Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

by Allan H. Ropper

In the United States and most European countries, the brain-death exam has become a generally agreed-upon series of bedside clinical tests that start at the top of brain, the cerebral hemispheres, and sequentially test the function of each part below: the midbrain, the pons, and finally, the medulla. While a dead brain is one thing, and a fairly easy thing to confirm, a dead person is another thing, and Marty was indulging in a bit of oversimplification when he said that “the person is in the brain, and virtually everybody in every culture agrees with that.” It would be more accurate to say that the medical establishment, via the medical schools, agre...

Here was Mike Kavanagh, a warm body, chest rising and falling rhythmically, oxygenated blood coursing through his arteries, fingernails growing, facial hair still sprouting, digestive tract still sending nutrients into his bloodstream, all of his vital organs save one most definitely alive. But both Trey and I were sure that he was in fact dead, or, more to the point, that after due process we would be signing a certificate that established not just the “fact” of his death, but the precise moment of it. The inherent absurdity in such cases is that whatever had happened to Mike out on Comm Ave, and whatever was happening inside his body and inside his skull right at that moment, his death and the instant of ...

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.

In 1981, a presidential commission codified the Beecher Committee’s finding as the Uniform Determination of Death Act, establishing the justification for organ retrieval as death by “whole brain criteria,” or “the irreversible cessation of all functions of the entire brain.” The

Medicine on the whole has no trouble making the determination of brain death. That is a technical matter. The nagging issue is whether a warm, pink, pulsating, live-looking body can or should be called dead. All of the organs are viable. The body could go through the onset of puberty, it could gestate an infant. There are such cases on record. What the Beecher Committee accomplished was to find a good reason not to utilize resources on people who would unquestionably die without ever regaining consciousness. Being able to change their classification and call them dead had virtue for society. They said, in effect, “It’s not living if your brain is irrevocably gone; it’s not living, so you can go ahead and take the organs.”

What somebody needed to say was: we’re going to have a societal shift, and if your brain is so irrevocably and totally damaged that there is no hope of recovery, and it’s total (so that there won’t be any quibbling), then the patient is in a state where it is reasonable to do organ transplants. Calling it death was the problem.

Thus, when the functions of the brain, which are, so to speak, at the service of the soul, cease completely because of some defect or perturbation—since the messengers of the sensations and the agents of movement no longer act—it is as if the soul was no longer present, and was not in the body, and it has gone away.

I once had a patient, a member of Hell’s Angels, who was shot in the face while driving his Harley down the interstate at eighty miles per hour—with a shotgun, no less—who then went off the road and creamed his entire cranium (no helmet), and was quite obviously brain dead. Some of his brain matter was left on the road. They might as well have decapitated him, except that when he was placed on a ventilator—intubated—his heart still pumped and the body was kept alive. Here was this outlaw, a tough guy, maybe a sociopath, and ironically, it said “organ donor” on his driver’s license. In the end, he turned out to be a humanitarian.

There was no question of transplanting his corneas. They were no longer there, and that was the problem: How do you know a person like that is brain dead without the all-disclosing eyes? We couldn’t examine his pupils. We couldn’t examine his eye movements or his corneal reflexes. I recall thinking, Oh my God, you don’t want to get a diagnosis of brain death wrong because it would be like committing an innocent man to the electric chair. How am I going to finesse this?

We could show that he had apnea (that he couldn’t breathe on his own), but that’s just one of the five elements of the tests for death by brain criteria. The Presidential Commission said that in certain circumstances you can use surrogate tests. So we did an EEG. He had barely enough scalp on which to place the leads, and the readout was flat, or, in tech-speak, isoelectric. We did a cerebral blood flow scan. The examination took hours, not because his face was blown off, but because I had a tough time persuading the nuclear medicine people to come in and do the test at night for a dead guy. They said, “We’ll come in and do it in the morning.” I said, “They don’t want to lose his organs. Come in now.” They said, “Oh, c’mon!” “No, get your ass in here and do it or I’ll keep kicking it up the chain until somebody does.” Finally their man came in, injected technetium, a radioactive element which circulates to show if there’s any blood going into the brain. There wasn’t. No one agonized over the case, possibly because the biker no longer had eyes, u...

Next came a more conventional and ostensibly more humane stimulus of applying serious pressure on a knuckle of each limb using the shaft of a reflex hammer, the neurologist’s favorite weapon. Women neurologists, I have noticed, tend to press harder than men, as if to insure that no one is getting out alive. In this instance there was not a whit of movement. All but a fully paralyzed, comatose patient would exhibit a straightening of the arms and pushing backward as the shoulders rotate internally. But here: nothing, no cerebral response.

Trey then peered in at the pupils. “Round, eight millimeters,” he shouted. “Did you measure or are you guessing?” Up went Trey’s eyebrows and out came a round laminated pupil gauge with a series of black circles of increasing size. Trey held it up to the patient’s eye. “Okay, seven millimeters and not reactive.” The midbrain could now be checked off the list, given that it controls pupillary size and reaction to light.

“Ambiguous,” I said. If the pupils are too small or too big, they indicate a remnant of brain function in the pons. Nine millimeters would have been unusual in a true case of ...

“Do you want me to do calorics or doll’s eyes?” Trey asked, referring to two methods of making the eyes move from one side to the other, thereby testing the integrity of the pons, the middle part of the brain stem. Because the patient had a collar on, and might have a broken neck, we couldn’t move his head from side to side, so we did the caloric reflex: squirting ice water into one ear, then the other. This provides...

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.

Alan Shewmon claims, rightly, that there are three concepts of death: a biological one that speaks of the organism, a psychological one that speaks of the person, and a sociological one that speaks of the legal person.

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.

As Coroner I must aver, I thoroughly examined her, And she’s not only merely dead, She’s really most sincerely dead.

Mirapex,

osteosclerotic myeloma,

ataxia

“boats against the current.”

meningioma.

Hirayama disease. Not seen much in the United States. Mostly in Japan. The ligament on the back of your spinal cord is buckling when you bend your neck forward, and all of your scans were done with the neck straight.”

tonic-clonic seizure.

Ativan

“It displays pleomorphism of nuclei, which means nuclei of different sizes and shapes, and then mitoses, very many, and thickened blood vessels with prominent endothelial cells.”

glioblastoma.

astrocytomas

That’s why what we do is as much shamanistic as medical, because society cannot relinquish that hope, the belief in the curative power of something, of medicine, of prayer, of diet, of therapy, of sheer expertise, of connecting with another human being, rather than acknowledge that the universe is like the eye of a dead fish: cold, uncaring, unreflective, unresponsive.