“Cows.” Not something I have heard often in medicine. Maybe it could be associated with mad cow disease or perhaps a cow stampede? However, neither of these were the topic of discussion in the ICU for the day.
Rounding with fourth year medical students, residents, a fellow and the attending—the “staff,” as attendings were referred to in this Canadian hospital, we walked into a patient’s room. The fellow walked over to open the patient’s eyelids and check his pupils. When I looked at the patient, I immediately felt uneasy, as there was nothing there. The face was blank, but not the staring-off-into-space-because-of-sedatives blank where you can tell the patient is seeing, they’re just not seeing you; this was a disconnected blankness. “How do you assess for brain death?” the fellow inquired. The residents began listing off techniques and guidelines to assure an appropriate diagnosis is made. The patient did not have any drugs in his blood, legal or illegal, to explain his state. He was unresponsive to verbal stimuli. He was not hypothermic.
The fellow then asked us to go through the Glasgow coma scale motor score and explain each one by one. Score of Six: patient obeys commands. Six of us receiving this information from the fellow. Score of Five: the patient can localize pain. Five fingers of the patient’s right hand laying limp next to where I was standing by the bed. Score of Four: withdraws to pain. Four corners of the sink as the attending prepares a cup of ice-cold water. Score of Three: decorticate posture—the arms flexed up to the chest. Three family members of the patient I saw anxiously waiting outside of his room. Score of Two: decerebrate posture—the arms extended rigidly to the side. Two blank eyes still detached and unseeing. Score of One: nothing—no movement. One patient hooked up to so many tubes and machines surrounded by a semi-circle of healthcare professionals.
The fellow then began to rub his fist on the patient’s sternum with slight pressure at first and then pushing harder and harder. No response. Next, he moved to the right hand, taking a small, pencil-shaped metal rod and pressing into the patient’s fingernail with the same technique—light at first and then again harder and harder. No response. The left hand, left foot and right foot followed. Again, no response. A Glasgow coma scale motor score of one. We all agreed. I felt a slight ache in my own right pointer fingernail as I imagined what that would feel like. I never thought I would wish that a patient would experience pain, but we were all hoping for at least a flinch — a reflex — to demonstrate the patient could feel what was occurring and was still with us in some way. However, there was nothing.
“What next?” probed the fellow.
“Oculocephalic reflex,” suggested a resident.
“Yes, also known as the doll’s eye reflex.” This is a test for brainstem function. With the attending’s approval, the fellow slowly rotated the patient’s head from left to right. What is normally supposed to happen is the eyes will move to the opposite side of the way of the rotation. A reflex that could be demonstrated on any one of us in the room, except for the patient. The patient’s eyes did not move in their socket. Rather, it appeared as though they were stuck in that position as they only moved with the motion of the head due to no functioning of their own. The reflex was absent.
The attending had long since finished preparing his cup of ice water in the sink and held a large syringe in his hands. It was time for the caloric test. He asked what was supposed to happen with this test. “The cold water in the ear will cause nystagmus [rapid involuntary eye movements] in the opposite direction of the side with the water.” The attending nodded in agreement with the resident and noted that if it were warm water the nystagmus would beat to the same side of the water. “Cold opposite. Warm same. COWS,” he told us as a mnemonic for our learning. I remembered learning this during our neuro block and it had always confused me. I couldn’t help but to have an image of a black and white creature flash through my mind. The physician extracted the cold water into the syringe and began injecting a solid stream directly into the patient’s ear canal. I was picturing the water rapidly moving through the canal and pounding on the eardrum. The patient’s eyes had no reaction. No “COWS” was observed. One more time in that ear just to make sure. No mistakes could be made. The process was then repeated twice on the other ear, again with no response. The pools of cold water that had drained back out from the ear were collected in tubs and disposed of in the sink.
The exam continued with various other tests and then as we left the room the respiratory therapist was told to begin the apnea test and the fellow ordered a CT angio of the brain. This was all to again be certain the patient truly was brain dead. The attending and fellow discussed at what time they would speak with the family.
The uneasiness from my initial encounter had never left during the exam, but it was overtaken by a blanket of sadness as I watched the three teary-eyed family members enter back into the room to be with their loved one. We continued on rounds and I knew I would never forget “COWS” again. I clung to it, telling myself (and mentally the patient) that although there were nothing that could be done, I would use what I had witnessed and learned to grow as a medical student and help other patients. However, I will always wish I could have done something for this patient and had the opportunity to thank him for this knowledge, seeing eye to seeing eye.
Jenna Koblinski is a member of The University of Arizona College of Medicine – Phoenix, Class of 2021. She graduated from The University of Arizona in 2017 with a Bachelor of Science in physiology and a psychology minor. She is an aspiring dermatologist. In her free time she loves to dance, socialize, and watch anything and everything on Netflix.