Case #1: It's Not Rocket Science (Case reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon.

This week, had some highs and lows, but there is nothing more thrilling for a doctor than to treat someone, and see an immediate improvement in their condition.

DM is a 50 year-old man who suffered a fall down an embankment after being pushed while walking along a road. He shortly thereafter presented to a large hospital in Nairobi with complaints of inability to move his left arm and unable to walk due to left leg weakness. After obtaining films, the physicians diagnosed him with a left scapular fracture, and acute on chronic left hip disease (even though the films looked normal to the Kijabe clinicians who reviewed them.) He was referred to Kijabe hospital for a left hip replacement. This is one of the ironic things about health care in Kenya. Even though the patient was being seen in a 1000+ bed hospital in the largest city in the nation, he was referred to our little 200 bed rural hospital, because we are the only affordable option for the procedure they thought he needed.

So 13 days after his injury, he was able to make it to our hospital to be evaluated for a hip replacement, since he had lost the ability to walk and move his left arm after the fall.
Fortunately, when the patient was seen by the registrar (resident) in Casualty (ER), the astute clinician was able to diagnoses hemiplegia, and referred the patient for a CT scan of the head. This meant going back to Nairobi, because we don’t have a CT scanner in our hospital. The next day, the patient returned to Casualty with the CT shown below.

DM’s CT Scan showing his lenticular hematoma with mass effect

Obviously, he had an epidural hematoma. The time was about 5pm, when I saw the scan and heard the story, so we were able to organize, and get him in the OR quickly (even though his symptoms had been stable through the 2 weeks). His head was shaved, prepped and draped, and I proceeded to perform a craniotomy by drilling 2 right-sided burr holes. I was unable to evacuate the hematoma through the burr holes, since it was too organized (old clot), so I drilled a 3rd hole, and used the Gigli saw between the 3 holes to do a small craniectomy. We then were able to easily scoop out the clot. I returned the bone flap, and closed the scalp incision. And went home wondering how much the procedure would help.

The following morning, the patient was able to move his left arm, and lift his left leg off the bed. By POD#2, he was walking, and on POD#3 he was discharged to home with a gait better than mine.

Post-op Day#3: Going Home

This was without a doubt the most satisfying operation of the week. Up until this case, my experience with neurosurgery has had some relatively unimpressive outcomes. (I have gotten quite a few closed head injury with low GCS and lateralizing signs, but unless your burr holes allow you to find a discreet hematoma, extradural or subdural, the end result is usually poor.) But to see a man who has been hemiplegic for 2 weeks, and then be restored to normal is quite exciting. I’m thankful that God allowed me to participate in and witness the healing.
What is more amazing is that I was never trained to do any of this. I did ~3 weeks of neurosurgery when I was an intern in 2001, and have not so much as touched the brain since then. (Anyone looking at that stellate incision I made could ascertain my lack of training.) But amazingly, by just doing my best and praying that God will do the rest, I have been able to grow more confident in many procedures I was not trained to do.  Just by reading a few chapters, talking things over with my local colleagues, and some neurosurgeon consultations via email, I have been taking care of basic neurosurgery routinely in only a brief period of time. Then again …it’s not rocket science.

In amazement,
chad

“If you act like you know what you’re doing, you can do anything you want – except neurosurgery.”
~Sharon Stone