This is a continuation from an earlier article.
The young boy had clambered out of the car like everyone else had. Sadly, as the door slammed to, his fingers got caught in it and he suffered an excruciatingly agonising crush injury to his fingerpads and nail beds. He fainted in response to the intense pain.
A faint is nothing much really: a brief interruption of the blood supply to the head is easily fixed by lying the patient down, preferably on their left side so that their airway remains patent, and waiting a minute or so for the blood to start coursing through the brain again. Unfortunately, as he fell, he hit the side of his head on a pointy stone protruding from the grass. He didn’t wake up after a minute or two like he would if he had simply fainted. The family were on a driving tour of the rural area when this took place, and being sensible, mum and dad wasted no time trying to summon an ambulance to the middle of nowhere. They bundled their son into the back seat and drove like fury to my hospital.
He arrived thus unannounced and the trauma team assembled around his trolley. Blunt trauma to the head plus deep coma means urgent CT scan: It’s a no-brainer really, if you will forgive the expression. I intubated him and took him off to the scanner fully monitored and tout suite. It took only a few seconds for that marvellous machine to produce a wondrously detailed picture of the problem: a large extradural haematoma, which was expanding and squashing the brain dangerously. By now, it was an hour since the injury. If this kid was to have any hope of a normal life, he needed to have his skull opened by the fourth hour. The neurosurgeons were an hour and a half away at least.
The large off-white thing is a blood-blister forming inside the skull. The pure white stuff is the skull. The disordered stuff on the left is the swollen misshapen scalp. The dark sliver is all that remains of the brain’s inner ventricles, its wriggle room. This brain is very tight, and needs urgent decompression!
While I brought him back to the resus’ room and got him onto the ambulance trolley, rigged for transfer, the images were beamed across to the neuro-guys and the phone call got made by our surgeon. The minutes were ticking by and I asked what the delay was.
The neurosurgical registrar at the other end was being obstructive. He wanted this test and that to be done, and for us to cross-match some blood for transfusion. I couldn’t believe my ears. Time really was of the essence, and this buffoon wanted us to waste some more. The red mist obscured my vision and I grabbed the handset off my colleague.
“Listen buster, we will finish this ‘fascinating’* conversation when we meet face to face in just a little while”, I yelled at him, rather sarcastically and rudely, before slamming the phone down and telling my team to “GO, GO, GO!!!!”
“How quick do want to get there, doc?” asked the paramedic behind the wheel. We were all aboard and ready for a 90 minute dash across winding roads to the nearest city.
“Pedal to the metal, please”, was my only reply, delivered stolidly. As I braced for a very uncomfortable journey, late into my shift, my eyes watered up. I blinked them clear and then closed them again to make a brief prayer: my own son was the same age as this kid. I had briefly met his parents and siblings to explain what was going to happen. They stood there, pale and distraught, in the corner of the resus’ room like some white marble sculpture, perfectly portraying tragic, grieving, powerlessness. I was already and inevitably involved emotionally with them, having lost a child. “Drive safely please”, I advised the family, as we were going out the doors. I didn’t want any more innocent blood shed.
Being strapped into a seat, sideways on to the direction of travel, inside a tin can with no view of the outside, hurtling, pitching, and yawing violently, is a perfect recipe for inducing motion sickness. Fortunately my technician and I were sea-legged veterans at this, and we both held it down for the duration. The second paramedic, who was out back with us, stood for most of the journey, holding onto the handrails and swaying with the dancing vehicle. He reminded me of a London bus-conductor, only this bus was on the Paris-Dakar rally route.
My main clinical concern was the amount of pressure inside the boy’s cranium (brain-box). Because it is a rigid container, too much pressure inside, can stop fresh arterial blood from entering the skull cavity to nourish the ever-metabolising grey and white matter that does our thinking and dreaming for us. Because the brain is hollow, the cerebrospinal fluid can get squeezed out and thus accommodate quite a bit of swelling from elsewhere. When that reserve is used up though, the intracranial pressure ramps up rapidly and the incoming blood flow gets pinched off rapidly too. Once brain perfusion ceases, there are only minutes before the brain cells start to die off permanently, leaving only serious widespread brain damage as the best possible result.
There are a few therapeutic options which can buy time:
- Hyperventilation: By significantly lowering the CO2 levels in the blood, the blood vessels throughout the body, but especially within the skull will constrict, and thus provide a bit more space. Blood vessels contribute a large part of any tissue’s volume.
- Head-up positioning: Raising the head drains the veins within the skull, also creating space.
- Osmotic agents: These act by sucking the water out of cells thus reducing their volume. It is a benign sort of pickling. All tissues shrink as a result.
- Raising the blood pressure: There are many drugs which can do this; the blood supply to the brain is artificially brute-forced against the opposing raised intracranial pressure, and thus perfusion is maintained.
The problem with an extradural haematoma, which is usually from a bleeding middle-meningeal artery running through the bit of skull that gets fractured, is that all these worthy interventions only serve to promote further bleeding into the haematoma! The only real solution is rapid opening of the skull to relieve the pressure.
We crashed the ambulance trolley through the theatre doors at our destination. The full home-team were there waiting for us, including the head-honcho in charge of heads. We all worked together like the innards of a Rolex to quickly get the boy onto the table and prepared for an urgent burr-hole decompression of his skull. My tech-guy and I were rapidly rendered redundant as our hosts took over all care. As we were both already in scrubs, though shop-soiled, we were allowed to stay to witness their Kung-Fu.
The head was shaved, the scalp was painted with antiseptic, and the drapes were applied in a minute or two. The scalp was incised and retracted at exactly the right place and the white bone of the skull was exposed. A normal drill cuts a cylindrical hole, but a burr cuts a bowl shaped hole because the burr-drill has a spherical tip, about the size of a large marble. The bottom of the bowl eventually breaches the inside of the skull while the shallowly sloping walls of the burr-hole prevent the whole drill plunging through and liquidising the brain underneath.
Top right is a traditional burr-drill. It can be driven by a powered source or even by a brace-and-bit, as beloved by carpenters.
It was like striking oil: The blood and clots gushed out under pressure, and the pressure within the head was relieved instantly. Though there was much more to be accomplished, the patient was now out of immediate danger. Barry-the-tech’ and I decided to withdraw then to our awaiting taxi. As we carried our voluminous transfer kit back out to the hospital entrance, waving to our distant healthcare cousins along the way, Barry remarked that the two of us must have resembled the “Ghostbusters”.
I had to laugh because this was exactly true: We were both bestrewn with backpacks, ventilator tubing, cables, hoses, assorted kit, etc, and we had both played our part in preventing a ghost from being created. Such is the “paranormal” world all healthcare workers inhabit when they “make a difference”.
[BETTER STOP THERE PLEASE: READERSHIP FATIGUE. – ED]
To be continued…..
- For “fascinating” substitute some other word beginning with “f”.