Coma caused by head injury or excess alcohol?

Difficulty in differentiating between unconsciousness caused by brain injury and excess of alcohol intake has always been a surgeon’s nightmare. The correct diagnosis, usually made in the middle of the night is imperative so as to decide on the right treatment.

Injury to the brain with collection of blood might call for urgent surgery to evacuate the haemetoma to release pressure on the brain, while alcoholic  inebriation will recover in a few hours. Before CT was discovered, we had to depend entirely on our clinical acumen and so, all textbooks of surgery carried this teaching :- “It is far better that hundred drunks are unnecessarily  admitted in the hospital for observation, rather than one head injury dies in a police cell.”

Since the advent of computerised tomography, the clinical burden of a surgeon has been eased, but we are still called upon by the court to give our medico-legal advice on what killed the patient – the head injury or the alcohol. In cases where both factors play a role, it  remains a nightmare.

All these conflicting thoughts rose in my head when I was giving a bed-side tutorial on a case of head injury, which reminded me of a frightening experience I had, dealing with a similar case. But to calm my nerves, a light-hearted distraction, in the form of a funny story, I heard at a surgeons’ conference.

It is about a young man exhilarated by a touch of alcohol, pressed the accelerator of his racing car and was enjoying the ride, until he saw in the rear mirror, a police car trailing him. The cop flagged him down. “I have booked a few cases of speeding today and they all had funny excuses. What’s yours?”

The man thought hard and replied. “Officer, a couple of weeks back, my wife ran off with a policeman and I thought it was him behind me racing to catch up with me to return her to me!”

He got off with a warning!

Now to my frightening experience. I was rung up by my house-surgeon, Dr Ndolo at 2am on a Saturday night. “I have admitted Edwin Njeru, who is deeply unconscious. The history is that he was involved in a bar brawl and was pushed, fell down the stairs and lost consciousness.” Then to justify calling me at that ungodly hour, he added. “I wouldn’t have bothered you at this time, but Njeru strongly smells of changaa and I can’t make up my mind if his coma is caused by head injury or excess alcohol. The X-rays don’t show a fracture in the skull.”

Realising the predicament, in which my house-surgeon was, I rushed to his rescue and examined Njeru. He was unconscious and strongly smelt of changaa. The smell of the homebrew was so strong that it made me walk away quickly from the patient’s bed, saying. “I think there is enough alcohol here to anaesthetise a patient!”

While I was examining Njeru, I saw another patient in the next bed with a recently stitched laceration on his forehead, holding a pad and pen, presumably writing what I said.”Who is he?” I asked Dr Ndolo.

He escorted me in the Sister’s office and gave me a full interesting account of the incident. “His name is Michael Kenda. According to Michael, he and Njeru were drinking in a bar in Kariobangi. Around midnight, a lady of twilight approached them and  made eyes at them, in an attempt to see who made the highest bid. After a few minutes of this enticing, Michael won and as he was walking off with his prize to one of the bedrooms upstairs, Njeru followed him in a rage. When they reached upstairs and as Michael was slamming the door in Njeru’ face, Njeru hit his head with an empty beer bottle and split his forehead.” As I was listening with great interest,Dr. Ndolo continued. “Michael retaliated by hitting him, sending him down the stairs, which rendered Njeru unconscious.”

“The bar owner called the police and they brought both Njeru and the alleged assailant here and decided to detain Michael here after his forehead was sutured in the casualty.”

 I said. “Like Shakespeare’s Hamlet, whose dilemma was, “To be or not to be,” our dilemma with Njeru is “To operate or not to operate.” As I said it, I saw Michael sneaking outside the Sister’s office with his pad and pen, scribbling it all down. After thinking over the case, I gave my considered opinion. “This seems to be a case of alcoholic coma and we simply wait and watch. In the meantime, we look after his nutrition and provide nursing care.” Then as an afterthought, I added. “I will inform our neuro-surgeon tomorrow morning and you can have a CT of his head done in time for Prof Mbui to see.”

Next morning happened to be my teaching round and I picked the case of Njeru to teach the students. Since the patient was still unconscious and couldn’t hear us, I conducted the tutorial around his bed. To emphasise the critical issue, surrounding the case, I reiterated. “One of the most difficult differential diagnoses facing a surgeon is to differentiate coma caused by inebriation from excessive alcohol and contusion of the brain and the decision is crucial.”

It did not escape my notice that my whole tutorial was recorded by Michael with his pen. As I was leaving my ward, wondering what Michael was up to, I saw Dr Ndolo showing Njeru’s CT scan to Prof Mbui, who had arrived to see my patient. “I have had the benefit of seeing Njeru’s CT scans, which show severe swelling of the brain, suggestive of contusion. “There is no evidence of localised pressure, needing urgent surgery. Continue as you are doing because you are on the right track.”  Michael was on the spot recording the professor’s opinion.

Two days later we lost Njeru. Before his death, his belly increased in size, suggesting collection of fluid in there and when we tapped his abdomen, we obtained serous fluid, a sign of unexplained liver failure. Then his kidneys packed up, gradually reducing his urinary output to zero. The cause of death, according to us was “multiple organ failure.” Being unexplained death after a fall, a police post-mortem was mandatory.

Dr Ndolo and I attended the autopsy and there we found Michael with his ubiquitous pad and pen, this time accompanied by his lawyer. As I arched my eyebrows in surprise at seeing him there, he explained. “My lawyer has obtained permission from the police surgeon for us to be here.”

That is when the coin dropped; he was there to collect evidence to defend himself. If Njeru had died solely of head injury, Michael could be charged with man-slaughter if not murder. He was recording all our conversations in the ward to prove that we were partly culpable for not operating on Njeru, when we should have. And if Njeru’s coma was caused by excessive intake of ethanol, he could go scot-free.          

The police-surgeon opened the skull first to see if there was extra-dural or sub-dural haematoma, pressing on the deceased’s brain, causing his death because it was missed by us. After cracking the skull, to our relief, he commented.”Nothing remarkable here except intense swelling of the brain, caused by severe contusion, for which the patient was receiving conservative treatment.” Turning to the distended belly, he said.”Let’s see if there is something in this cavity to explain his death.”

As he opened Njeru’s abdomen, adjusting his mackintosh, to protect himself from the serous fluid gushing out, he remarked,.”Chap has a lot of fluid here,” he straight went for the liver, suspecting it to be the cause of it. Looking at the shrunk hobnail liver in the right upper corner, he shouted.”Eureka, I think I have found the culprit! Did this chap drink a lot?”

“He did,” replied Michael. “He drank every day with different friends. Saturday was his day with me.”

“That settles it.” The police- surgeon said as he sliced one of the knobs from the liver.”I will see this under the microscope, but you can all be rest assured that the cause of death here is alcoholic liver cirrhosis.”    

As we all, greatly relieved, walked to our respective cars, Michael joined me and said.”Thank God we are all acquitted. I was worried if it was his fall and head injury which killed him.” Looking hard at me, he added.”You were also worried if that was the cause of death, in which case, you should have prescribed a different management. Good bye” He concluded and shook hands with me. I couldn’t help noticing that his hands were warm. Mine were cold and clammy!