Thank you for your opinion: Here is my comments back

1. "A lot of edematous change in the entire brain" -- NO! Just the bifrontal and adjacent temporal lobes.

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Did you see any clear gyrus structure on the temporal, parietal area? I did not see. That is why I not only mentioned bifrontal bleeding but also said edematous state, well possibly due to increased ICP.

2. "Enlarged ventricles." ---- NO NO NO NO NO. If the radiology report says there is "enlarged ventricles", his/her lisence is gone. There is NO ventricular enlargment. In fact the right lateral ventricle is too small. This is because the ventricular shunt catheter is inserted from right side. And I suspect there is even little too much drain from the catheter (too aggressive decompression is not neccessarily good).

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Please do not use license or those emtional lines. Did you see the posterior angle of right ventricle? Do you think it is the same as the left side? I do not think so.

3. "Prognosis is bad"---- what are you talking about??? Patient has either coup (falling face-down) or contracoup (hitting back of head) injury to the inferior frontal and temporal lobes. This has resulted in hemorrhagic contusions and subarachnoid hemorrhage. The rest of the brain is fine and there is no herniation or midline shift. The life center--brainstem and the pons are fine so I expect patient will regain self breathing very soon. Patient will be moved out of ICU and stay couple of days on regular floor then move to rehab and d/c to home, if there is no further complications.

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I am not sure if you reviewed his early message, which I reviewed many times. There was no injury involved at all. I hate to bet on patients' outcome but some physicians do that sometimes. Let's forget about ethical issue here. You said he can move out of ICU soon. I will say he will probably go to a LTAC (long term acute care in US) the best and he may never get out of there. Let's keep all informed.

4. "I would call family to discuss code status." ---- code is determined when patient is admitted. Patient is only 66 and no one should dare to suggest withholding treatment as yet.

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Is this in Canada? If in US, I am pretty sure I can advise patients' family anytime regarding the code status, unless patients have a living will mentioning that he should be a Full Code all the time. Otherwise, Chem Code or even No Code should be discussed. Not to discuss code status with family if the patient did not have previously stated, in addition to patients' recent acute change or deteriation, IS COMPLETELY Unenthical in US!!!

Withholding treatment without noticing family is not ethical and I do not think any physician will do that in US.

5. "The best outcome would probably be vegetative status and breath on vent for the rest of life. " ---- this is just plain irresponsible! If my resident or even fellow say things like that "based on the CT", s/he is not graduating. Period.

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See my comments in #3. Please do not use these big words "If my resident or even fellow say things like that "based on the CT", s/he is not graduating. Period." We can have different opinion but to use these big words just seem funny to me!!! I hate to attack people back and I will leave things here. We will keep informed to see what happen next, FAIR?


This is an unfortunate case but is not uncommon. Most of those cases recover largely. Patient may have mood disorders later on. Make sure ask them to look at bone window images to exclude fracture. At least they should have done MRI to look at the dead/infarcted brain area and most importantly to exclude diffuse axonal injuries (DAI) which in deed does have a bad outcome. CT should be repeated frequently (I know it is in Canada).

所有跟帖： 

• Please carefully read my original response -fakedoctor- ♂ (299 bytes) () 10/07/2007 postreply 18:36:51

• Sorry about one mistake: -fakedoctor- ♂ (186 bytes) () 10/07/2007 postreply 18:44:53

• 老大真是严谨；你们几位这么费心，我真心感激！ -莞尔~- ♀ (0 bytes) () 10/08/2007 postreply 01:08:49

• I would support you. -familydoc- ♂ (536 bytes) () 10/07/2007 postreply 21:08:28

• 不是不trust医生的医术，而是病情发展让人灰心 -莞尔~- ♀ (844 bytes) () 10/08/2007 postreply 01:26:29

• 不是神经科医生，也不是放射科医生，姑且用我的观点娱乐一下大家。 -饿狼陀- ♀ (1030 bytes) () 10/09/2007 postreply 17:05:12