The Dying Brain – Part 1

The Dying Brain – Part 1

City hospitals team up to better understand brain death

Over 99 percent of deaths are cardiac related. This means the heart stops; its monitor’s metronome-like beep flat lines. It’s what TV and movies have made us come to expect death to be like.

Then there’s the other 1 percent of deaths, the ones caused by brain death. With brain death, there is no flat lining. The heart keeps pumping and sometimes the patient is even breathing, but the brain (including the stem) has suffered irreversible loss of function, and, hence the person has died.

A neurologist or neurosurgeon most often declares brain death, and they have to do it about 30 times a year, according to the American Academy of Neurology. “In general, brain death is not difficult to diagnose,” says Dr. Jeffrey Frank, director of Neuromedical/Neurosurgical Intensive Care at The University of Chicago Medicine (UCM). “However, in order to always accurately diagnose brain death without ever making a mistake, the physician must have a strong conceptual understanding of brain death.

“These skills are not usually taught in any medical-training environment, but they are so essential to appropriate, contemporary, high-quality practice for those interfacing with brain death diagnosis and management,” he says.

Frank and his UCM colleagues, Dr. Fernando Goldenberg, Dr. Agnieszka Ardelt, as well as those from the NorthShore University HealthSystem Center for Simulation and Innovation, Dr. Morris Kharasch and Dr. Ernest Wang, devised a way for physicians to gain that understanding with a hands-on workshop to experience brain death diagnosis and management.

“We have been able to work together and develop several exciting and unique initiatives relevant for education physicians and nurses about important challenging neurological situations (acute ischemic stroke and brain death),” Frank says.

Last year marked the first University of Chicago International Brain Death Simulation Workshop with 19 in attendance. This year, on November 12, the workshop was an even greater success, with nearly double the amount (36) in attendance.

The unique training session took place at NorthShore’s Evanston Hospital’s Center for Simulation and Innovation. The 13,000-square-foot lab was specifically designed to help healthcare practitioners improve their clinical performance, reduce errors and refine their teamwork and communication skills using a variety of simulation modalities including task trainers, human patient simulators, virtual reality and standardized patient actors.

The daylong workshop included a morning and afternoon session. During the morning session, the trainees visited three stations: one in which they conduct an exam on a mannequin that simulates a patient who has experienced brain death, another in which they share the news of death with family members (as portrayed by trained actors), and the third in which they review six case studies and brain scans of selected patients who appear brain dead, though only one of the six actually meets the criteria for brain death.

During the first station, one resident, one attendant and one nurse are teamed up in a simulation lab room, which looks just like a hospital room. As soon as they enter the room, the stress is palpable. There’s a high-tech mannequin on the table. The nurse says, “Jay is not responding; what would you like to do, doctor?”

This is the resident’s cue to step up and start a thorough neurological examination, including the apnea test, and manage the complex physiological derangements that occur when the brain stops working.

When the trainee completed the exam, an experienced neurologist (Dr. Eli Feen, from St. Louis University) entered the room from a separate control room, where he was watching and listening to the resident the entire time. Feen provided the trainee with individualized feedback, talking him through the positive points and any pitfalls during the exam.

“The simulation lab is not what created the learning,” Frank says. “The learning is based on capitalizing on the simulation lab as a vehicle for more effective teaching and learning. So, the experts observing and providing feedback to the participants was an essential element of the workshop and its effectiveness.”

After the exam, the trainee moved on to the family-interactions station. There, he delivered the news of death (while Feen watched over) to two actors playing the role of family members, who were sitting in the waiting area of the simulation lab. The trainee took about 35 minutes to explain to the family the difficult concept of brain death. This station allows any trainee as much time as he or she would need to talk to the family.

“Certainly, the participants learn from themselves and their own capacity for introspection about their performance,” says Frank. “However, the structured feedback from experts and other essential, experienced observers is as critical. There is no doubt that the participants have greatly benefited from the workshop.

And in the afternoon session, trainees participated in small group discussions on topics ranging from medicine to ethics and legal issues.

It is apparent that behind the scenes, there was a vast amount of time and organization that went in to providing the background for each participant to approach these stations.

“This workshop is essential, since brain death diagnosis and management is very complex,” says Frank.

Next year’s simulation is already in the works. “We are hoping that this workshop not only improves clinical practice for the individual participants but that they become local change agents to spread the word and educate their local colleagues to improve contemporary, uniform high-quality practice everywhere,” Frank says.

*For a closer look at the step-by-step process of determining a brain death, be sure to check out part two of this story in two weeks.