And I saw a brain die
Nitin K. Sethi, MD
As an intern in medicine I had responded to and
participated actively in many cardiopulmonary resus-
citation (CPR) code calls. Even though the code was
often unsuccessful, there was something reassuring
about giving chest compressions or ventilation and I
felt I had done something and given my all. Nothing,
though, quite prepared me for the helplessness I felt
the day I saw a brain die on the EEG.
It started off as any other day for me. I went to the
neurologic intensive care unit (ICU) to review the
EEG study of a patient. As a fellow in clinical neuro-
physiology, a good part of my day is spent looking at
EEGs. Over the course of a year and a half of clinical
neurophysiology training, I have seen many interest-
ing EEG patterns and have learned to recognize their
importance in the critically ill neurologic ICU pa-
tient. I feel empowered by the armament of antiepi-
leptic drugs (AEDs) at my disposal to treat them.
Mr. X had been found face down in his house by
the emergency medical services, the victim of a mas-
sive aneurysmal bleed from rupture of a posterior
communicating artery aneurysm. He had a Glasgow
Coma Scale (GCS) score of 5 and prognosis was
listed as guarded in the chart. The neurointensivist
had requested video-EEG monitoring to rule out
nonconvulsive seizures. I did my customary neuro-
logic examination and then began to review the EEG
at the bedside.
The background was diffusely slow consisting
mostly of a mixture of delta and some theta fre-
quency rhythms. As I was reviewing the study in real
time, I noticed a sudden change in the EEG
The background progressively started getting attenu-
ated right in front of my eyes.
I looked feverishly at the cardiac monitor at the
bedside; the heart rate read 64 beats/minute. I
glanced at the ventilator; it was making its usual hum
as air moved in and out. If this was the heart dying
out on me, I knew what to do.
Run the code!
The ACLS protocol clearly laid it out and I had
drugs like atropine and epinephrine at my disposal. If
the rhythm changed to one of ventricular fibrillation,
I could call the defibrillator into action.
As a neurologist I was acutely aware of the im-
portance of this fistful of 1,500 g of wrinkled tis-
sue, the seat of our emotions, our memory, our
senses, and the motherboard of all other body sys-
tems. It is surreal when something so beautiful has
such a silent death.
There were no loud noises, no creaks or groans, and
no loud gasping sounds to be heard.
No drugs had been injected feverishly by doctors
in white coats. For a moment I wistfully yearned for
this to be a traditional code and that I could some-
how reach in and CPR the brain to life. It is relatively
easy to restart the heart with traditional CPR; I real-
ized it was considerably harder to restart the brain.
As I stood and watched helplessly I saw a brain die in
front of my eyes.
From the Comprehensive Epilepsy Center, Department of Neurology, NYP-Weill Cornell Medical Center, New York, NY.
Disclosure: The author reports no disclosures.
Address correspondence and
reprint requests to Dr. Nitin K.
Sethi, Comprehensive Epilepsy
525 East 68th Street, York
Avenue, New York, NY 10021
Mitchell S.V. Elkind,
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