The Neurotransmitters: Clinical Neurology Education

Life after cardiac arrest with Dr. Samantha Fernandez

May 24, 2023 Michael Kentris Episode 24
The Neurotransmitters: Clinical Neurology Education
Life after cardiac arrest with Dr. Samantha Fernandez
Show Notes Transcript

Many times neurologists are called to evaluate people who aren't waking up after a cardiac arrest.  There are guidelines which help guide the medical field with respect to neurologic prognosis. But what happens to those patients who survive once they leave the hospital? 

Dr. Samantha Fernandez shares her unique perspective as both a survivor of a cardiac arrest and as a neurologist and talks about her experience and what we as a profession could be doing better for patients and their families. 

You can reach Dr. Fernandez on Twitter @DrSamanthaF

Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest

https://link.springer.com/article/10.1007/s12028-023-01688-3


Neurologic Outcome Prediction in the Intensive Care Unit

https://journals.lww.com/continuum/Fulltext/2021/10000/Neurologic_Outcome_Prediction_in_the_Intensive.13.aspx

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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Dr. Michael Kentris [00:00:02]:

Hello, everyone, and welcome back to the Neurotransmitters podcast, a podcast about everything related to clinical neurology. I am very fortunate today to have a special guest with me, Dr. Samantha Fernandez from the Baylor College of Medicine in Houston, Texas. Dr. Fernandez, thank you so much for joining me today.

Dr. Samantha Fernandez [00:00:21]:

Thank you so much for having me. I'm pretty excited that I get to to have this conversation with you.

Dr. Michael Kentris [00:00:26]:

Well, me too. So just to kind of start things off a little bit, you are a fellow neurologist, and just tell me a little bit about what path led you into neurology to start with.

Dr. Samantha Fernandez [00:00:38]:

Yeah, so I knew I wanted to go into neuro pretty early on. I think I was almost two, and it was the easiest subject for me. It wasn't taking too long to learn things. I really enjoyed it. The localization part of it, I really loved. I feel like the one specialty that you don't need a bunch of, like, imaging or labs to kind of diagnose that it's helpful to have it, but oh, sure. If you know your anatomy, you know your neurosis, you kind of have an idea of what's going on. So that's what drew me to neuro. So I went to my school in Mexico. Yeah. And we don't have as many subspecialties, I guess, as we have here. So going into neurocritical care was not even in my mind, but I did know that I really liked neuro. So that was, like, my plan for the longest time. And, I mean, clearly then it changed a little bit, but yeah, I just knew I wanted to do neuro pretty early on.

Dr. Michael Kentris [00:01:54]:

That's awesome. Obviously, you went through the whole medical school pathway. You matched into Baylor, an excellent program.

Dr. Samantha Fernandez [00:02:03]:

Yeah. Love it.

Dr. Michael Kentris [00:02:04]:

So you've been practicing in Houston now, in training there for a few years, and you had gone in for surgery, if I remember correctly. Is that right?

Dr. Samantha Fernandez [00:02:13]:

Yes, that is correct.

Dr. Michael Kentris [00:02:14]:

Tell me a little bit about that.

Dr. Samantha Fernandez [00:02:16]:

So it's actually a little bit funny, but before residency, actually, before even, I was in research, which was, like, four years before residency, I started having some weird pain. It wasn't related to anything that I ate, but it was kind of in my back, actually, like, right side in my back, I'm sort of the flank, but a little bit higher up. And it was really odd. Like, I didn't know what it was then it would be epigastric. So I was super confused, but of course, I thought that I knew what was going on. I started taking Nexium, and for some reason, it kind of improved. So for the longest time, I thought, I have gastritis, I have GERD. And Nexium was helping me, but then it stopped helping me, and I was actually six months into six months into intern year, and I was having, like, biliary colic. Oh, well, before that, I finally went to Di, to GI specialist did an ultrasound, and she said that I had a pretty big gallstone, like, essentially the size of my gallbladder. Yeah, I know, but in my mind was like, well, it's big. It can't come out, right?

Dr. Michael Kentris [00:03:39]:

True.

Dr. Samantha Fernandez [00:03:40]:

So I thought, I'm not going to be too concerned about this. I'll just change my diet and it's going to get better. And it did. But eventually it started giving me more trouble. I got to a point where I was having an episode of biliary colic every month, at least once a month. And I said, well, yeah, I might consider surgery down the line, but it wasn't anything crazy. And then November I want to say 2019. I don't know what happened, but it just got out of control. I was having constant biliary colic, like, every minute of every day. I couldn't eat. I could barely drink water. Like, I lost like 1517 pounds in a month, which I was happy about, but wasn't healthy. So I went to see one of the surgeons at Baylor, and he's like, yeah, we can do it in three weeks. And so we scheduled everything. I was actually going to go on an anniversary trip with my husband because it was going to be our first year anniversary. And so going for the surgery super simple. And I was pretty scared. I've never had any kind of surgery, and so I was pretty nervous beforehand. But I was looking at statistics, even, like, mortality rate, and I think it was like a 1.6-1.9 mortality rate. So I'm like, okay, stop worrying. So I go in, and all I remember was going to the or. And then starting to wake up and I hear just commotion in the room. Like, everybody was kind of freaked out. And in my mind, I'm just thinking, oh, it's over. They're just about to change me to another bed, take me to pack you. But then I hear, I don't have a pulse. Literally, someone saying, like, I don't have a pulse, and it freaks me out. And then I feel pain. Wasn't pain, actually. It was more pressure, like, on my chest. And I was thinking to myself, like, you have a tube down your throat. Why would you have pain? I feel like you can't breathe. And I remember even trying to take a deep breath, and I felt the tube, so I wasn't sure why it felt like I couldn't. It felt like I had an elephant sitting on my chest and I could not breathe. And there was just a lot of pressure. So there's still commotion around me. And all of a sudden I don't feel the elephant in my chest anymore, but I feel horrible pain on the sides of my chest?

