending explained to the whole room about the protocol to declare him officially dead.
I never really met the man. I’d read his name on the patient list, but I never had the chance to ask him how to pronounce his name properly. I never knew what his life was like, what his demeanor was, what pushed him to drink day and night daily. All I knew of him was that his body lay in front of me, tubes protruding every which way, head half shaved, heart beating on, and brain all gone. Family and organ donation coordinators were notified. His name disappeared from the patient list. Then, we walked off to finish morning rounds.
When I wrote my first post about witnessing a birth on my first night on the wards, I wondered when I would witness the mirror event. Death. As certain as birth. I didn’t know what it’d look like, but that first death I saw was unnervingly placid and academic. That’s the benefit of scientific foresight and medical intervention, I suppose.
The post was originally planned to end here, but… hospitals see lots of death, so it’s no wonder that it wasn’t long before I witnessed more.
The next day (this morning), many new names appeared on the patient list, including an old man with a bowel obstruction and necrotic extremities. As the night team read off his vital signs and lab values, the entire room of residents balked. Temperature of 34.7 C, heart rate of 142, blood pressure of 70/45, blood pH of 7.05, white blood cell count of 28k. Those were lab values of a doomed man. Indeed, when we walked into his ER room, we saw a cachectic old man with eyes closed, a shriveled toothless mouth senselessly agape, and no signs of life. Then, we walked off to continue rounding.
Later in the afternoon, another of our patients died. She was a nice old lady who had fallen onto her wrist last week and recovered well, but hours before discharge we found her unarousable due to a devastating brain bleed. There was nothing to do but intubate her and keep her comfortable until her family arrived to bid their farewell. Over the weekend, her sons and daughter flew back from around the world, and watched from the bedside as she passed peacefully on. We happened to be standing right outside when we heard her son choke out a painful sob. The nurses outside looked at the clock to mark the time of death. Then, we left to continue rounding.