Five: The Burr Hole
There are very few experiences in emergency medicine for the seasoned physician that rival those first tastes of life and death during training when the student physician participates in making the critical difference in survival of a patient. In this era of sub-specialization, intimate and dramatic interaction with the critically ill (open-chest cardiac message, for instance) is often done only by specialists called in to help. In a small rural hospital, where specialists do not exist, the emergency physician is in a position to do things most emergency physicians will never do. One evening, it was my turn.
We got a call that the EMT 2 team (capable of advanced life support management) was heading to rendezvous with a BLS (only certified for basic life support, no IV’s, etc.) crew from the tiny town an hour northeast. They were bringing us a critically injured patient. There had been some type of altercation and this adult male had suffered head trauma, having been beaten with a two by four board. He was unconscious. The BLS crew was out of radio contact with us so information was sketchy. At the time the ALS crew met up with them, the patient remained unconscious with stable vital signs (blood pressure, pulse, and breathing) but had a badly beaten head and low blood oxygen when measured with an oxygen saturation meter (O2sat, in the vernacular). The extremely competent EMT2 on board was unable to intubate (put a breathing tube through the mouth into the trachea - the upper airway) because of facial trauma but an oral airway was placed which improved the patient’s oxygen level. EMT personnel were unable to establish an intravenous line in the field (where the patient was found or in the ambulance). Upon presentation to our facility, the patient was observed to be severely wounded with a swollen bloody head, stable vital signs, deep rapid respirations suggestive of a brainstem (the primitive part of the brain which controls vital functions such as breathing) injury respiratory pattern (bad), and complete flaccidity (no muscular movement or tone). Injuries were confined to the head and included a crepitant (crunchy when felt) loose and moveable midface (nasal and upper jaw area), midposition right pupil, inability to visualize the left pupil because of eyelid swelling, right hemotympanum (blood behind the eardrum - usually from skull fracture), and multiple swollen, contused (bruised) lacerations. He smelled badly of feces (the brain trauma had caused him to involuntarily soil himself). He did not smell of alcohol (almost all patients we see from altercations have been drinking). He had old surgical scars on his abdomen and according to the family, a skull defect - missing bone from prior brain surgery. Evidently ten years ago, his wife had stabbed him in the abdomen. Two years ago he had some type of neurosurgical procedure consequent to head trauma. He had a persistent skull defect having failed to follow up for plating. He lives in Roundale where family feuds run ancient and deep and violence is a way of life. Unfortunately for him, a young man assaulted him by kicking him in the head (we never did ascertain whether a board was used) until the sheriff arrived. He was unconscious when found.
As major support services such as neurosurgery are at least ninety miles away, I have wondered if I would ever have to place burr holes (drilling half-inch holes to relieve pressure from bleeding) in a skull to save a life. If a patient were to come in with classic findings for an epidural bleed (high-pressure arterial bleeding on the surface of the brain), the procedure could be life saving. Transport to a neurosurgeon without this pressure relief would take too long. Often there is a fifteen to thirty minute time window for this life saving treatment. Beyond that interval, continued bleeding causes irreversible brain damage and death. Placing a burr hole never seemed technically difficult, as schematically described to me in training, but there is no escaping a sense of radical invasiveness. Drilling a hole in someone's head seems major enough to be left to neurosurgeons. At least, this is not a standard ER technique that is required of most ER staff at most institutions. I don't know anyone who has done one (other than neurosurgeons) and most physicians practice where there is someone else to do it if needed. But, sooner or later, I figured my number would be up and I would be faced with the challenge of do or die. In anticipation of this day, I assembled a burr hole tray (all the tools needed in one spot) eight years prior. I hadn’t thought much about it since then. I've had lots of other things to think about.
