List Archives

Mon Dec 25 13:01:14 GMT 2006

>"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."
>"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 one of us
bad people."

DB,
Your two quotes above, are, to me, the crux and essence of this entire
thread; on those, and almost everything else in your post, you and I are
in the same church and same pew.

So, as to the last suggestion, first round is on me, and we certainly
will continue to see how close you and I are in our approach, mine
being, I believe, governed just a bit more by the "legalistic" approach
of our brain death protocols here.

Merry Christmas,
Ron
>>> <bensonblues at comcast.net> 12/24/2006 4:02 PM >>>
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
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

Confidentiality Notice

This e-mail message, including any attachments, is for the sole use of
the intended recipient(s) and may contain confidential or proprietary
information which is legally privileged.  Any unauthorized review, use,
disclosure, or distribution is prohibited.  If you are not the intended
recipient, please promptly contact the sender by reply e-mail and
destroy all copies of the original message.

List Archives

For your convenience, find the Trauma List Archive Below

Brain dead and bleeding