Head Bleeds

I was on call last weekend, working the Saturday morning to Monday afternoon shift (Yeh, tell me about it). The ICU was hopping and the battle with the Angel was fully engaged. The theme was head bleeds. Specifically, intracerebral hemorrhages in middle-aged, previously healthy men.

The first was a 48 year old who lived with a roommate, worked various constructions jobs, and whose hobbies consisted of smoking, drinking and otherwise abusing his body. He hadn't seen a doctor in decades (a policy I approve of wholeheartedly) and likely had undiagnosed, untreated hypertension. He called his buddy to tell him that he didn't seem to be able to move the left side of his body. His buddy, rather than calling 911, drove over, and by the time he got there the patient was unresponsive and on the floor. By then the friend figured out that calling 911 was probably a good idea. In the ER, the blood pressure was 220/110 and the CT showed a huge, essentially fatal brainstem bleed. The surgeon looked him over and admitted him to my service to prepare for organ donation.

The next one was 52 years old, had also ignored his high blood pressure, and was found on the floor of the Men's room at his job, unresponsive and with a gash on his forehead where he had hit the sink on the way down. The CT showed an occipital bleed (back of the brain) and not too much else. The neurosurgeon took a look and again admitted him to my service in the ICU for blood pressure control and observation. We gave him IV fluids and administered several intravenous blood pressure meds, and he stabilized pretty quickly. Within a few hours he was semi-awake and communicating with slurred speech. I told him what was going on and went out to the nursing station to write a note. Five minutes later his wife was in my face very irate.

"My husband is very upset. I want to know why you told him he had a stroke?"

I looked at her.

"I don't know, I guess because he had a stroke."

It took me a while to explain what the word stroke means, that it is not just for old people who develop sudden paralysis, and includes various types of head bleeds. We talked for some time about his prognosis (doctor speak for how he's going to do) and the need for careful control of his blood pressure in the future, and she went away somewhat calmer.

The third patient had complained to his wife about a real bad headache and she had brought him promptly to the ER. His CT showed a big intracerebral bleed with a shift or compression of the rest of the brain. Bad news. I got the call from the OR where the surgeon had buzzed open his skull, scooped out the collection of blood and put in an intraventricular drain to monitor the pressure. He was on a ventilator and the plan was to keep him sedated, control his blood pressure and give him IV fluids and nutrition. We would let him wake up in a few days and see what his brain function was like.

The fourth patient presented with a sudden loss of consciousness, hypertension and a bleed on CT. By this point it was getting a little repetitive and a little ridiculous. It was like the Angel was jacking me around. Unfortunately, this one died before he could even be brought to the OR.

Final Score: Angel 2
ICU doc one definite win, one tie.