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Thu May 28 14:40:02 BST 2009

I assume there are no patient privacy regulations in effect?  

Else, we should be careful how (or even IF) we discuss these details in an open global forum.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of julie miller
Sent: Wednesday, May 27, 2009 7:11 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Blind burr holes - word from the source

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

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Blind burr holes - word from the source