Body Trauma

by David Page

  What does the adolescent feel after being abused?

  • Guilt

  • Anger

  • Helplessness

  • Depression

  • Anxiety

  • Reduced confidence

  These feelings result in confusion and self-blame. This may precipitate flashbacks and a reenactment of the event in the victim's mind. She may regress and become antisocial, and at times, self-mutilation occurs. Alcohol and/or drug abuse may become chronic problems.

  Interpersonal relationships suffer because the young person feels betrayed. There is no one to turn to, and he may begin to feel a growing resentment and anger for his parents or other caretakers who can't or refuse to recognize the problem. If the abuse continues and no one helps to extricate the adolescent from the abusive environment, he may begin to experience thoughts of violence and formulate ideas about injuring others, including the perpetrator. Another way a young person may express feelings of being mistreated or ignored is to become inappropriately active sexually and "act out" her frustrations.

  Adolescent victims of sexual abuse must be hospitalized if symptoms progress to where regressive behavior is observed and particularly if the youngster entertains destructive thoughts. Regressive behavior includes acting younger than one's age or becoming labile, silly, then withdrawn. The victim needs to sense her own safety in the hospital because nightmares, flashbacks and fear are common. These terrors may be conquered as therapy progresses. It takes time. Authors Rew and Shirejian emphasize the sense of unworthiness, lack of purpose and feelings of isolation that sexually assaulted adolescents experience, which may lead to anger at God and a profound hopelessness.

  Treatment includes giving the young person back some control over his life in a safe environment. The victim is taught to cope with his past feelings and memories and is encouraged to actively learn how to protect himself from further abuse. Finally, the adolescent is encouraged to rediscover his belief system and engage in healthy activities.

  Specific messages are passed on to the victim during the initial treatment session. These include reinforcing that she was the victim and the victim is never at fault; that there is no affection or love in the act of incest—it's purely bestial; and if she thought there was any element of pleasure or body response to the sexual act, it was reflex or instinctual—she had no control over it and there is nothing about which to feel guilty.

  Lastly, the victim is taught she has control over her body and who is allowed to touch her. With time and help, she will hopefully regain control.

  The gift of a functioning organ requires an unequivocal diagnosis of death unless the donation is voluntary and the donor is living. Although the study of our victim's demise isn't our prime focus in this book, death occurs with regularity in cases of multiple organ as well as severe single organ injury, despite excellent trauma care. The ethical rope bridge that spans the uncertain chasm between severe injury and death is narrow and must be constantly guarded.

  Insidiously, the discussion of organ donation from a trauma patient arises.

  Organ donation spells the end of hope for the horribly injured trauma victim and the beginning of opportunity for the recipient. Before the gift of donating an organ may be pursued, death must be certain. The process of considering a patient as a potential donor may begin at any time but often commences when the patient's demise seems likely.

  The donation discussion begins before death occurs.

  There is a natural progression from severe brain damage or multiple organ injury without recovery to the slippery slope of potential death, from the uncertainty of acute coma to the persistent vegetative state. Never are we quite sure about survival. And from the outset, this discussion of body injury has captured a major chunk of our attention because of the possibility of death.

  Justification for including organ donation in this book falls upon the harsh reality that there is a fine line separating severe head injury, persistent coma and brain death. Lingering in the minds of everyone involved in the care of a severely injured trauma victim is the issue of recovery, the remote possibility for survival. Could we be wrong if we give up hope? High-voltage tension for your tale.

  It's important to understand this next heart-lurching step in the management of a trauma victim, even though we're really only interested in the ones who limp away into the sunset. In the real world, and therefore in the world of fiction, the trauma surgeon and the victim's family must be prepared to answer the question: Are you prepared to allow your patient/loved one to be an organ or tissue donor?

  As of January 1994, the following numbers of patients awaited transplants: about 25,000 people for a kidney, 3,000 for a liver and 2,000 for a heart. The results obtained after successful transplantation of these organs have improved over the past few years. Currently, the one-year survival rates are:

  • Cadaver kidney transplant, 80 to 90 percent

  • Heart transplant, 80 to 90 percent

  • Liver transplant, 65 to 70 percent

  Before the recent flood of modern medical technology, a patient was dead when heart and lung function ceased. Today, heart and lung support as well as dialysis for kidney failure may be carried out by machines almost indefinitely. As technology improved, a new definition of death became necessary.

  Above all else the responsible doctors involved in a potential organ procurement case must assure the victim's family that meaningful survival is not reasonably possible. Acceptable criteria for brain death include:

  • Clinical signs of irreversible brain death (see sidebar on page 216) as determined by a neurologist or other physician and confirmed by apnea tests (a bedside test that proves the patient cannot breathe spontaneously, that is, without the ventilator)

  • Electroencephalogram (EEG) that shows no brain activity

  • Special x-ray dye studies (cerebral arteriogram) that prove there is either no or inadequate cerebral blood flow

  Also, the cause of death must be known: A massive head injury, massive intracerebral hemorrhage, brain anoxia (prolonged exposure to lack of oxygen for whatever reason) or an incurable brain tumor is seldom survived. Organs may be salvaged for transplantation if adequate ventilation and drug support of the heart have been maintained.