Dr. Michael Kentris [00:06:37]:

No.

Dr. Samantha Fernandez [00:06:39]:

So I had a pneumothorax, and they had two place in chest tubes, but of course they think I was in Pea. So they didn't like politicane? No, it was just cut, put the chest ups in. And I can tell you it was the most excruciating pain like I have ever felt in my life.

Dr. Michael Kentris [00:07:00]:

Normally imagine.

Dr. Samantha Fernandez [00:07:02]:

Yeah, it was pretty painful. But that's kind of when I realized there's something really wrong going on. And I started, well, I'm thinking, okay, what are they going to look for right now? They're going to try to see if I'm opening my eyes, if I'm wiggling my toes, or if I'm moving my fingers, because that's what we ask our patients right, when they're unconscious. So I tried to do that. I remember I had so I think they had me like this on the table, and my head was turning to the left, and my eyes were closed, but not completely closed. So I could kind of see my hand. And I'm trying to move my fingers, and I don't see it moving. I try to move the other hand. I don't feel anything moving. Then I try to wiggle my toes. I also can't and definitely couldn't open my eyes. Like I really tried. And so they're changing me. Well, not changing me, but I think they were like getting some X ray. So they were moving me around. Then I hear someone say, like, Ms. Fernandez, I'm so sorry, as they were about to place my IJ yeah, it was not fun. And while all of this is going on, I hear the anesthesiologist say, we're going to have to get the ECMO team. That's when it really hit me. I guess if anybody else had heard ECMO team, they don't know.

Dr. Michael Kentris [00:08:34]:

They don't.

Dr. Samantha Fernandez [00:08:35]:

Yeah, but that's when I was like. Okay, this is pretty bad 

Dr. Michael Kentris [00:08:38]:

For people who are listening who may not be familiar with ECMO. Could you just give a kind of 10,000 foot view?

Dr. Samantha Fernandez [00:08:46]:

Yeah. So essentially it's a huge system where they pump blood for you and oxygenated because your body is not able to get the amount of oxygen that it needs to in the blood. So essentially, you have like a circulatory system that's not in your body. It's a machine.

Dr. Michael Kentris [00:09:10]:

Right.

Dr. Samantha Fernandez [00:09:12]:

So that usually means that someone is really sick. Right. It's a pretty specialized procedure. I think most physicians that don't do ECMO are very scared of it. I know I'm pretty scared of ECMO.

Dr. Michael Kentris [00:09:27]:

There's a lot of things you have to know to do it right, right?

Dr. Samantha Fernandez [00:09:30]:

Yeah, I know. The lines are huge. So anyways, I hear that they might need to call the Agmo team, and they actually call them. And so I feel like I am about to fall asleep. And what kept on going through my mind was, don't fall asleep because it doesn't mean that you're falling asleep. It means you're going to die. So I just kept trying and trying and trying to wake up, and I wasn't able to. And then finally, they were actually cleaning the area in order to put the line for ECMO. And somehow I just woke up. They said that I opened my eyes first, which also kind of was weird. They said usually you'll start moving and then you open your eyes. But I went straight to opening my eyes. My oxygen saturation went up. It was in the think thirty S. Forty s and all of a sudden goes up to mean I have a pulse X. Of course, by then that's all I remember. Then I don't know what happened, but I know that they had the interventional cardiology team come by. There were like a bunch of people in there and honestly, my thought was, these are all my coworkers. I'm naked on this table and there's a bunch of people looking at me. So it wasn't the best.

Dr. Michael Kentris [00:11:12]:

Yeah, it's literally that nightmare everyone has in grade school.

Dr. Samantha Fernandez [00:11:16]:

Yes. And it was happening to me. So then I remember feeling like a really big tube down my throat and I was confused because I already had the Et tube. So the breathing tube, it turns out they did an echo like a tee. So it was a probe. Very uncomfortable. Very uncomfortable. But they did the little procedure there. After that they take me to the recovery room. And this is pretty tricky because it was around Cove. Well, it was during COVID The vaccine hadn't even come out yet.

Dr. Michael Kentris [00:12:02]:

Right.

Dr. Samantha Fernandez [00:12:03]:

So family members are not allowed to visit. My mom was here, my husband was with her, but they could not come see me. Eventually they did, but my surgeon was amazing. He immediately called my husband, told them what was going on and said she didn't have enough oxygen go into her brain for quite amount of time. So we don't know what she's going to be like when she wakes up. My husband tells my best friend, who's an obtain, about this, and then she calls the surgeon, he gives her more updates. My mom is having the most horrible night of her life. And I'm pretty unaware by this point. When I was in the recovery area, I sort of remember. So I wake up and the first thing I see is the surgery resident who's crying. She was bawling. And she tells me, you're really scared us in there. And I feel like that really created a pretty special bond between us. I mean, I see her now at work and it's like, you saved my life, right. She's bawling and she says, what can I do for you? Tell me anything you need. And I keep on pointing to the tube because it's super uncomfortable. Oh yeah, they had me sort of sedated, but even like okay. So I remember it was so uncomfortable that I kind of had to teach myself to breathe with it as opposed to just like kind of breathing over the bunt because that was super uncomfortable. So somehow I got them to excavate me at like 03:00 A.m. Or something. It was great.

