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Thu May 28 11:40:02 BST 2009

Sometimes I have to stop and remind myself how incredible modern  
medicine is...I know a lot of head injuries don't do this well, but I  
just had to put these two statements side by side:

He had a craniotomy day 1.

He went home on day 3.

Wow...just - wow.

Fiona.

On 28/05/2009, at 9:10 AM, julie miller wrote:

> OK, have just got off the phone with neurosurgeon involved - David  
> Wallace. Here is his account:
>
> - there was NO CT scan done
> - the child had a bruise just superior and anterior to the right ear
> - the child had a fixed, dilated right pupil and was coning (I think  
> he said something like 'opposite clonic attack')
> - the neurosurgeon  took the call at 10am from a general  
> practitioner (not a surgeon)
> - they found a household drill in the hospital kitchen and dipped  
> the tip in alcohol-iodine solution
> - the GP didn't know how to put the drill together - someone had to  
> do it for him
> - he drilled through both tables of skull and enlarged the hole with  
> bone forceps with the neurosurgeon talking him through it on  
> speakerphone
> - he was able to suction out 20 mls of blood.
> - the pressure head was relieved and the pupil came right down
> - a drain tube was placed and he was airlifted to the Royal  
> Children's Hospital where he had a "big craniotomy" within a few hours
> - there was still considerable clot and the artery was still bleeding
> - the child was extubated that evening and was fine
> - he was discharged home post-op day 3
>
> Furthermore, this neurosurgeon (with 35 years experience) told me of  
> two other cases in his professional memory where country general  
> surgeons performed burr holes and then let the patients wake up  
> intact and go home without referral to a neurosurgeon for formal  
> craniotomy. One patient (a 16 year old girl) died at home later that  
> night and the other is still in a persistent vegetative state now 20  
> years later.
>
> So I suppose the lesson is that burr holes are a good temporizing  
> measure for someone in extremis to take the pressure off until they  
> reach definitive care, but on their own won't solve the problem.
>
> Regards,
> Julie
>
>
>
>
> ________________________________
> From: "mvossak at yahoo.co.uk" <mvossak at yahoo.co.uk>
> To: trauma-list at trauma.org
> Sent: Thursday, May 28, 2009 12:26:46 AM
> Subject: re: Blind burr holes
>
>
> Thanks for the reference, Matt. Maurice King also covers the subject  
> thoroughly in his "Primary Surgery". Julie, I would love to know  
> whether this patient had a scan. Perhaps the life saving blind burr  
> hole is the stuff of surgical legend, not surgical myth as I have  
> recently been suspecting!
>
> A neurosurgeon friend of mind drilled six when their scanner was  
> broken. The clot was eventually found at autopsy in the posterior  
> fossa.
>
> Maybe instant gratification will come with the next one...
>
> Miranda
> Worcester South Africa.
>
> Miranda
>
> I think most people who work in developed countries don't get it.  
> One has to
> do what one can do with the facilities you have. In Rwanda and similar
> places a dropping conscious level with localising signs/fracture/ 
> blown pupil
> mandate exploratory burr holes: 3 on each side. There will be a lot of
> negative burr holes, but there is no way you can avoid that. A  
> fracture in
> the temporal fossa with a lucid interval will have a high yield of
> extradurals.
>
> If you have an X-ray machine you can see where a fracture is and  
> that then
> becomes the most likely site of mischief. You could also do a direct
> puncture carotid angiogram and take a couple of films which could  
> show you a
> midline shift or haematoma.
>
> If you have a CT scanner then you get the most accurate info and do  
> not do
> negative burr holes.
>
> Check out http://openlibrary.org/b/OL10554765M/Neurosurgery-in-the-Tropics
>
> Matt Oliver
> Bendigo
> Australia
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org 
> ]
> On Behalf Of Miranda Voss
> Sent: Tuesday, 26 May 2009 11:27 PM
> To: trauma-list at trauma.org
> Subject: Re: Blind burr holes
>
>
> No, truly blind, most recently in Burundi just after the war when we
> couldn't even get a plain x ray.
>
> Didn't realise the Australian case was post-scan and thought the  
> general
> flavour of the posts suggested that all you need in a remote  
> environment is
> a Black and Decker, a doctor with a bit of backbone and a non  
> litiginous
> environment and all will be well. Clearly not! My misunderstanding.
>
> It can be very difficult to find the clot without a scan and I hope  
> I never
> have to do it again.
>
> Miranda Voss
> Worcester, South Africa.
>
>
> The Australian story was post-CT demonstrating an extra-axial
> collection.....are your cases truly blind or post CT? -
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Miranda Voss
> Sent: Monday, 25 May 2009 9:00 p.m.
> To: trauma-list at trauma.org
> Subject: Blind burr holes
>
>
> Re: Congratulations to Australian Doctor
>
> I also read this case with great admiration for the doctor, the system
> and the outcome. However, I would like to give another perspective on
> blind burr holes.
>
> I have had to do it a handful of times when in the bush with no
> possibility of referral/advice (NOT South Africa) and I think it is a
> HORRIBLE operation. I have only done it with documented decrease in
> consciousness and localising signs, but I have never found a nice
> hematoma that could be evacuated with good results; either high  
> pressure
> brain has come pouring out of the burr hole, or occasionally there has
> been bleeding that I have not been able to stop satisfactorily. It has
> always left me feeling far from warm and fuzzy and to be honest, I am
> now very reluctant to do it.
>
> Am I the only general surgeon/occasional skull trephiner who has never
> had a patient waking up on the end of the drill?
>
> Miranda Voss
> Worcester, South Africa
>
>
> From: "ramalinga reddy" <drarumalla at yahoo.com>
> To: trauma-list at trauma.org
> Congrats to Rob Carson for saving the chaild
> Many times doctors are afraid to do such thing for fear of legal
> implications
> It is the medical faculty which should educate the general public so
> that
> litigations are minimised and doctors do such things confidently
> Hats off to Dr RobCarson
>
>
> Dr.A.R.Reddy
> SKS Neuro Hospitals
> Mobile: 9849018017
>
> --- On Fri, 22/5/09, trauma-list-request at trauma.org
> <trauma-list-request at trauma.org> wrote:
>
>
>
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Blind burr holes - word from the source