The surgeon is letting students pick their three topics for our oral exam DAYS prior to test day. This is ludicrous on so many levels, I don’t even want to go into it.
I was told I had to choose topics, or else my classmate would choose them for me... so, fine. Sighs. I chose three and thus am now extra-reading up on:
symptoms and surgical treatment of chronic pancreatitis
classification of skull fractures
determination of brain death
I chose this last one because two weeks ago, I stood beside a paramedic as she went through the steps for a fresh ED admit ... and I realized I didn’t even know what things to check before someone could be declared brain dead. In fact, I always confused the ideas of comatose, brain death and persistent vegetative state. So I’ll clear it up for myself (and perhaps others?):
BRAIN DEATH: a state of irreversible unconsciousness (GCS 1-1-1) which meets very strict criteria. Importantly, there is an absence of brainstem reflexes, motor response, and respiratory drive. There are many other criteria as well, but for starters, the reflexes to check are the following:
1. corneal reflex (CN V1 + CN VII)
2. oculocephalic reflex (CN VIII + CN III and CN VI)
3. gag reflex (CN IX + CN X)
4. pupillary light reflex (CN II + CN III)
5. cough reflex (CN X + CN X)
6. pain reflex (CN V + CN VII)
Because the determination of brain death is so crucial to get right, there are other criteria as well, which are explained really well on teachmesurgery.com (linked the article here). These include that the patient not be on sedatives, be apneic, have no reversible causes in the background, and many more.
Brain death differs from persistent vegetative state, although both are in an irreversible unconscious state. A patient who is brain dead cannot breathe on their own. A person in a vegetative state actually does breathe on their own. A comatose patient is also unconscious, with no reflexes, but they may be awakened -- it depends on the cause of the coma.
In the case of the patient on that fateful day, the presentation was GCS 1-1-1, and she was intubated in the field. The husband called the ambulance because the patient had a seizure while sitting on the toilet. The toilet... yes, you guessed right. When we did a CT of her head, there was a very large subarachnoid hemorrhage. It’s a textbook case: undiagnosed cerebral aneurysm ruptures in the background of straining (i.e. being on the toilet), and if the bleed is large enough, it can be fatal.
In her case, it was. However, you need to wait 5-6 hours to declare someone braindead, so we observed her in our ED while the family came to say goodbye. She was young... 50-something? ... and no significant medical history except smoking.
In medicine, you learn best by seeing, then doing. I saw my first case, and one day in the future, I’ll have to do it myself.