Dr. Michael Kentris [00:14:10]:

Which we all know how people don't like overnight excavations yeah, they don't.

Dr. Samantha Fernandez [00:14:15]:

So it had to be very convincing. The anesthesiologist, I remember, came examined me, and I was following commands. I was answering questions. I was writing. They gave me a notepad. I was writing it's pretty funny because I remember they were checking my cranial nerves, and they asked me to raise my eyebrows, and I just shake my head, and they freak out, like, Please, can you try? Can you try?

Dr. Michael Kentris [00:14:43]:

Yes.

Dr. Samantha Fernandez [00:14:43]:

And I asked them to give me the notepad, and I just write Botox. Super relieved. But I wanted to mess with them a little bit more, but I could not.

Dr. Michael Kentris [00:14:55]:

Oh, my goodness.

Dr. Samantha Fernandez [00:14:57]:

I know. But finally they took the tube out. I was texting that night. I was on the phone with my mom, with my husband, and I was just like, okay, something crazy happened, but I'm here, and my gallbladder was not taken out.

Dr. Michael Kentris [00:15:15]:

Oh, my God.

Dr. Samantha Fernandez [00:15:16]:

I know. But has not given me trouble in almost, like, two and a half years. So I don't know what they did, but it worked.

Dr. Michael Kentris [00:15:25]:

It doesn't sound like an option that most people would pursue.

Dr. Samantha Fernandez [00:15:29]:

Oh, definitely not.

Dr. Michael Kentris [00:15:31]:

I have so many questions. So first of all, did they ever figure out why why you went into cardiac arrest in the first place?

Dr. Samantha Fernandez [00:15:41]:

Yeah, so there's a few theories that they have. One of them is that they had already done the pneumocoritinium, so essentially they put gas in my stomach, right, to inflate it, because it was laparoscopic. So they needed the space to go in with all their little toys and do the surgery. So I have a pretty short torso. So what they think is that it kept on pushing, like, my diaphragm and my lungs upward, and my right means stem bronchus was intubated. And they kept on retracting. They pulled it back. They pulled the tube back because there are X rays. Like, I saw all of them, but every time after they retracted, it would go to that one again.

Dr. Michael Kentris [00:16:31]:

That's very strange.

Dr. Samantha Fernandez [00:16:32]:

That was really odd. Yeah. And, I mean, I had a pretty experienced anesthesiologist, pretty experienced surgeons. I trust this, and I trust them all with my life. After a bunch of tests that they did, that's what they think happened. Because it was respiratory arrest first for like, 15 minutes or so, and then the cardiac arrest, essentially.

Dr. Michael Kentris [00:16:57]:

Okay. And I guess the second piece would be, most people don't wake up in the operating room. So I know there are some people who are like, fast metabolizers of anesthesia. Was it similar, or was it just that they had turned it off when all this other stuff started going down?

Dr. Samantha Fernandez [00:17:17]:

So it was still on. That's why they couldn't explain why I was so aware. I'm pretty sure that when I first told them, oh, I could hear you, they were like, yes, you did. But then I started telling them things that did happen. They're like, oh, my gosh, so the oxygen in my blood, my PO two, was in the 20s, like, the entire time, so they couldn't explain why. But I went to PubMed, and I did a little bit of literature search, and it seems like it's about, like, one point. I think don't quote me on this, but I think it's like 1.21.6 of cortex arrest where they are aware.

Dr. Michael Kentris [00:17:56]:

Not the majority.

Dr. Samantha Fernandez [00:17:58]:

No, definitely not. There's crazy cases where people are awake talking to you as they're getting chest compressions even though they're still in cardiac arrest.

Dr. Michael Kentris [00:18:11]:

Interesting. I'm sure you're familiar with BIS monitors and things like that. The bispectral indexes, which I know are not necessarily used in all routine surgeries, but I assume that they probably weren't monitoring functional brain activity in your case. Otherwise they would have known that you weren't really in deep anesthesia.

Dr. Samantha Fernandez [00:18:32]:

Right? Exactly. I don't remember honestly having any sort of, like, this monitor or anything like that. Another thing that I did wonder I never asked, to be honest, but I did look at all my vital signs. I don't know if my heart rate at some point went up and with the pain, because it was a lot of pain. If I have ever had an adrenaline rush, it was that moment. I don't know if it did anything. I don't think it did. So nothing really objective for them to.

Dr. Michael Kentris [00:19:06]:

Know that I was aware, that is crazy. So you've been through all this. Now move on to the recovery phase. What did that look like?

Dr. Samantha Fernandez [00:19:19]:

So I had taco tsubo. So my heart pretty much took a hit from the arrest, and I had an injection fraction of, like, 2025.

Dr. Michael Kentris [00:19:30]:

Oh, my.

Dr. Samantha Fernandez [00:19:30]:

I think that eventually went up to, like, 30. When I left the hospital, I was in the hospital for five days. Two, three days in ICU. And then two days on the regular floor. I started getting better. I did not seem to need any rehab. The physical therapist evaluated me, and they're like, no, you're fine. You can do everything. So I just needed to take it easy, take my medications, and just slowly kind of not work out, but just walk a little bit more and slowly try to go back to my my normal life. So I called my program director. So I was an intern year. So it was I was, like, part medicine and part neurology.

