Reaching Down the Rabbit Hole by Allan H. Ropper Read Free Book Online Page B

mental dullness accompanied by considerable head pain. The bluntness told me that her hydrocephalus was pressing on the frontal lobes from the inside, and winding down the engine that makes the nervous system spin. The pain that caused her to intermittently clutch her head and neck suggested that the pressure inside her skull was not only very high, but rising.
    The skull is like a fixed container. If pressures within the skull are unevenly distributed, there is a breaking point at which the entire brain gets squeezed downward like a plunger, compressing the brain stem. This is precisely what happened when Mrs. G blew her pupil later that afternoon, resulting in the code blue. I just happened to be outside the door to her room when the problem came to a head (so to speak).
    Once a code blue is called, it takes a minute or two for the team to materialize from the other pods and from the ICU a floor below. In that brief interlude the nursing staff swings into action. Three nurses rushed in to help move the patient from her recliner onto the bed. As we prepared to roll her onto a board for chest compressions, I wiped the sweat off her back so the defibrillation pads would stick, then pushed the triangular mask of the Ambu bag around her mouth and nose.
    “She’s going to need mannitol,” I said, and as I came out of the door I ran into Hannah, who seemed genuinely surprised when I told her that Mrs. G had blown a pupil.
    “This woman needs mannitol!” I yelled again over to the desk nurse, and Hannah went to help her get it. Mannitol, a drug administered by IV, is a sugar alcohol used to pull fluid out of the brain inorder to reduce the internal pressure. In this case it was just a stopgap. Mrs. G was going to need more than mannitol.
    A code is a highly choreographed performance executed in a small space measuring approximately eight by twelve feet. Among the dozen people who rushed into the room in the next few minutes, each one had a specific part to play, much like the musicians in an ensemble. The code leader, a senior medical resident, is nominally in charge, but because Mrs. G was my patient, I took up a position at the head of the bed and “directed” the code while the senior resident “ran” it. In a sense, I appointed myself guest conductor. I had to be there to provide my perspective, because for a code team, whatever’s going on with the brain is secondary. Their primary focus is to restore respiration and circulation—keep her heart and lungs going.
    A passerby could be forgiven for mistaking a code blue for an assault. A junior resident was kneeling over the bed, stiff-arming the patient’s breast bone to force blood through the heart chambers. On the third pump, I heard the audible crunch of Mrs. G’s ribs cracking, a sign that the resident was doing the chest compressions forcefully enough. That was her job. My job was to tell the code leader that the brain was not secondary in this case, that its internal pressure was pushing the brain stem down onto itself, causing the nerve cells that control breathing and heart rate to shut down, and that the only way to resuscitate her would be to reverse that vertical displacement.
    At two minutes into the code, the mannitol was being infused, but I lost her pulse at both the carotid and radial arteries, and asked one of the nurses to call down to the neuro-ICU and get a neurosurgery resident with a ventricular tray right away. Hannah, who had placed the intravenous line that delivered the mannitol, would later admit to me what was going through her mind at the time: nothing. She was completely nonplussed. For weeks afterward she agonized over whether, had I not been there, she could have composed herself enough to figure out why the patient had crashed and what needed to be done about it. What Mrs. G needed, literally, was a hole in the head. She needed tohave a tube threaded into her brain through which the excess fluid could be drained from her