In a more serious tone, this is much closer to what really happened as explained by a Registered Nurse. My account is from my memory, which in light of what happened as described below, is understandably fractured.
“The original bleed was worse than I had thought. Not because anyone told me it wasn’t bad, but no one said it was, and Ming’s neuro exam had been so stable.
The original bleed and subsequent swelling of the brain in response to the injury caused a pretty significant right to left midline shift. That is, a fairly good part of the right side of the brain was pushed over into the left side because there was no where else for it to go. This is a kind of herniation. Ming has had serial CT’s that have all been pretty stable. No new bleed and only mild increase in swelling but nothing surprising. It is difficult to see the clot as they are doing quick CTs without contrast and he said an MRI is best to evaluate the bleed. That said, they do not expect any of these things to change significantly (improvement wise) for quite sometime. It could take a month to see any improvement in the swelling on scan. But a worsening would be obvious, and goes without saying, bad.
they have been managing his blood pressure, oral or IV depending on the circumstance (as he has now been in and out of the ICU three times).
Managing the clot with anti coagulation therapy, first heparin drip and now lovenox injections (which neurosurgery said that now with therapeutic levels of lovenox there is no indication to switch him back to heparin)
Managing his pain as much as they can non narcotic but recently have had to resort to narcotics as the pain has worsened.
This brings us to the swelling and the event that happened yesterday evening. They have been using 3% sodium solution with a goal of pulling extra fluid from the brain tissue to help relieve the pressure that is causing the pain and deficits. The bleed and swelling are both contributors to this midline shift. Well, he can’t stay on this solution forever as it will affect his kidneys and it’s hard to keep all of his other electrolyte in balance with that much sodium. Because his neuro exams had been so stable (aside from the seizure activity) they decided to start weaning the sodium solution. Ming’s body decided it wasn’t ready. As the day went on he started having increased headaches and nausea/vomiting. Then he declined rapidly with a significant drop in heart rate and stopped breathing. They quickly intubated. Luckily the response team included the Neurosurg fellow. He said he literally watched Ming’s pupil blow in front of him. Not that this is good by any standard but the fact that they were all there meant quick response. They gave him a drug called mannitol, which does the same thing the Na does only super fast. With the lowered Na infusion throughout the day Ming’s brain started swelling again. Only this time instead of pushing right to left it pushed down. All of it is bad, but down is really bad because this puts pressure on the brain stem which controls your heart rate and breathing. The Mannitol acted quickly, Heart rate recovered and pupils returned to equal and reactive. They took him for another scan and it still showed no significant change.
They left him intubated and lightly sedated overnight. Another video EEG which they plan to keep him on through today. They woke him by stopping the sedation several times overnight and did neuro exams. Of course he tried to pull out the tube each time but they had his wrists restrained. Once calmed he would follow commands and then they would give more meds and let him go back to sleep. This morning they turned off the sedation and he woke up and they extubated him. He was doing ok, I happened to call 15min after extubation, sleeping but waking easily and following commands. She said he was not speaking clearly, just kind of mumbling. But that could be all the drugs.
She said the EEG overnight did not show any further seizure activity. They had started him on Keppra the first time around and have now added Dilantin. These can make you super sleepy especially since he got a loading dose last night.
I asked the neurosurgeon what he thought as far as long term prognosis and why they weren’t doing anything more to relieve the pressure. The surgical intervention has risks that far outweigh the benefit given his current condition. I can explain it to you guys if you want me to, but since right now it’s not an option, I’ll skip it. He felt this event tells them they have to go much slower in weaning him off the Na. All things considered he felt Ming could make a close to if not full recovery, but it wasn’t going to be quick or easy. He said he was looking at minimum of a year of rehab.
All of this to be figured out once he is out of the woods for everything else. “