Dr. Michael Kentris [00:20:14]:

Right.

Dr. Samantha Fernandez [00:20:15]:

But they were super understanding. They were like, how long do you need? Two months? I'm like, no, I don't think so. Oh, them. They were willing to just give me as much time as I needed. They were super understanding. My co residents actually went all well, not all of them, but a lot of them just went to see me when I was still in the hospital, which was, of course, pretty cool. And then I go back home, and I was out for three weeks. I think, besides the hospital, I was out of work for three weeks. Then I went back, and physically, honestly, it wasn't too bad. Just had to take it easy. Working three, 4 hours would put me out for eight. I was so fatigued.

Dr. Michael Kentris [00:21:02]:

Yeah. And I think for those who haven't gone through medical training, the life of an intern is one of constant sleep deprivation and long hours capped, quote unquote, at 80 hours a week. Right. Which we all know.

Dr. Samantha Fernandez [00:21:17]:

Right.

Dr. Michael Kentris [00:21:18]:

A little bit of blurriness around the edges of those numbers.

Dr. Samantha Fernandez [00:21:20]:

Exactly.

Dr. Michael Kentris [00:21:20]:

But yeah, for someone who'd just been through something like that, I can only imagine the physical strain, let alone the emotional or mental strain.

Dr. Samantha Fernandez [00:21:29]:

Yeah. So it's pretty interesting because I'm a baseline. I'm a pretty positive person. And I honestly don't think I realized how positive I was until this happened. Just that I was, like, a normal, just average person. I mean, I am, but you know what I mean? But, yes, I wanted to get back to work, and I saw my cardiologist. They did an ultrasound of my heart, and my heart function was back to normal. They did an MRI, and it was perfect. It's like nothing had happened to it. So they're like, you know, you're good to go. He was like, Go back, work out, do what you need to. It's fine by me. So slowly built that back up. The fatigue kind of got better. Then I started noticing a few things. So I started having trouble sleeping at night. I started having really bad memory issues. My husband multiple times would tell me, we've had this conversation, or I already told you, and I legitimately did not remember. This got not worse, but I started to notice more of it. Like, maybe two weeks after going back to work, things that I knew by heart, I had to relearn. I think I was in consult, and I was in renal, I think. And so cure acute kidney fail or dialysis, stuff that I really knew I didn't remember. And I had to study again, a bunch of things and reread them five times, otherwise it wouldn't stick. It started getting a little bit difficult, like, emotionally speaking. When I was back in the ICU where I was, we had a patient that we were seeing. He was on the floor, and he went to have a heart surgery, and he had a cardiac arrest. And then, of course, he wasn't in the CVICU. And the next day I go to see him, and I was so upset. I was so upset that this had happened to him. And he had a bunch of lines in him, the tube. He also, by the way, got chest tubes, so I knew the pain that he was in. And I started talking to him, and the nurse is like, oh, no, he's super sedated. And I'm like, well, yeah, but you never know, right? So that was, like, the first one that hit me really hard. Then it started being a few others where if I just heard the overhead calling a code blue, a cornic arrest, I would burst into tears like, no reason. Thankfully, I was alone in the team room, but several times it was too much, and it was the same hospital where my surgery and everything happened. So start dealing with all of these things. I keep on remembering feeling, well, everything that I was feeling during the arrest or feeling the pain, hearing that they were saying, and it would just make me cry, like, multiple times a day. There was, like, no warning at all. And I was super confused because I'm like, I'm super positive. And I was happy, and I was grateful, but I felt helpless. I was back to normal. I was working out already. I had my life back. I was with my husband and my mom, and I was happy. But I still felt, like, super helpless, and nobody around me could really understand. So I tried talking to my husband, to my best friend, and at some point, my husband said, I don't know how to help you. I think you need to talk to someone that's a professional. And so Baylor, actually, they give free therapy sessions for residents, which is pretty cool. And I started seeing one, and she was like, well, yes, this is all very normal for what did she say? For PTSD? I'm like what? And she says, well, yeah, you're PTSD. Like, what do you mean? I don't have PTSD. And she says, yes, you do. So that was the first time. This was, like, three months or so into it. And she says, yeah, you have PTSD. Then more things started to happen. Like, I had my first anxiety attack when we were in the Nora ICU. One of our patients went into cardiac arrest, and I was there, and I'm like, oh, my gosh, this is the first one that has a cardiac arrest in front of me, and I don't know what to feel. I don't know what to do. And it was just, like, a bunch of emotions. And she's like, yeah, that's an anxiety attack. So it was a learning curve.

Dr. Michael Kentris [00:26:30]:

Yeah, it's something that I think we don't really learn about it as students or even sometimes as residents. You're probably familiar with the book every Deeply Drawn Breath I'm Not no. By Wes. I think it's Wes Ely. Yeah.

Dr. Samantha Fernandez [00:26:46]:

I have not read that one, but.

Dr. Michael Kentris [00:26:48]:

Yeah, he was, like, one of the people who did a lot of storytelling and I think some of the initial research into post ICU syndrome and things like that. And it's one of those things where I remember myself as a neurology resident. I would see these people in the clinic. It's like my memory is not quite right or things like that. And older, less healthy people than yourself or even people who just had anesthesia for a complex surgery, things like that, and they didn't come back out of anesthesia quite like themselves. And it's this really thing that we don't necessarily talk about very much, and we're probably missing a lot of things for people who are going through these situations.

