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Fri May 29 01:43:00 BST 2009

This isn't a transaction.  That he should be grateful is as true as it is
irrelevant.  This patient doesn't owe anyone his privacy.  As a community of
professionals we should take pains to respect that.

The details in this case are unsurprising and probably harmless; but they're
still the kid's details to discuss or publish; not his doctor's.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of LNMolino at aol.com
Sent: Thursday, May 28, 2009 3:54 PM
To: trauma-list at trauma.org
Subject: Re: Blind burr holes - word from the source

Pret I agree on point one but I think you're reaching on point 2. 

1) Kid is not in the US so a semi moot point

2) I think based on the media the family was told point blank he's dead or  
we do this and here is what this is.

3) The vast majority of folks even in the US would be grateful given  
outcome. 

4) had he still had a negative outcome I am glad for the Dr he was NOT in  
the US as I am sure he'd be eaten alive even in a courtroom with a level 
balance  sadly but that's another thread. 

Louis N.  Molino, Sr., CET
FF/NREMT-B/FSI/EMSI
Freelance  Consultant/Trainer/Author/Journalist/Fire Protection  Consultant

LNMolino at aol.com

979-412-0890 (Cell  Phone)
979-690-7559 (IFW/FSS Office)
979-690-7562 (IFWF/SS Fax)

"A  Texan with a Jersey Attitude"

"Great minds discuss ideas; Average minds  discuss events; Small minds 
discuss people" Eleanor Roosevelt - US diplomat  & reformer (1884 - 1962)

The comments contained in this E-mail are  the opinions of the author and 
the author alone. I in no way ever intend to  speak for any person or 
organization that I am in any way whatsoever involved or  associated with
unless I 
specifically state that I am doing so. Further this  E-mail is intended only

for its stated recipient and may contain private and or  confidential 
materials retransmission is strictly prohibited unless placed in  the public

domain by the original author.

In a message dated 5/28/2009 11:04:59 A.M. Central Daylight Time,  
p.bjorn at netzero.net writes:

And with  respect, it doesn't matter.  If anything, the boy's notoriety  
makes
his protected health information more difficult to  sterilize.

In the US, Julie's email would likely be evidence of a  federal crime
committed by Dr. Wallace -- unless the patient's family had  consented to
this detail of description.

Pret

-----Original  Message-----
From: trauma-list-bounces at trauma.org  
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of  LNMolino at aol.com
Sent: Thursday, May 28, 2009 10:49 AM
To:  trauma-list at trauma.org
Subject: Re: Blind burr holes - word from the  source

Pret with respect the kid was on the International news.  

Louis N.  Molino, Sr.,  CET
FF/NREMT-B/FSI/EMSI
Freelance   Consultant/Trainer/Author/Journalist/Fire Protection   
Consultant

LNMolino at aol.com

979-412-0890 (Cell   Phone)
979-690-7559 (IFW/FSS Office)
979-690-7562 (IFWF/SS  Fax)

"A  Texan with a Jersey Attitude"

"Great minds discuss  ideas; Average minds  discuss events; Small minds 
discuss people"  Eleanor Roosevelt - US diplomat  & reformer (1884 - 1962)

The  comments contained in this E-mail are  the opinions of the author and  
the author alone. I in no way ever intend to  speak for any person or  
organization that I am in any way whatsoever involved or  associated  with
unless I 
specifically state that I am doing so. Further this   E-mail is intended 
only

for its stated recipient and may contain  private and or  confidential 
materials retransmission is strictly  prohibited unless placed in  the 
public

domain by the original  author.

In a message dated 5/28/2009 8:41:58 A.M. Central  Daylight Time,  
pbjorn at emh.org writes:

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