Where life hangs in the balance

WHEN people are rushed to Addenbrooke's Hospital with terrible head injuries, the very mention of that name brings a chill realisation that their lives hang in the balance.

By Tracey Sparling

WHEN people are rushed to Addenbrooke's Hospital with terrible head injuries, the very mention of that name brings a chill realisation that their lives hang in the balance. And what happens to them next?

In the first of new series of behind-the-scenes articles from Cambridge, features editor TRACEY SPARLING visits the critical care unit.

THE man lying in front of me shows no sign of life.

His body is kept ticking over only by the silent but insistent input of machines. His mind is dormant in the deepest of sleeps from which he might never awake.

But this is the place where precious lives are saved. In these 21 beds at Addenbrooke's Hospital's neurosciences critical care unit, people like him, from across the region fight to survive odds which can be ultimately stacked against them.

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It seems incongruous that there is no outward sign of this man's peril. As he lies with the smooth white sheet turned down to expose his chest, there is not a mark on his body, no wounds or bandages. If it were not for the surroundings – punctuated by his 24-hour nurse quietly bustling to and fro, and the occasional bleep of monitors - you wouldn't know he had suffered a traumatic head injury.

On either side of the bed, banks of monitors loom sentry-like, guarding rafts of statistics which change by the minute, fed by a mass of bright blue sensor pads hooked up to a tumbling mass of wires and tubes.

Nobody visits this sleeping man today, so his fight for life continues alone.

The beds are set out in the shape of a ring, and next door a woman sits on a plastic chair, clinging to the hand of her mother who is in a coma.

The visitor mutters a few words of comfort to the unhearing ear, or could it be a prayer?

In this hushed place you feel an intruder into a heady atmosphere of grief and hope. But the visitor glances up at me and I feel a brief moment of connection.

One day could see any one of us in her tragic position; waiting, praying and hoping against hope that our loved one will pull through.

When a new patient arrives, senior clinical nurse Sandra Rees-Pedlar, leads the team in Addenbrooke's neurosciences critical care unit.

She said: “During the first few days in intensive care, the family's priority is 'are they going to live or die?' We can't give any real answers at that point, even 24 hours ahead. We have to take things hour by hour, day by day depending on how sick the patient is.

“When we start to reverse the artificial coma they have been put in, they open their eyes, they wake up and a second set of anxieties come in. Then we start to look at what sort of recovery the patient might have. We get an idea within the first few days off sedation, but it is usually 18 months later when that can be seen fully.”

Sometimes the decision has to be made to turn off life support. In her 11 years at the unit, Sandra has helped many families through that ultimate heartbreak.

She said: “In a severe head injury the brain can swell down on to the brain stem, and if it squashes that there is nothing we can do for that patient.”

Tests are done twice to confirm that the person is what is known as 'brain dead', by two senior consultants, before life support is stopped. Sandra said: “That person would never be, in any proper sense, alive. It is a completely irreversible situation, the person is in legal terms dead, and will not come back. But they are still warm, they are still pink, their heart is beating because the machines support them, so that is quite a difficult concept to get across.

“We can help the family through that, by the way we look after them, and helping them gain some closure. In some respects, that is not as hard to bear as the times when a patient leaves here, trying to cope with the effects of a brain injury. They didn't die but the family can still be grieving for the personality they lost.”

Head injuries happen most to teenagers and young adults, and Sandra said: “A lot of our patients are young, so we see children coming in to visit their parents, and we know that it is going to take a long, long time to get them back to some sort of independence.

“Having said that, one man who we looked after eight years ago, came back to visit a couple of weeks ago. When he left here he couldn't walk, talk or feed himself. His ten-year-old son, who is now 18, had witnessed the accident and can remember being here. The dad has some problems with his speech now, and he gets very tired but he is walking, talking and leading a fairly independent life.

“We do get people who surprise us. Sometimes I think to myself 'I would never have expected that in a million years.'”