  As compared to organ donation, tissues such as corneas, bone, bone marrow or skin may be removed and placed into a recipient patient after all vital functions in the donor have ceased. Whole organs require

  Uniformly Accepted Bedside Criteria For Brain Death

  Patient must meet all criteria.

  ■ There is no evidence the victim was exposed to toxic substances or suffered from metabolic illness.

  ■ The cause of brain damage is known.

  ■ The condition is considered irreversible (no known treatment is available).

  ■ The victim will not breathe spontaneously with severe artificial elevations in blood carbon dioxide levels to stimulate the brain's breathing centers.

  ■ The victim does not react to painful stimulation.

  ■ The victim does not show any spontaneous movement.

  ■ There are no gag, cough or corneal reflexes.

  ■ The victim's body temperature is normal.

  A previously healthy person who suffers massive brain damage or is brain dead by the above criteria may be an organ or tissue donor if:

  ■ Between the ages of newborn and seventy.

  ■ Free of systemic infection and transmissible diseases, including cancer (except a primary brain tumor).

  ■ No history of drug abuse or risky behavior that would make HIV infection a possibility.

  adequate perfusion, a continuous supply of oxygenated blood, and will only tolerate twenty or thirty minutes of what doctors call warm ischemia time (diminished oxygen delivery). After that length of time, proper function of the organ cannot be assured.

  Tissues, on the other hand, may be used twelve hours after death if the body is not refrigerated and up to twenty-four hour
s following death if the body was refrigerated within four hours of the patient's demise.

  Since 1992, a new patient in need of an organ has been added to the national waiting list every twenty minutes. Only about ten to fifteen thousand organs are donated yearly.

  Who Becomes an Organ Donor?

  We've talked about patients who have been declared brain dead as appropriate organ and tissue donors. These patients are managed in the ICU with complete vital function support including ventilation, blood pressure support, kidney support (including dialysis) as well as intensive nursing care. At times, they are referred to as HBCDs—heart-beating cadaver donors. It was long hoped this pool of donors would grow, but instead it shrank and become stable at about ten thousand donors a year.

  What other source of organs is available? The following is a source list for organs and tissue:

  • Heart-beating cadaver donor

  • Non-heart-beating cadaver donor

  • Living, related donor

  • Anencephalic ("no brain") infant

  • Animals

  To date, artificial organs, e.g., a mechanical heart, have only been used successfully for temporary support while the patient awaits a donor organ. Kidney dialysis is the obvious exception.

  Controversy surrounds the issue of using anencephalic infants as donors, but it is unquestionable that infants and children are dying because of a lack of transplantable organs—-just like adults. It's a shame because these children cannot have a conscious, sentient life, and their parents can and should make the gift of an organ for other kids in need.

  Non-heart-beating cadaver donors are another matter. This could be a fascinating topic for the clever writer. After a traditional cardiac arrest with the patient's life ending because heart function ceased—our classical definition of death—organs may be salvaged. The problem is that warm ischemia time. How long will these organs continue to work after they stop receiving oxygenated blood?

  The issue becomes one of redefining terminal care and death itself. If you want someone's kidneys, do you ask the doctor to keep the patient comfortable with morphine? Perhaps a little more comfortable than she is even though she hasn't twitched in a day? Extra morphine that just happens to cut off her life a day or so early making her kidneys available?

  A horrible issue to raise in polite company, the dilemma is real, topical and therefore in need of ethical exploration through fiction. The recently dead donors bring up several issues:

  • How does the doctor behave in controlling the dying process?

  • What does the doctor tell the patient who is considering foregoing life-sustaining care?

  • Should doctors insert special catheters to preserve kidneys, for example, before asking the family of a victim of near-certain death if they consent to donation? (It's being done.)

  • Should doctors immediately take the recently dead body to the operating room for organ removal to decrease warm ischemia time if the patient and family consented before death?

  The most commonly transplanted organs are:

  • Kidneys

  • Liver

  • Heart

  • Lungs

  The most commonly transplanted tissues are:

  • Corneas

  • Skin

  • Heart valves

  • Ligaments

  • Iliac bone (hipbone pieces)

  • Ribs

  • Cartilage

  • Saphenous veins

  What about legal considerations?

  Many ethical issues surround transplant surgery and the procurement of organs. The availability of organs doesn't match the actual demand by needy patients. It's a matter of coordinating what's available with the demand. It's all enmeshed in the dilemma of getting past emotional and religious arguments against proceeding with organ donation.

  Interestingly, the legal channels for organ donation are wide open.