Dr. Samantha Fernandez [00:27:32]:

Oh, definitely. Like you said, even as a neurology resident, even though it was an interim back then, but I feel like all of us kind of come in knowing a good amount of things. I just had no idea that these were things that were expected to be dealing with after, like you said, a surgery or a cardiac arrest or just being in the ICU period. And I started paying more to pay more attention. And like, our patients, the ones that we were conflicted on when they complained about those things, like the memory issues or I have worse headaches, I'm like, oh, my gosh, I can relate. Yes, that's true. And then I wondered, why are we not seeing these people as neurologists in clinic? They go home, and particularly in cardiac arrest or even after ICU, they usually follow up with, like, their primary care or maybe one or two specialists, but very rarely with neurology unless they were seen by them in the hospital.

Dr. Michael Kentris [00:28:38]:

Right, yeah. No, it's it's very true. It's and, you know, obviously, I'm I'm biased in favor of of neurology assessments, like you said earlier. Right. A lot of the information comes from the bedside. Talking with the patients and having done this for a little while, I'm sure you can sympathize where it's perhaps the next day when they realize after a heart procedure, like, oh, Mr. So and so's, left arms kind of weak, and you're like, oh, it's because he had a stroke, but thank you for calling us. But yeah, it becomes one of those things where and again, right, we are trained specifically for those assessments, and people may not be looking for those kinds of things specifically, and it can be subtle in some people.

Dr. Samantha Fernandez [00:29:24]:

Yeah, definitely. Again, I did not have any appointments with a neurologist, so I was just trying to figure out what was going on. And it's funny because when you look up stuff, kind of what to expect after cardiac arrest, none of this is out. I mean, the awareness has definitely increased the past couple of years, and I see a lot more information on it and more resources, but still, I just had to go straight to PubMed, and it took me a while to find something that made sense. And I really was like, I would like to have neurologists just follow these people in the hospital and then also in clinic. And as I was kind of looking if any of this was sort of a thing, I found Sachinograws Neuro Cardiac Clinic in Columbia. And I saw what he's doing, basically following any cardiac arrest survivor and their families, they see them in clinic and it's like a one step shop, sort of. They provide resources, they have it ignore psychiatrists, rehab, a chaplain. It's amazing what they're doing.

Dr. Michael Kentris [00:30:41]:

Yeah, that's really awesome.

Dr. Samantha Fernandez [00:30:43]:

It's amazing. It really is. And it's like, the only one in the country. It's the only clinic like that.

Dr. Michael Kentris [00:30:51]:

Yeah. Those types of multidisciplinary clinics, unfortunately, are challenging to implement.

Dr. Samantha Fernandez [00:30:56]:

Yes, definitely.

Dr. Michael Kentris [00:30:58]:

Now, have you lobbied this? I know as a resident, you have your own continuity clinic. Have you been accumulating these patients? I know certain people draw certain kinds of others to them for care. So how has that affected your actual practice?

Dr. Samantha Fernandez [00:31:14]:

So it's affected it in a few ways. Number one, whenever I take care of a patient in the ICU, I think my approach is completely different. Number one, I try to pay more attention to the family than I did in the past. And this also took me a while to understand, but when it was about to be like, my first anniversary, rebirth, whatever, when it happened, my mom was Ms. She was like, I just want this day to be over. And I'm like, but it's happy. Like I'm here. And she's like, no. And I started to notice that it's not just me, it's affecting other people, too. And then I had already been in touch with a few co survivors, like wives that their husband had cardiac arrest or like, Kristen Flannery. I gave CPR to Will, and they're like, well, yes, it's pretty bad for us, especially because most of them are the ones that are aware of what's going on and the patient is not so much. So that's one thing. I talk to the family a lot more. Like, I pay more attention to them. Then I talk to the patients. Even if they're super sedated intubated, I actually explain to them what I'm doing. As I'm in the room, I tell them, hey, we're going to or. I'm about to check your reflexes, and I'm sorry I have to pinch you, but I have to see if you can feel me touching you. And maybe the 99% can't hear me, but there's got to be that 1%.

Dr. Michael Kentris [00:32:48]:

That might you and I. Right. I was on call in the hospital last week. I think I saw at least three or four patients who were kind of straddling the line of brain death. Right. And as neurologists, that is just every week that you're going to see that, and you almost build up this protective callous because it is emotional. It's a lot, especially for our staff who is primarily in the ICU. It's like if you don't find some way to cope, it's very mentally taxing. But I think that sometimes we kind of veer too far towards that side and become perhaps more brusque and emotionally detached than we probably should be.

Dr. Samantha Fernandez [00:33:36]:

Yeah. Initially, I thought I wanted to go more towards that side because the first year, it was really difficult to deal with these kind of consults when they call you to. A neuropragnostic aid or just basically say, hey, this person is essentially brain dead. But it actually went more towards the other side, and I started being a little bit more careful. Well, a lot more careful, actually, with any sort of prognosis that I gave. And my practice is to wait. Don't just it's 72 hours when we don't have, like, a devastating brain injury and the exam is kind of not the best, but also not the worst. Try not to tell them, well, 72 hours, and this is bad prognosis because I have seen several cases where it's been like, two, three weeks, and then the patient awakes and they're talking and their cognition is intact. And if we had actually given a bad prognosis at 72 hours, they probably would not even be here.

