amish neurosurgeon

A few weeks ago my attending let me do my first solo vetriculostomy. This is a common bedside procedure we do to relieve intracranial pressure from either trauma, a tumor causing mass effect, or if a pt has a intracranial bleed they may not be able to properly drain their cerebrospinal fluid/CSF (called hydrocephalus).

We were called in because this pt had driven drunk home from his bachelor party and crashed into a tree at a high speed. He was 27 years old and only 6 days out from his wedding with a worsening neurological exam by the minute.

The first thing you do in any cranial neurosurgical procedure is give the pt a very bad haircut. Essentially, you only shave the right frontal area of the skull to locate an anatomical spot called Kocher's point for a ventriculostomy. This is a spot found if you would draw two lines upward onto your head first from your right ear and secondly, from the mid-point of your right pupil; the intersecting point of the two lines is Kocher's. Once you have located the spot you numb the area with lidocaine, incise with a scalpel, and open the 1-2 cm incision with a small retractor.

Next comes the fun. You take out your trusty hand-powered drill (hence the title of this entry), set the drill bit; which I was reassured was designed to not allow the operator to plunge into the brain once you've drilled through the skull. This is the critical stage of the procedure. The angle of the drill needs to be perfect and unchanging while your right hand presses downward on the drill and your left hand cranks the drill to power the bit through the skull. The drilling is done until you feel a "pop" as you go through the inner table of the skull and hit dura. The dura (outer covering of the brain) needs to be incised to allow the passage of the catheter (hollow tube) through the burrhole (nice way to say hole you just drilled into someone's head) into the brain and hopefully directly into one of the two lateral ventricles to drain off the CSF and relieve the pressure. Once proper drainage is confirmed the catheter is secured and connected to a drainage system to monitor the fluid output.

The outcome's are mixed in the patients we perform this procedure, depending on the contributing factors which caused them to need a ventriculostomy. In the case of this young man sadly, he did not recover. He is clinically brain dead but, his family refuses to let go at this time. I haven't seen him in a few weeks. I don't think I'll likely ever forget his story or the feeling of that pop when I finally drilled through his skull.

-07.31.08 Update: Just saw the pt again today. He is totally unresponsive on neurological exam other than a cough (one of the last reflexes to go). He is dependent on a ventilator to breath and has a feeding tube placed. Realistically, he is no longer alive. His family and fiancee however feel he will awaken one day, they've moved the wedding date to November. Very Sad.

tales from the nsicu

Hey. Sorry for the lapse in my blogging, not that I was ever very routine, but it's been a while. Most to blame is my new job as a Neurosurgical Physician Assistant, which is what prompts today's post. Since, starting this job 3 months ago I've already experienced first hand the sadness of telling someone they have an incurable cancer or treating them emergently to save their life. There is a sadness in this job when you treat a large group of people with cancer, often which is fatal, regardless of if we treat them or not. So, when we find any humor in this job we tend to latch onto it, albeit some dark humor at time.

Which brings me to the story for this post. We were consulted by the trauma team about 2 weeks ago regarding a 21 year old female who had been in a motor vehicle accident; which was very likely occurred due to her intake of heroin and cocaine. It had been a prolonged extraction on scene by EMS and Fire and by the time she had arrived at the hospital she had a Glasgow Coma Scale score of 2 (normal is 15) according to the ER resident freaking out on the phone with my attending. The pt had pretty normal appearing CT of her head and her low GCS could also be due to the large amount of illicit drugs she had taken. So, the recommendation was to let her go to the OR for her ruptured spleen to be taken out and then see if she wakes up after the surgery. If not, then she may need a vetriculostomy (read - tube in head to relieve pressure) placed to relieve any pressure on her brain.

Now, jump forward to this past week. Pt now is awake, spleen-less, and her mom is visiting her in the Neurosurgical ICU. The trauma team is rounding on their pt's and as they come by the mother recognizes the trauma attending physician as the same doctor who save her life when she crashed her car, all hopped up on drugs, and almost died about 3 years ago. So the mother is singing the doctor's praises and introduces her boyfriend; a very active Pagan (a motorcycle gang here). So the mom and scary motorcycle gang member boyfriend are talking to the doctor about how they almost lost their little girl (the 21 year old pt) last year when she took some bad heroin which was laced. The mom proudly boasts that that drug dealer is dead now, he "drowned" *wink, wink*.

The trauma team is is trying to continue on their rounds and the pt's mom thanks the trauma attending one last time saying that she is so great now that she is even back to work. That's great say's the trauma doctor......what doe she do for work you might ask? She's a stripper. Who happened to have one of her legs amputated 3 years ago in her drug-induced car wreck. A one-legged stripper whose stage name is, "Feather". Whose motorcycle gang boyfriend kills people if you give his girls laced heroin.

Sometimes I think advanced medicine gets in the way of natural selection.