  The Uniformed Anatomical Gift Act (UAGA)

  Actually, two UAGAs appeared in the medical literature in the latter half of the twentieth century. The last Act confirms the propriety of people over eighteen years of age donating organs or tissue for transplantation in the event of catastrophic illness. The potential donor may make his wishes known by filling out a donor card, having a notation placed on his driver's license or creating a document such as a living will or advanced directive.

  The Act also allows other family members to make the donation on behalf of the injured patient. The following family members may grant permission in this order of priority:

  1. Spouse

  2. Adult son or daughter

  3. Either parent

  4. Adult brother or sister

  5. Legal guardian

  6. Person responsible for disposal of the body

  In many states, laws exist that require doctors to request organ donation. Of course, the family isn't required to comply, but the request must be made. The mandatory notification of families about a potential donation arose because of the desperate need for organs. Opportunities for organ donation are wasted every day. With improvements in immunosuppression and new drugs becoming available, the missing ingredient in transplantation became opportunity.

  Transplant surgeons need more organs.

  The federal government got into the act in 1972 when amendments to the Social Security Act (End-Stage Renal Program) allowed reimbursement by Medicare to needy kidney failure patients for dialysis as well as kidney transplants. Twelve years later, the National Organ Transplant Act was passed providing financial assistance to regional

  organ procurement organizations as well as to a national Organ Procurement and Transplant Network.

  Strict standards of care were established by the Omnibus Budget Reconciliation Act as well as "required request" protocols. This meant hospitals were obligated to take measures to identify potential donors and inform families of their options in this regard.

  So far, pretty interesting. Your "plot brain" should be firing impulses to your cortex with untold possibilities.

  There's a lot more to come.

  The Process of Obtaining Organs lor Donation

  Like a good story, organ transplantation is initiated by a good beginning, possesses a carefully orchestrated middle and culminates with a flawless end. Each part of the process demands teamwork. Each of the four steps involved is discussed to provide you with "points of entry" for your story; that is, you'll see where conflict may arise in the continuum of organ transplantation.

  Identification of a Potential Organ Donor: The Process of Referral

  The process begins at the bedside when a member of the hospital staff—the trauma surgeon, in our case—evaluates a patient, usually in the intensive care unit, and mentions for the first time that survival may not be possible. If the criteria mentioned above have been met, or are close to being met, the patient is considered a potential candidate for organ donation. The hospital staff then contacts the regional organ procurement organization (OPO), and this starts the process.

  A procurement coordinator goes to the hospital and evaluates the potential donor. This individual is usually a physician's assistant or a registered nurse with special training through the American Board of Transplant Coordinators. Depending on the procedures worked out in a particular hospital, the family may be approached either by a physician who is trained as a requestor or by the OPO coordinator. This individual must compassionately and objectively explain to the next of kin the process of donation and be sensitive to their feelings. When the records have been thoroughly reviewed and the appropriateness of a donation confirmed, the next step is taken.

  The Process of Obtaining Consent

  Once the family accepts the idea that their loved one is dead, only then is mention made of a donation. The procurement coordinator will discuss options. These, the family is informed, include the potential for considering the donation of transplantable organs as a gift. If acceptable to the family, consent forms are filled out. The discussions
include what organs and tissues may be donated as well as the general organization of national recipient waiting lists. If the victim died under questionable conditions or if there are legal questions about the death to be considered, the coroner's office or the local medical examiner must be contacted for clearance.

  Evaluation of the Potential Donor and Maintenance of Life (Organ) Support

  The procurement coordinator next reviews the chart for specific information about the donor's past medical history, searching particularly for anything that might exclude the patient from making the donation. Indications for donation have recently been expanded, and even some people with diabetes and hypertension may donate organs. Also, once brain death criteria have been met for organ donors, the donor's heart and lung functions are supported and the patient is evaluated for and must be clear of metastatic cancer (spread throughout the body) and systemic infection.

  Several tests are then performed including ABO blood typing, CBC (complete blood count), blood chemistries, HIV screening, hepatitis screening, syphilis screening, screening for cytomegalovirus, blood and urine cultures and special tests to assess adequate function of the organs to be transplanted. The national computer is accessed for a potential recipient, and then the major task shifts to managing the donor until organ and tissue removal occurs.

  The interval problems seen while waiting for the transplant team include:

  • Hypovolemia—too little volume or body fluid because patient was "dried out" to improve brain function; must now be corrected and maintained by continuous IV fluid replacement and cardiac drugs such as dopamine. Brain dead patients get diabetes insipidus—a loss of a water and salt conserving hormone—which aggravates body fluid losses.

  • Hypothermia—loss of brain stem centers; may result in a serious drop in body temperature. Warming devices may be used.

  • Clotting problems—dead brain tissue may release substances into the circulatory system that cause clotting factors to misfire; results in diffuse bleeding.