Dr. Michael Kentris [00:34:49]:

Yeah, and there were that the new guidelines just came out, like, last week. Have you read them yet?

Dr. Samantha Fernandez [00:34:58]:

It's a lot, but yes, I have.

Dr. Michael Kentris [00:35:00]:

Not read through them, but it essentially boils down to, like, don't be too hasty, but I need to dig into them more thoroughly myself as well.

Dr. Samantha Fernandez [00:35:09]:

Yeah, they definitely touch more on multimodal prognostication, which I think is great, and something that we really need to improve and kind of how can I say this? Like, not just be okay with the markers that we have right now because not a lot of them are the best. I think it's only, like the vote potential thread that are pretty good, but.

Dr. Michael Kentris [00:35:35]:

Not every center does them, and they're incredibly, technically difficult. In the ICU, the signal is usually bad, it's technically challenging, et cetera, et cetera.

Dr. Samantha Fernandez [00:35:46]:

I have never seen one, I've never done one, and all I know is from literature that, yeah, it's technically pretty difficult. So I think that maybe we need to try to find other markers, if possible, and kind of go from there. But yeah, I definitely started and even telling my attendings, like, well, maybe you want to wait. It's maybe a little bit too soon at some point. I actually wanted to emulate what session Agarwal is doing in Columbia with a clinic, and I went to a couple of my attendings like, hey, we have to have this clinic, and it's going to give everything to survivors. And they're like, Sam, we need resources for that. We need a lot of support.

Dr. Michael Kentris [00:36:30]:

That eternal question. Yes. Where does the money come from?

Dr. Samantha Fernandez [00:36:34]:

Yes, I know. I'm like, Maybe we can convince some people. And they're like, well, there's only well, back then we only had four intensiveists, but they're all so busy that it's hard to have a clinic dedicated for this. And also intensiveists usually don't like outpatient. No, yeah, I don't like it, but I was able to kind of after, like, a year and a half of project ideas that were just not feasible, start a Qi project, and a few of the residents also got involved, and they were pretty interested in it. And with the help of my program director, we were able to pretty much have the cardiac arrest survivors from our county hospital follow up with neurology, like, automatically a patient, and she's helping me so that the referral goes through immediately. There's no blocking it. And then we follow them ideas for up to a year, longer if necessary, of course, but they would have a neurologist seeing them, and then there's specific questions, of course, also, that we would ask that they might not even realize, like, oh, yes, I'm having memory issues, or I can't sleep. So that was, like, my big win.

Dr. Michael Kentris [00:38:01]:

That's really excellent, actually. Now, have you got any preliminary data that you can share, or is it still pending analysis?

Dr. Samantha Fernandez [00:38:10]:

Yeah, no, unfortunately, nothing yet that we can share. It's taken a while to kind of get it to this point, but I'm pretty interested to see how they do too. Even if quality of life improves, if these interventions do make a difference, I'm hoping that it will, but nothing yet.

Dr. Michael Kentris [00:38:32]:

Absolutely. Yeah. I'll be looking out for it, definitely. One other question I did have. I know that you had said that you're planning on becoming a neurocritical care specialist. Did that happen before? Was that something that developed over the course of your neurology residency, or was that something that you went into neurology residency kind of thinking, I like the ICU. I want to work there with those people.

Dr. Samantha Fernandez [00:38:56]:

So I have known that I like the ICU for about nine years. Yeah. So when I was a student, I was in the ICU, and back then, I just knew that I wanted neurology. But I was in a hospital. I was in ICU, and that was the only med student there. There were no residents, no fellows, nothing. And one of our patients comes back from surgery and starts crashing, and then we get Rainbow Labs, and they're looking horrible, like, shockwaver. His oxygenation was really bad. Hemoglobin wasn't, like, five, I think pretty bad. And he was surf spacing. So all the fluid that we were giving him was just, like, leaving the vessels and kind of sticking around in other areas that we don't want the fluid to be in. And so the nurses are like, the attending is not answering, which never happened, by the way. He's super responsive, so I don't know what well, I think he was sick. I don't know. But he wasn't answering. The other attendings in other ICUs, and the Ed, they were super busy because apparently all the patients decided to crash that day.

Dr. Michael Kentris [00:40:18]:

Oh, no.

Dr. Samantha Fernandez [00:40:19]:

So they're like, what do we do? And I was like, the best thing that they had that day. So I tell them, well, what if we do this? Or what if we do that? And they're like, Might as well. So they started to do it, and it worked, and he got better, and we got him stable. I mean, within like, an hour. He was definitely stable. Like, subsequent labs were looking a lot better. And that's the first time that I realized I liked the ICU. It was amazing.

Dr. Michael Kentris [00:40:51]:

That must have been a rush.

Dr. Samantha Fernandez [00:40:53]:

It really was. Doing stuff and seeing it work right there in front of you, it was. It was great. But I was kind of conflicted because in Mexico, we don't have neurocritical care. Right. So I didn't know how I was going to be able to do neuro and then critical care. I thought that I was going to have to do, like, a separate internal medicine residency and then do critical care and have my neuro knowledge. So when I got my first job here as a research coordinator in a neuro ICU, that's when I knew that. But I found out that there was neurocritical care, and this was, like, eight years ago or something, so I knew this is what I'm going into.

Dr. Michael Kentris [00:41:38]:

That's awesome.

Dr. Samantha Fernandez [00:41:39]:

Yeah.

