Sunday, March 22, 2009

Case Report #6: Driving at Night Without Headlights (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.

One of the most difficult aspects of being a surgeon is taking care of trauma patients with closed head injuries. These are often healthy patients who have been in a severe accident of some sort or maybe they have been assaulted. Despite being previously well, the consequences of severe traumatic brain injury can be death or permanent disability, devastating outcomes for otherwise healthy individuals. One of the things that makes managing traumatic brain injury exceptionally frustrating is the difficulty in predicting who will do poorly. Prognosis is notoriously difficult and inaccurate at times…so much so that we usually tell family members “we will just have to see how he does”. Some unconscious patients will wake up and be totally normal, but some others that initially seem only mildly injured may decline suddenly and rapidly to brain death.
For acute trauma patients who present with an altered mental status (anything from mild confusion to profound coma) and evidence of head injury, the brain must be imaged promptly to determine the extent and type of injury after the patient’s airway, breathing, and circulation have been assessed and appropriately managed. In the developed world, this means a CT scan of the head which will tell the surgeon (neurosurgeon usually) whether there is extra-axial blood that needs to be drained (i.e. subdural and epidural hematomas). If there is no drainable hematoma, and the patient has a severely altered mental status, then he will be admitted to the ICU and have a pressure monitor place in his skull to help the ICU staff keep the intra-cranial pressures (ICP) appropriately under control.

While my clinical interest in trauma patients is higher than most general surgeons, I must admit that I have not enjoyed taking care of acute brain injuries here in Africa. In addition to the problems mentioned above, these patients are particular challenging because we don’t have a CT scanner at Kijabe Hospital. That means I have to make decisions about who to operate on without any imaging (except maybe a plain film of the skull, which is largely unhelpful). This is a little like driving a car at night without any headlights, because imaging is so central to managing closed head injury.
The usual approach is that anyone who presents with lateralizing signs (a unilateral blown pupil, hemiplegia, etc) goes to the operating room for decompression. Also anyone who has a documented drop in their Glascow Coma Scale (GCS) of more than 2 points (from their baseline score on arrival) goes to the OR for urgent burr holes as well, but this is a relative indication, and takes some judgement. If they don’t meet these criteria for surgery, we focus on preventing secondary brain injury (hypoxia, hypotension, elevated ICP), and they are managed accordingly. If they are stable, and make it through the night, (and have family members with money) we sometimes send them to Nairobi by ambulance for a head CT the following day, but by that time, imaging is rarely helpful.
My experience with managing acute severe closed head injury so far has been disappointing. To illustrate my frustrations, I present the following case.


TS was a 58 year old male passenger in a motor vehicle collision. The patient was found to be unconscious at the scene, and was brought to Kijabe hospital at night by some good Samaritans. On arrival, he was hemodynamically stable and breathing spontaneously, but his GCS was 8 and on close examination he was found to have unequal pupils, with a “blown” pupil on the right. The patient was quickly moved to the operating theater where he was intubated.  I confirmed the examination and prepared to drill burr holes.
After prepping and draping, I drilled holes on the ipsilateral side of the blown pupil first. I found no extradural blood, but on incising the dura, CSF spurted from the durotomy across the room at high pressure. This confirmed elevated ICP, but no hematoma was found on this side. I then turned my attention to the contralateral side, drilling more burr holes there. Again, no epidural or subdural blood was found, but only CSF (under slightly less pressure, since I had decompressed him a little on the other side). At this point, I was not sure what to do, I had found no blood, but there had clearly been elevated ICP’s. I talked to my colleagues who counseled against a craniectomy, but said perhaps a ventricular drain might prove to be helpful for ICP monitoring and even drainage. I tunneled a catheter under the scalp and through the burr hole into the anterior horn of the left ventricle. I then attached the drain to this low-tech cylindrical column/drainage system before closing the wounds and taking the patient to the ICU.
Over the next 12 hours, his ICP remained controllable without having to drain anymore CSF, but his mental status did not improve. He remained with a GCS of 6T, so after securing funding from the family, we packaged him up to go to Nairobi by ambulance for a head CT scan (a somewhat risky adventure for many reasons, the most obvious being traveling on Kenya’s dangerous roads with an intubated patient). The patient returned that afternoon with the CT scan, but it showed little to help us…some small contusions and evidence of edema was all that was seen. Surprisingly, we often get amazing radiographic studies from Nairobi including the 3-D reconstruction you see below, but we were still left with an unconscious patient with no real plan of how to help him.

Fancy 3-D rendering of head CT after burr holes and drain were placed

Over the next 7 days, we attempted to support TS hoping he would wake-up from his head injury. We fed him via an NGT, and even extubated him at one point when it appeared he could protect his airway, but without recovering consciousness, he slowly began to decline eventually developing complications including an aspiration pneumonia which he eventually succumbed to.


TS was just one example of the many patients with acute closed head injury that I have cared for since arriving in Kijabe. It’s very difficult to have patients come in alive, sometimes only mildly confused and only hours later be looking at fixed and dilated pupils. To be honest, my interventions and care seem to have little effect on the outcome.

Despite the discouraged tone of this post, I am very pleased that I have been allowed to participate in caring for these patients. It’s invaluable experience to get to do craniotomies, and that has helped me immensely in managing the sub-acute subdural/epidural hematomas (those patients have uniformly done quite well after having their brains decompressed). Also, I hope that one day, I am able to actually “save” an acute closed head injury patient with a correctable problem. And with all the practice I have had, I feel that I am well-prepared to do so, should such a patient present while I am on call.

And finally, while medicine is humbling at times, and we can often feel helpless in treating our patients with life threatening problems, the one thing I am learning at Kijabe Hospital, is that the care we attempt to give is often of great comfort to the family (to believe that “everything was done”).
The brothers and cousins of TS came to me after he had expired. They all shook my hand individually. They expressed their deepest gratitude to me for caring for him. And though their loved one had been taken from them suddenly, they were accepting. 
In my mind, I was more hesitant to accept that death was the inevitable outcome, but I had done everything I knew how, and lost the patient despite my best efforts. In the minds of his family members however, TS had received world-class care from a stellar ICU team of health care providers… led by a first-rate “neuro”surgeon named Dr. Wilson. Humbling indeed.

Yours in reluctant acceptance,

“Acceptance of what has happened is the first step to overcoming the consequences of any misfortune.”
~William James


At Sun Mar 22, 10:46:00 PM, Blogger Joanne Wilson said...

What amazes me about your stories is that they keep getting more and more intense and I bet there are many more that have not been documented. I am so happy you took the road less traveled by and took on the Kenyan Adventure. I don't think you would be having quite the same experience had you went straight to fellowship:)

You are amazing Chad!

At Fri Apr 17, 12:13:00 AM, Anonymous Anonymous said...

I am an ER doc doing some research for a talk on emergency department evacuation of epidural hematomas and came acroos your blog.
Thank you for sharing your experiences.

At Wed Apr 22, 12:58:00 AM, Blogger Albinho said...

I don't know if you meant to say that this experience was humbling "in deed" rather than "indeed" but it reminds me of the great responsibility that a surgeon has and how humbling the act of surgery can be. It is truly amazing, and truly humbling, to see with what God has entrusted you. You were/are a great man, a great attending, and a great friend. Keep in touch. I'm sure I'll be looking to you for advice years down the road. The crucible of missions and of surgery can forge such lasting bonds when the work is couched in Christ. Press on.

At Sat May 25, 03:48:00 AM, Blogger Cycle Heart said...

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