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Hey Gemini, How are you??? I haven't talked to you in forever and just wanted to see how you were :) Hoping to get an ICU job at a local hospital-have an interview tomorrow. Hope to talk to you soon!!!

— Stephanie, RN

I'm really, really tired of the Texas/Texan bashing that I'm seeing on the 'Vine. I don't bash your home states, and I surely don't appreciate the constant bashing of mine, nore do I appreciate the stereotyping of all Texans as ignorant, moonshine-drinking, gun-toting idiots. Those of you who got your kicks by bashing Texas and Texans have been removed from my friends list, because that kind of mentality is not welcomed nor accepted by me.

— GeminiGirl

As a nationally Certified Neuroscience RN with 26 years of ICU experience, I will disagree with you, Joanna. If you walk into any Neuro ICU - which I specifically mentioned in my comments - the degree of injury determines if we allow any stimulation of the patient other than what is absolutely necessary. Grade IV and V aneurysms with massive subarachnoid hemorrhage...severe traumatic brain injuries within a week of initial injury...anyone we're having to chemically paralyze or put into a drug-induced coma to mimic brain death (used with continuous EEG monitoring)....those patients do not get any type of extraneous stimulation - not by RNs, not by Respiratory Therapists, not by MDs - unless absolutely, and I stress - absolutely, necessary.

These people already have critically high intracranial (not cranial) pressures, and touch has been scientifically proven to not only increase afterload, but to also increase intracranial pressures (ICP) to increasingly dangerous ranges within the first week (minimum) after injury. That's why we keep the rooms dark *light is a stimulant*, quiet *noise is a stimulant*, and why we do not touch the patients unless we have to. I have personally watched intracranial pressure readings spike into the 50s (the normal is less than 10-15, depending on your center's neurosurgeons) with a single pat on the arm or a person speaking to the patient. These patients are at severe risk for brainstem herniation already due to the injury and cerebral edema complictated by blood in the ventricular system that does not allow for proper drainage of cerebrospinal fluid (CSF). All of these patients have external ventricular drains with ICP monitors in, so I can easily see the spikes and watch the CSF rapidly drain in response. In the case of massive cerebral edema, it doesn't matter how much CSF drains off - the pressures increase rapidly and precipitiously and can, if continued, lead to immediate brain stem herniation.

Do not confuse the immediate injury phase with the course of injury and recovery. When the danger of herniation is over, we encourage family and friends to touch, talk to, and even set up portable CD players (with or without headphones) so that the patient gets familiar stimulation instead of just hearing the voices of medical and nursing personnel.

Just what "TBI groups" are you referencing, since all of my current scientific journals do not agree with your statement about stimulation in the face of severe TBI or Grade IV/V aneurysm rupture/leak with subarachnoid hemorrhage? I would like to see the sources you quote, please, to see if these are rigorous scientific studies or simply trials without adequate monitoring and evaluation.

Of course, now, when hospice centers remove TBI patients from feeding tubes, morphine is used to ease any "discomfort" leaving no chance that even hunger pains will rouse a patient to life.

You are confusing terminology. You mention "rouse a patient to life" after TBI - yet they are already alive, so how can I rouse a live patient to life? Morphine does not make people comatose - irreversible brain injuries do that. Note the use of the word irreversible. I have seen people wake up 4-5 months after TBI. I have seen people herniate and die within 48 hours in injury. I have seen patients come to visit from rehab who remember us RNs by sound of voice and how we said his/her name. All of them were on enough morphine around the clock to keep them comfortable without causing them to be "comatose" - they were that way already from their injury or aneurysm rupture.

If hospital records from across this country were reviewed, I bet you would find that 90% of those with a TBI were taken off life support within 30 days of their injury...too soon and certainly negligent.

I will vehemently disagree with this statement, because, as I have mentioned, I have seen patients stay in my ICUs for months. I'm talking 3-5 months before they were ready to go to rehab - not nursing homes and hospice. I have also seen MDs, after 4 months, ask the familes what they wished to do. I'm not sure where you get your "knowledge", but no MD removes life support - including feeding tubes and intravenous hydration - without talking to the legal next of kin (which includes the Medical Power of Attorney for Healthcare) first. Your misconception in this regard is dangerously wrong, and I would hate for you to continue to spread that untruth. Only the legal next of kin/MPOA-H can remove life-sustaining treatments. Only the legal next of kin/MPOA-H can decide if a patient goes to rehab or a nursing home. Only the legal next of kin/MPOA-H can decide to remove ventilator support, vasporessure/anti-arrhythmic support, intravenous hydration/feedings, or gastric tube feedings and hydration. Only the legal next of kin/MPOA-H can make a patient a "Do Not Resuscitate/Allow Natural Death". Your statement is so far from the truth that it is appalling to me that you even believe such a thing.

BAC, R.N., CNRN

— GeminiGirl

With respect to your comments re the PA couple accusing a hospital of killing their son for his organs, you responded to RN 'no touch, no talk..." is common in TBI's for fear of causing cranial spikes - not necessarily so. TBI groups believe it is the lack of touch, smell, noise that keeps the patient in a state of hibernation and deeper in the irreversible coma and believe stimulation should start within hours of the trauma. Doctors are the first to admit their lack of understanding when it comes to the human brain - and patients who suffer from TBI are often prematurely removed from sustenance (not life support). Of course, now, when hospice centers remove TBI patients from feeding tubes, morphine is used to ease any "discomfort" leaving no chance that even hunger pains will rouse a patient to life. If hospital records from across this country were reviewed, I bet you would find that 90% of those with a TBI were taken off life support within 30 days of their injury...too soon and certainly negligent.

— Joanna Carol

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