Dr. Michael Kentris [00:41:43]:

I assume because you're fourth year now, third year. Did you already go through the match?

Dr. Samantha Fernandez [00:41:50]:

So I'm actually in the middle of interviews.

Dr. Michael Kentris [00:41:54]:

Well, then we'll keep this on the DL. I won't ask you where you want to go most. We'll leave that up to the future to decide.

Dr. Samantha Fernandez [00:42:02]:

Exactly. I'll let you know in August where I want to go.

Dr. Michael Kentris [00:42:06]:

Absolutely. That's awesome. That's so great. So for people who are neurologists, other healthcare workers of different types, what are the things that you see? That because I'm sure there are more than a few things that you see most often that just really drive you crazy about the way people comport themselves, where they act in the ICU with patients. What are the things that you if you could just get rid of them or change them overnight, what's the top of your list?

Dr. Samantha Fernandez [00:42:39]:

The top? My number one is stop joking and laughing in a patient's room. It does not matter that they are on 50 protocol super sedated, and they're intubated. You just never know who might be aware. And whoever is aware, they're super scared already.

Dr. Michael Kentris [00:43:01]:

Right.

Dr. Samantha Fernandez [00:43:02]:

So to hear that the people caring for them are laughing and joking, it doesn't make you feel good. When I was aware, it's funny because I wasn't scared because I heard everyone just on the ball. They were really doing their best to bring me back. And that gives you a comfort that I'm not alone. I'm not trying my best not to die just all by myself. There's a bunch of other people that know what they're doing, and they're helping me. So that's the number one and the number two. Don't neuropragnosticate. So early on.

Dr. Michael Kentris [00:43:42]:

Yeah. Do you ever find anyone trying to go before 72 hours?

Dr. Samantha Fernandez [00:43:45]:

Yes.

Dr. Michael Kentris [00:43:47]:

That's a no, isn't it?

Dr. Samantha Fernandez [00:43:49]:

Oh, yes, it really is. Yeah. You just have to remind them it's, one, not appropriate, and two, you could be killing someone. If you give a prognosis well, a bad prognosis before that time.

Dr. Michael Kentris [00:44:08]:

Yeah, I first came across this phrase when I was in the neurocritical care issue of Continuum from last year. And I really should look up the author to give her credit. Do you know her?

Dr. Samantha Fernandez [00:44:21]:

Catalina Marcel, she's actually one of my mentors.

Dr. Michael Kentris [00:44:28]:

Yeah, she used the phrase medical nihilism for this self fulfilling prophecy in neuroprognostication. And it really is. And it's such an easy trap to fall into, especially with all these people coming in like opioid overdoses. They were down for an hour, everything stacked against them. And so it's very much like, well, that all makes sense. This looks like a very bad picture and it will probably end badly, and then, well, we prognosticate as such and family terminally extubates the person and well, look, they did badly, just like I expected they would, right? And everything lines up. All of our expectations are met. So it is such a logical trap to fall into, logical in air quotes, obviously, with your own personal experience. But how do you keep people from falling into that trap?

Dr. Samantha Fernandez [00:45:28]:

So it's been challenging, particularly when you're talking to people that have done this for longer than a decade or two. And I do understand that my case is not everyone's case and they're stayed out there for a reason. But I think you need to think of that 1%, that 2% of people that maybe don't fall into the norm. And imagine if that person was you or your family members. What if it was your mom, if it was your spouse? You would not want your own bias to cost their life. So I tell them this honestly, let's give the care that we would want for ourselves or for our families, because these people are not just a patient, they're somebody's daughter, they're somebody's mom, somebody's husband. And so treat others how you would want to be treated.

Dr. Michael Kentris [00:46:36]:

No, I think that's the best we can do. How do you deal with because as you said earlier, right, a lot of our tests for neuropragnostication MRI has low sensitivity. If they have intact cranial nerves, right? Particularly the pupillary reflex, the corneal reflex, I mean, those are the two that tend to correlate most, as I'm sure a lot of our listeners are aware. They're not brain dead, they're not waking up. Testing is normal. Now, what, how do you mentally wrap your head around that?

Dr. Samantha Fernandez [00:47:06]:

So there was a speaker at AHA last year and she showed some data of some cases in Europe, I believe, that people woke up. Well, physicians waited, I think up to 30 days in some cases, and eventually these people woke up. Because of the way that our rotations work, I can't unfortunately follow them the entire time. But I think the key is just hope. I hope that whatever brain injury or other pathologies going on will slowly subside and chill and they will be able to wake up. And if they don't, they truly will just not wake up, just hope that the family has the ability to accept it and find those support that they need and the resources that they need in order to move from it. Pretty difficult, but it is. It's help.

Dr. Michael Kentris [00:48:21]:

Yeah. I find those patients, I would mostly put them in kind of like the minimally cautious state category. Those are, I think, the most challenging ones because they're reacting to their environments, but they're not themselves. And it's like some of them, like you said, they will wake up and they probably will improve, but there's still a large percent that may not and may remain in that state. And that's the really challenging part, is you don't know who is who and.

Dr. Samantha Fernandez [00:48:52]:

When you take into account external factors like insurance or do they have the means, the financial means to keep this person in an LTAC. Or I don't think nursing home would be the appropriate place, but let's say an LTAC, or even take them home when they don't have that and they want to give their family member a chance, what do you do? And like here in our county hospital, we recently had a case of something similar. Postcardios patient brain injury wasn't devastating, not from what we could see in imaging, at least. EEG was not bad, just low exam, wasn't crazy, horrible, but still just not waking up. And the family had to make a decision because they were not citizens of this county, of Paris county, so they couldn't get any sort of medical benefits, and they didn't have the means. So they had to base their decision solely on, well, can we afford this?

