Big Meeting

My sister Rachel felt it was time for a meeting with John's doctors, and with the help of the social worker on our case, made it happen. Dr. Binter, the attending neurosurgeon, and Dr. Commichau, the attending neurologist, spent over an hour with my family discussing John's current state and outlook.

Summary of current state:
-John's condition as still very critical. He has a closed head injury in which the impact of the fall resulted in brain contusions
-He is currently stable and doing well on the current drug regimen and other interventions. There is significant variabilitiy in his ICPs minute to minute and hour to hour but with a progression toward stable.
-He is suffering from a second round of infection of ecoli pneumonia in the lungs. It has not reached his brain or spinal fluid. John arrived at the hospital with lungs in poor condition (some of you may have noticed a bad chronic cough beforehand). The alvoili in his lungs had collapsed and were not functioning properly (likely due to smoking). Infection goes to the weakest point, which for John is his lungs. The doctors and nurses have tried multiple times to clean the lungs including a bronchial clean, but with only partial success.
-The EKG has shown no heart issues.

Outstanding risks:
The doctors cited several risks that could effect John's stable condition.
-A blood clot could form from him lying in bed for a prolonged period of time. If it were to form, it could cause an embolism. This can often be addressed surgically.
-He could suffer from additional infections or the existing infection could worsen.

Extent of brain injury:
-The CAT scans show some damage to 2 areas of his brain, the side with the initial impact and the side opposite the impact. The CAT scans have stayed the same over the past 2 weeks. CAT scans can show injury but not predict the effect of that injury on brain functioning.
-The EEG measures brain waves. The brain waves were slow (as would be expected for someone in a compromised state), but showed no sign of seizures (misfiring brain cells).
-The kind of injury that John had can cause twisting of the brain and "sheering" of axons (neuron wires disconnecting)which can result in major deficits in functionality. This type of damage can be assessed with a MRI but John cannot currently tolerate a MRI as he would have to leave the ICU (not safe for someone in his critical condition)and lie flat for 40 minutes (which would likely raise his ICPs too much).
-Even with all of these tests, we will only know the extent of brain damage when John wakes up.

Outlook:
The doctors discussed how dealing with brain trauma is an art to which a lot of science is applied and that the specialty has really come about in the past 10 years. Thus, while much is known, even more is not known. Before coming to the meeting with us, Dr. Binter told the neurosurgeon residents that she was going to tell us 3 things- "I do not know, I do not know, and I do not know". What she and Dr. Commichau were willing to say about his outlook for the future was:
-A full course ICP program is usually 2-3 weeks. John is at 2 weeks and appears to be at the tail end of the pressure problems if status quo is maintained. They will try step by step to reduce interventions, going to the next step as each is tolerated. The next step was planned to be to change the height of the bag connected to the brain in his head (more on what actually happened later). Raising the height of the bag would cause the drain to go from constantly working to working only when his ICPs spiked.
-We should expect a long recovery but impossible to predict the timing. It would likely involve intensive inpatient rehab followed by outpatient rehab.
Many, many thanks to the doctors for taking the time to discuss John's condition in such great detail.

Update since the meeting:
Now, as for the drain, the plan to move slowly toward removal starting first with changing the height of the bag was changed last night. The drain stopped draining, which apparently can happen after extended use. The neurosurgeon on duty attempted to unclog the drain. When that failed he tried to insert a new drain. After working on him for 2 hours, he was not able to do either. The inability to put in a new drain was due to the extent of the swelling in the brain. After 2 hours, the neurosurgeon team decided to instead remove the clogged drain, put the pressure monitor back in his head, and manage his pressures medically. His pressures had been high during the surgery and hours following, but came back down with saline and have stayed at a safe level since then. So, we ended up with an accelerated path to drain removal that hopefully John will continue to be able to tolerate.