Indexing Title: JPINGUL's Medical Anecdotal Report  [04-8]

MAR Title: Milestones for me and for the Patient

Date of Medical Observation: September 18, 2004

Narration:

“Procedures done for the first time were always exciting and become embedded into our memories.”

            The patient was a three-year-old female who fell from a flight of six steps, and landed on her head sustaining injury.  She was brought in the ER and was diagnosed with a subarachnoid hematoma and a depressed occipital bone fracture.  She was referred to our consultant and was planned to undergo craniotomy.

            Craniotomy in OMMC happens only rarely, so having the opportunity to see and learn how to perform the procedure brought about great excitement.  The plan of the consultant was to teach us how to do it so that we would be able to do it for ourselves even if the consultant was not around.

            From the preparation of the patient at the OR table, to the draping, to the incision, every step had a purpose, the way it was prepared for neurosurgery was very different from general surgery.

            The consultant gave us residents, the opportunity to incise and open up the scalp, and how to clamp the bleeding arteries.  I took the instrument to remove the edge of the skull, until we were able to freely lift the depressed bone.  I was given the hand drill to make burr holes into the skull.  After removing the skull that affected the fracture, the consultant gently and slowly suctioned the hematoma, carefully moving so as not to damage the brain parenchyma.

            The bleeders was stopped by cautery, but since we had no bipolar tip, each cauterization was very short and the frequencies, very minimal.  Eventually the bleeding stopped. 

The next step was to close the dura, its characteristic was very tough, such as when I tried to suture it together, the edges of my sutures were tearing.  The consultant showed me to suture very close to the edge and to gently handle the tissues.  Eventually the dura was closed.  After which we tried to fix the skull into its place so as not to injure the underlying brain.  We used only towel clips to puncture small holes to slide a suture inside so that it will form an anchor to the rest of the skull.

After washing with normal saline solution, we placed a Jackson-Pratt drain, and closed the scalp.  And the patient was transported to PACU in guarded prognosis.  We tried to prepare the patient’s relative to pray for their child’s recovery

During the first post operative day, the patient was drowsy for most of the day, spent most of it asleep, barely awakening, if at all.  At this time I was anxious of her condition, as if I was telling myself that the operation failed.

But by some miracle, on the morning of the second day, the child uttered the words to call her parents, and asked for a glass of water.  I was so happy, that tears started forming at the edge of my eyes.  By the third day after operation, the child was sitting upright, playing, and her memory and brain function was intact.  Eventually on the fifth day after operation, she was sent home.

This was my first craniotomy, assisted by a consultant, and the patient survived and was sent home.

Insights: (Discovery, STIMULUS, REINFORCEMENT), (Physical, PSYCHOSOCIAL, Ethical)

        Doing craniotomy to evacuate a hematoma or to lift a depressed fracture, was not as complicated as it sounded, and it can be done in about 2 to 3 hours.  Although I have heard of craniotomies that lasted for 12 hours, but these involved removal of space occupying lesions.  General surgeons can do craniotomies in the provinces, the equipment can be made available, the skill can be learned.  Even other procedures like, ventriculostomy or VP shunting for patients with increased intra-cranial pressure can be learned and done.

        I usually hear neurologists complaining to neurosurgeons for making the patient wait too long, before being operated on, only when the patient becomes isochoric that triggers them to direct the patient to the operating room, which means the patient has poor prognosis than the awake state.  Hence the recovery rate in the tertiary hospital is low due to delay in operating time.  If general surgeons can do such procedures, then the bulk of these patients can be reduced, resulting in increased survival.

            This procedure stimulated me to look for ways to learn how to do the basic neurosurgery procedures, having the hint that my wife, a neurologist will be referring patients needing emergency procedures.  For the more complicated procedures, I will let the neurosurgeons in urban centers handle them.  But for the basic, general surgeons should know how to do these procedures.