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The Editorial Group of the John J. Lynch, MD Center for Ethics
Complexity: 1 2 3 4
PRESENTATION
Mr. Roitman is a 57-year-old man who arrived at the Emergency Department (ED) after suffering a stroke and collapsing in the square of his apartment community. Mr. Roitman remained conscious and was found by three children who were playing in the square at the time of his collapse.
The children called their parents, who then called emergency services. A parent of one of the three children who claimed to know Mr. Roitman and his family followed the ambulance to the hospital while they attempted to contact Mr. Roitmans mother. When Mr. Roitman arrived at the ED, both brain imaging (a CT scan-a computed tomography scan) and a toxicology test were ordered. Prior to any test results, Mr. Roitman went into cardiac arrest, was successfully resuscitated, and intubated. Although hemodynamically stable, Mr. Roitman was no longer conscious.
The toxicology report did not find any illicit drugs in Mr. Roitmans blood at the time of arrival, however, the CT scan revealed a significant intracranial hemorrhage (ICH) from rupture of the basilar artery that appeared to be spreading into the ventral pons. After he noted a clear toxicology, the units attending physician, Dr. Hayes, performed a Glasgow Coma Scale (GSC) assessment to determine Mr. Roitmans degree of consciousness, which resulted in a GSC score of 3 (E1V1M1): Dr. Hayes observed no involuntary eye movement, no verbal response, and no voluntary physical movement, which indicated a severe coma via the GSC. Given the pons involvement in helping to regulate certain autonomic functions, although Mr. Roitman appeared stable, the concern became one about whether his breathing and circulatory functions would continue if the hemorrhage should progress to his brainstem or damage the autonomic pathways that extend from the pons to the brainstem.
The accompanying parent of one of the witnessing children was able, finally, to contact Mr. Roitmans mother. She arrived that evening after Mr. Roitman had been moved to the neurointensive care unit, and was visibly emotionally affected by the condition in which she found her son. It wasn't long before Dr. Hayes came to discuss her son's condition in clear, kind, appreciable detail. Mr. Roitman's mother, a 79-year-old woman,...