Excerpted with permission from Reaching Down the Rabbit Hole: A Renowned Neurologist Explains the Mystery and Drama of Brain Disease, by Dr. Allan H. Ropper and Brian David Burrell. Available from Saint Martin's Press, LLC. Copyright © 2014.



It was a bad omen when my beeper went off one morning at 6:10 as I warmed up my car in the garage. Trey, my senior ICU fellow, asked me to meet him in the emergency room to save time on an admission. “A guy fell on Comm Ave this morning and cracked his head,” he informed me when I rang him back. “He’s got a big subdural, but the neurosurgeons don’t want him because he may be too far gone.”



A subdural is short for a subdural hematoma, a brain hemorrhage typical of traumatic brain injuries, caused in this case when the skull hit the sidewalk and the brain caromed off the inside of the skull, in the process tearing veins that run across its surface.



When I arrived at the Emergency Department, I found the poor guy—a very thin, elfin-looking man, with pallid skin and short, whitish, sparse hair—breathing on a ventilator. According to his driver’s license, his name was Mike Kavanagh, and he was an organ donor. A huge gash decorated his scalp, with dry-crusted blood cascading onto the bedsheets like a frozen brackish waterfall.



Knowing when someone’s alive and knowing when someone’s dead: it’s one of the most important jobs that doctors do. If we can’t do that, we can’t do anything.



The person must have an apnea test. Then you can prove to yourself that the whole brain, including the brainstem, is gone. Just remember, when you take a patient off a ventilator, either for an apnea test or after a declaration of death, make sure that family members are out of sight, and forewarn the nurses. Many brain dead patients, once the ventilator is removed, exhibit the so-called Lazarus sign, where their arms spontaneously contract and their hands come up to their chest as though they’re grasping for the endotracheal tube. It’s creepy no matter how many times you’ve seen it.



This test is the big one. It grew out of Moses Maimonides’ practice of holding up a glass to see if the breath fogs it. The object is to see whether the patient will breathe on his own. We sent 100 percent oxygen through Mike Kavanagh’s lungs for two minutes, enough to sustain his heart and blood pressure without a ventilator for the next ten minutes, then shut off the ventilator.



Silence. I could hear my pocket watch ticking. As Trey and I watched closely, we could see a few arching movements in Mike’s back, definitely not Lazarus signs, but something not entirely compatible with brain death. We waited. With the palm of my hand acting as Maimonides’ mirror, I felt air moving almost imperceptibly in and out of the ventilator tube. Was he breathing? It was important to be sure.



Ten minutes were up, and the result was conclusive. Mike Kavanagh had failed the apnea test.



“That’s a wrap,” Trey said, snapping off his gloves.



“Is it? If he’s dead, in what sense is he dead?”



“In the dead sense,” Trey replied.



“Well, his brain may be dead, but his other organs are alive. They can be transplanted.”



“But they’re just organs. Organs can be sustained, even grown outside of a body, independent of a body.”



“The gash on his neck where the transplant surgeon cuts out a lymph node would heal.”



“Those are just cells,” Trey countered. “They’re on automatic pilot. You provide them with blood, they keep going, but there’s nothing meaningful going on.”



“But if Mike Kavanagh were a pregnant woman,” I said, “we could keep him alive in order to bring the baby to term. What could be more meaningful than that? My point is that we just engaged in an operational decision, not a biological one. The end result is still correct, but we shouldn’t pat ourselves on the back and say that we have come to an ontological certainty. We need to be honest about what we’re doing. His brain may be dead, but the rest of him is not dead, and we can use the rest of him. I have no problem with what we’re doing, but we should think it through more carefully.”



Trey paused, and said, “And that’s what we just did, right?”



“You’re not buying it, are you?”



“No,” he replied.



Trey and I knew very well what would happen when I signed the death certificate. Brain death is a firm, unambiguous, and operationally solid determination, an absolute point of no return for the brain. Any two competent neurologists or neurosurgeons who examine a brain-dead patient will come to the same conclusion, just as we had: this entire brain will never recover, and all the king’s horses and men can’t do a damn thing about it.



The problem is the word dead. It muddies the important issue, as does diagnosis. Brain death is not a diagnosis—a word that suggests probability—but rather a determination. A diagnosis raises the specter of false positives, of fallibility, of someone being buried alive. That can only happen if someone does the test incorrectly, and we hadn’t.



“Look, Trey,” I said, “it’s fine to have an operational definition to work with. We couldn’t get through the day without that. But you are in a position, because you are a doctor of the brain, to think about these things more broadly, and you should, because if you don’t, nobody will.”



In The Wizard of Oz, after the tragedy of the tornado and the falling house, the medical examiner of Munchkinland was called upon to check under the front porch for the remains of Evanora, the Wicked Witch of the East. After due consideration, he solemnly pronounced to the mayor:



As Coroner I must aver,

I thoroughly examined her,

And she’s not only merely dead,

She’s really most sincerely dead.



In the case of Mike Kavanagh, Trey was satisfied with “merely dead,” as was the Presidential Commission, the Commonwealth of Massachusetts, and the Vatican. I’m not entirely sure.

