[kloget]

I am up against a deadline for a novel I am writing about a man who is in a coma. I want to be sensitive to those who are actually dealing with this situation, as well as the nurses involved in the coma person's care. BUT I have a few specific questions that I can't seem to find answers to. Is there a NICU nurse out there who would be willing to help me by providing accuracy to this fiction piece? I could email the questions to you, in context. Thank you.

[glascow]

you can pm me your questions. I'd love to help.

[RNonsense]

Ditto here!

[kloget]

Thank you so much for your kind reply. It is extremely important that I do this with integrity. You see, I have had nine spinal operations myself (in real life) and am going through a painful time. I know what its like to be on the receiving end of treatment and I want to honor the nurses that have taken such good care of me time and time again. (I have written several into this script). It is important that I don't just blow off the facts, and that I remain sensitive to families who are actually going through TBI situations. So, thanks again and here are the specifics. You can email me at kloget02@yahoo.com if that would be easier than posting here and thanks again. I will use your name in the acknowledgments if you send it along with the answers.
Facts without the fluff: Distracted driver runs red light at intersection. He is traveling north/ south, and is hit by driver going through green (east/west) at quite a clip. East/west guy dies and the subject of these questions is in a coma by the time he gets to the hospital.
• Question#1 is “could the force of the impact from the left (driver’s side) cause the following: He has TBI, with a Glasgow score of seven. “The force of the impact from the left, the driver’s side of his car, caused his brain to slam against the right side of his skull. It bounced back and forth, wobbling his brain stem in the process.( It is a shearing injury, which means he has some tearing in his brain stem.) The car spun around and slammed into a retaining wall which compounded the already violent back and forth motion of his brain. There is swelling and bleeding. Also, He went into respiratory arrest and cardiac failure while being transported here by helicopter. Though in critical condition, he is certainly lucky to be alive.” “Research has shown that there is a 50% chance that he will die or remain in a vegetative state. Only 30% recover. But please remember, too, that this is not an exact science.”
• Question#3 what would be done in surgery to help him?

Question#2 is which of the following would he have in NICU after surgery Brain Stem Evoked Response Equipment, Catheter, Electrocardiogram (ECG/EKG), GI Tube, Intracranial Pressure (ICP) Monitor,
Respirator/Ventilator, Subarachnoid Screw, Tracheostomy Tube

• Question #3 is “what would the family see when they walked into NICU?” (just need the facts) Here is what I have so far and would appreciate critique if it doesn’t seem real. “Bruises belted the left side of his cheek and ran the length of his chin. Defined deeply in colors of blue and purple, with golden hues, they were like no bruise she had ever experienced. The bruise was pitted, probably from the glass that had shattered onto his face on impact. On the same side, his eye was swollen shut. Stitches worn on his forehead didn’t follow a precise line, but rather zigzagged in several different directions. Was that an actual staple by his ear? He had a metal contraption at his throat and a long tube coming out of his nose. It was held in place by white tape. Down the front of his gown were remnants of a brown liquid of some sort, smeared in the mop up attempt. Why didn’t they give him a fresh gown? Monitors by his bed were beeping and flashing lights at different intervals.”
• Later it was explained this way: “When the other car plowed into your son’s car it was a violent collision. His brain was moved so radically inside of his skull that it caused severe bleeding and tearing of tissues. The skull was cracked and the bone’s edge actually cut into the brain and caused bleeding. If he had been wearing a seatbelt…”

[Lorus]

I want to read more!

[Elenaster]

Me too!

Wow, I just want to say this is the most action the Neuro ICU board has seen in a while!!!

I'll try to answer some of your questions, but it sounds to me like you've got a pretty good handle on alot of the ICU stuff.

#1: Most likely sounds like a severe closed head injury (CHI) with a diffuse axonal injury (DAI) and intracranial/intraventricular hemorrhage (ICH/IVH). The "bouncing around" in the skull is known as a coup-contrecoup injury. Most likely a skull fracture on that left side as well. Status post code with brain stem involvement paints an extremely poor prognosis to me. Clinically, he would most likely be very unstable with increased ICP (we normally like to keep them less than 20), hypotension, tachycardia, febrile, and respiratory issues despite adequate ventilatory support.

#2: He would have the works: ICP monitor (commonly referred to as a "Bolt"), ECG, pulse-oximeter, continuous arterial pressure monitor, central line with either central venous pressure monitor or Swan-ganz catheter with pulmonary artery pressure monitoring, rectal temperature probe, foley catheter, Naso-gastric tube to suction (to help prevent vomiting and aspiration of gastric contents), small bore feeding tube for nutritional support. If you really want to go for drama, sustained ICP greater than 30 unresponsive to typical intervention would result in the patient being paralyzed and sedated with medication, or put in a barbituate coma, which requires continuous EEG monitoring at my facility. After two weeks, he would be taken to surgery for tracheostomy and a permanent gastric tube for nutritional support. He would most likely require the use of vasoactive drips, such as dopamine or neosynepherine to keep his blood pressure high enough to perfuse his brain.

#3: I can't see any surgical interventions that would help this young man unless he had an active arterial bleed that neurosurgery could clip or had a huge hematoma compressing his brain that could be evacuated.

#4: The family would barely be able to recognize him. Despite being covered in tubes and wires, he would probably have two black eyes and alot of cranial and facial swelling. After a few days, his body will likely become swollen from all the IV fluids. They may find his skin to be very cold even though his core temperature may be very high.

I think your description is very good and you might get more impact from a non-medical person's reacation simply because we seasoned ICU nurses are so used to seeing people in this state.

Good luck with your book, Kloget! I can't wait to read the finished product. If you have more questions, please share them here. I'd love to see more action on the Neuro board and this is really fun and interesting.