Peter Hutchinson's are the steady hands which remove part of a patient's skull, to give their injured brain room to swell, and recover.

The brain often swells after being shaken or damaged, so it is a common procedure to remove part of the skull, and replace the scalp over the hole in what's called a decompressive craniotomy.

Consultant neurosurgeon Peter said the procedure dates back to Hypocrates, although new techniques continue to evolve. A research project is currently going on to see what the best treatment is for head injuries, comparing surgery with drugs. Both treatments work, but both have side effects, and Peter said it aims to establish which gives the best quality of life later.

He sees about 140 patients a year, as part of his contract to work for the NHS at Addenbrooke's, supported by the Academy of Medical Sciences and Health Foundation.

Many of the terrible injuries he sees, are as a result of car crashes. But sports like boxing and cycling can also bring victims; the force of a professional boxer's fist is equivalent to being hit with a 13-pound bowling ball travelling 20 miles per hour. That impact can lead to a blood clot, which takes a couple of hours to remove in the operating theatre.

When it comes to cycling, riders with helmets have an 85pc lower risk of head injury but Peter shook his head in frustration and said: “Sadly there is still a stigma associated with cycle helmets, which is all about fashion.”

He also runs the hospital's traumatic brain injury clinic, which is a follow-up to the NCCU to ensure patients get the aftercare they need.

In his role, he has achieved his dream of saving lives. “I always wanted to go into medicine,” he said, “and the brain is the most fascinating area. It's what makes us all different and I will never tire of it.”

He also trains trauma teams in A&E departments at hospitals like Ipswich, how to give the correct life support, as the first few minutes after a head injury are crucial.

To unwind, motor racing is the surgeon's passion - he shrugs off the fact that he used to travel the world with the British Grand Prix team, and is still its neurosurgeon - although it takes up less of his time now he has two children.

An Ipswich anaesthetist and nurse travel with the patient by ambulance to Cambridge. They keep the patient is stabilised, sedated and on a ventilator, and brief staff when they hand the patient over.

The brain is scanned and the surgeon makes a decision whether to operate. A pressure-monitoring bolt is usually inserted in the head.

Patients are usually given strong anaesthetic drugs to put them in an artificial coma for 48 hours, so staff can control their blood pressure and breathing etc. That reduces the need for the brain to function – thereby minimising the risk of swelling. A state of 'therapeutic hypothermia' is induced, by lowering the body temperature a couple of degrees to 35 degrees compared with 37.

After surviving the initial accident, the brain swells just like any other body part which was injured, would. But the brain is in the sealed box of the skull so the only place it can expand is down into the top of the spinal cord, where the brain stem is located. If it squashes the brain stem, which controls messages from your brain to your body (like the instruction to breathe), that is fatal.

Surgery can be performed to cut away a small section of skull, and replace the scalp, so the brain can swell. If blood clots form elsewhere in the body, they have to be removed or they can induce a stroke when the brain is starved of oxygen and nutrients.

Weblinks:

www.addenbrookes.org.uk

www.neurosurgerytoday.org

The top causes of traumatic head injuries are: road accidents (50pc), assaults (10pc), falls - especially by children and old people - and sporting accidents (15pc) like boxing, horse riding and cycling (20pc of head injuries in children). Domestic and industrial accidents account for 30pc.

Addenbrooke's has one of the biggest neurosciences intensive care units in Europe.

About 450 patients are cared for by the NCCU each year; about 100 need intensive care.

Patients are from across East Anglia, but also are referred from other parts of the UK or the rest of the world.

70pc of patients are emergencies, mainly head injuries or brain haemorrhage, plus uncontrolled epilepsy, stroke, or respiratory failure. The remaining 30pc are for postoperative intensive care following brain surgery.

There are 21 beds and if they have been transferred from Ipswich, patients are usually ill enough to need one of the 13 special beds for the sickest patients.

The Wolfson Brain Imaging Centre research facility attached to the NCCU, is the only one of its kind.

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See part two tomorrow, for what happens on the wards.

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