Dr. Michael Kentris [00:49:52]:

That's terrible.

Dr. Samantha Fernandez [00:49:55]:

It's complicated. I don't think that we'll find the right answer anytime soon.

Dr. Michael Kentris [00:50:00]:

Yeah, no, it's definitely a lot of pieces and very complicated. Now, you've also been involved in some advocacy work, is that correct?

Dr. Samantha Fernandez [00:50:08]:

Yeah.

Dr. Michael Kentris [00:50:08]:

Tell me a little bit about that.

Dr. Samantha Fernandez [00:50:10]:

Yes, of course. One of the things that I did when I started realizing that I needed some support from others that had gone through the same, I looked up some support group survivor networks here in Texas, and I couldn't find any. There's a few for youth cardiac arrest, but clearly I am not in my teens or early 20s, so I needed to find, like, a grown up, so I needed to find something that was more for me, and I couldn't find anything. I talked to Dr. Benfoprow, who is, I think, the head of cares here at Texas, and I was like, hey, is there anything here? He said, no, there's nothing, but you could start something. I'm like, I think I could. So I created the Texas Cardiac Arrest Survivor Network, which is essentially the only survivors group here in Texas in its very baby stages. It takes a while to kind of grow it, but we've been able to reach out to some people, help a few others. They're telling their stories. My thing is providing evidence based information, but in very simple terms, because it's impossible, I think, to reach your entire audience. But if I'm able to help those with low health literacy as well, which I think are the ones that mostly needed, then I've done something good. And so I try to keep it just very simple to the point. There's like, little meetings. They have been all over him because COVID, but just even them, like, finding someone that they really connect with, another survivor that they can talk to, and that hopefully they don't have to go through what I did and trying to figure out who to talk to, who to connect with. So that's the one thing. And then Dr. Bennebella from Penn was the first one to actually reach out to me on Twitter, and he invited me to talk at his cardiac arrest court that he leaves Biannually. And so I started talking about my story, and I reached a few people. Then I actually reached out to Sachin Agarwal from Columbia after reading his paper on PTSD, and he took me under his wing, Carolina too. They're like. Yes, I can help you. And through them, I was able to connect with more survivors, more co survivors who have dedicated truly their lives to raising awareness and even, like, the effects of brain injury. There's a friend that had pretty severe brain injury from her cardiac arrest, and you look at her and you would never think that today. So thanks to all of them, we have been able to come up with certain initiatives to really help people in what happens after they leave the hospital. So that's been pretty cool.

Dr. Michael Kentris [00:53:35]:

That's some amazing network building, and it's very impressive.

Dr. Samantha Fernandez [00:53:43]:

It's all thanks to Twitter. And I think my cardigrest had to bring something good.

Dr. Michael Kentris [00:53:51]:

That's that optimism coming through again, right?

Dr. Samantha Fernandez [00:53:53]:

I guess, yeah.

Dr. Michael Kentris [00:53:54]:

Yes. Any final thoughts that you would leave our listeners with about cardiac arrests, about the heart and the brain in general? Anything that big? Take home points?

Dr. Samantha Fernandez [00:54:06]:

No, for sure. So I think the big thing would be and OC for our fellow neurologists, be careful. Be careful with those neuroprognostication consults. Don't just give a bad prognosis right away, especially if the exam is looking a little bit iffy and you don't have anything for sure. I know it's hard to say, well, yes, this person could wake up, but again, just imagine if it was you or if it was your family member. Just give them the chance that you would like to have. And I guess for the entire audience, the brain and the heart are definitely connected. They are pretty connected. And advocate for yourself, for your patients, for your family, if this ever happened to you or to your loved ones, just advocate to get that support to maybe see neurology. If you think that there's something going on, if you're having memory issues, just fight for you. Fight for your care.

Dr. Michael Kentris [00:55:16]:

That's something I always tell my patients, bring someone. It's always good to have someone who can fight on your behalf, because sometimes it's hard to do it yourself.

Dr. Samantha Fernandez [00:55:26]:

Exactly. Especially when you're just coming if you're sick.

Dr. Michael Kentris [00:55:29]:

Right, right. Absolutely.

Dr. Samantha Fernandez [00:55:30]:

Yeah. No, definitely do that.

Dr. Michael Kentris [00:55:32]:

Dr. Samantha Fernandez at Baylor. An amazing story. Thank you so much for sharing all of your experiences and all the work you've been doing. I very much look forward to seeing I'm sure you'll be a pillar in the neurocritical care community for decades to come.

Dr. Samantha Fernandez [00:55:49]:

You're so sweet. Thank you so much for having me. Michael, it was really great talking to you. And thank you for inviting me. I hope that this can help people or two out there.

Dr. Michael Kentris [00:56:00]:

Thank you so much. Thank you, everyone, for listening. If you enjoyed this podcast, please rate review and share it on Apple, Spotify or wherever you get your podcasts, and please subscribe. For future episodes, you can reach me on Twitter at dr hentris. That's D-R-K-E-N-T-R-I-S or by email at the Neurotransmitterspodcast@gmail.com with any questions or show suggestions. We'll see you all next time.