Our unfortunate gentleman was in need of a reliable airway so I performed a cricothyroidotomy (cut open the airway in the neck just below the "Adam’s Apple" and stick in a plastic tube to ventilate the lungs) with moderate difficulty. With his deep brainstem respirations (breathing driven by the most primitive of neurologic reflexes - a sign of impending brain death), each inhalation was accompanied by a large laryngeal excursion. My target was in constant motion. His short, stocky build placed his chin awfully close to his chest so there was precious little neck to work on. I didn't want to paralyze him with drugs(commonly done to eliminate movement during the procedure and resistance to mechanical ventilation) just yet because he needed all the ventilation he could get and he was doing a fair job of it on his own so far. I placed my vertical incision in the front of his neck without anesthesia or protest from him. By moving both my landmark locating fingers of my left hand with the tools in my right up and down with his respiratory cycle, I eventually found my mark and made the plunge. I got lucky, popped a #4 Shiley tube (a plastic breathing tube) into his trachea, and sutured the base in place.
This was about my twentieth cricothyroidotomy in five years and I confidently rely on this procedure to establish an airway in critically ill patients who cannot be intubated from the mouth because of facial trauma, altered neck anatomy, or excessive vomitus. It seems to be highly recommended at major emergency medicine conferences as the way to go in various situations but I don't personally know other ER physicians who have done this much if at all. I'm not sure why unless it is because they work in hospitals where other people ultimately manage patient respiration or perhaps technical inertia holds them back. In any case, I'm glad I've got this experience under my belt because this eliminates a source of fear and anxiety in this work. The job is hard enough without having to worry about if one should do a major procedure which should be done, without which the patient WILL worsen, and which you've never done before. Scary stuff unless you're a surgeon at heart. Perhaps the ideal emergency physician needs to be part surgeon when necessary.
His airway secure, we ran him down to the CT (computerized tomography - a high tech x-ray capable of showing brain detail or bleeding) scanner. At that time, we had just entered the modern age of medicine with the purchase of a shiny new CT machine. We were also blessed with the first full time local radiologist in several years. Transferring people down the road just to get an ultrasound scan or CT made the practice of modern medicine tedious and if not exasperating. The radiologist called me a half-hour later with the following reading of the CT. "Interhemispheric blood, herniation; midface fractures, basilar skull fractures," and, yes, finally, "RIGHT EPIDURAL HEMATOMA, LARGE". As they say with regard to lumbar punctures (spinal tap), 'think of it - do it'. Gulp.
There are some procedures in emergency medicine that entail technical difficulty and moderate patient discomfort. Any hesitancy to perform the procedure, which may give critical information about the illness, must be put aside when it is clearly indicated. As it can be tricky knowing whether one of these procedures is truly needed, we come to rely on clinical instinct. Thus the rule, ‘think of it - do it’. This most commonly applies to the LP or lumbar puncture - spinal tap. It also applied in this situation.
I knew my patient needed to be flown south to the neurosurgeons. I guessed he was going to die. I knew I should do a burr hole and if it did him no good, so be it, but without it, there was hardly any point in transporting him. It is our practice, however, to transport mortally wounded head injured patients who are alive to the care of a neurosurgeon so that they may die in the hands of those most able to alter this fate if we are wrong. Also, the family may get some peace of mind knowing that all possible treatment was done. Futility is a large and multifaceted entity best tackled with a lot of resources and a large support system. We have neither in our practice setting, though we do know better....
I asked my right hand nurse Cindy whether she thought we ought to go for it. Without hesitation, she agreed. I had to decide within a few minutes. His clock was ticking, the alarm was ringing and there was no snooze control. I called the neurosurgeon down the road to establish acceptance for transfer and when I suggested that perhaps I should place the burr hole, he also agreed. He did not inquire as to whether I had ever done one, or even seen one, but that was minimally relevant at that moment. I instructed Cindy to set up the tray. She already had.
"Are you the family of Mr. Lucas" I inquired of the growing crowd in the hallway? They anxiously turned to my voice. "I'm Dr. Sterngold, I run this emergency department, and I want to let you know what's happening with your relative. He's very badly injured. When he arrived here, he was unconscious and still is. I think that he has very serious brain injury and I can't be sure that he will recover." They gasped in disbelief, a sickening mix of horror and denial.
"Because his head and face were so seriously injured, I put a breathing tube into the airway in his neck to be sure that he would get enough oxygen. That seems to be working well. His heart is fine and he doesn't seem to have injuries other than his head and face." Giving family whatever is positive is important to help them to cope with the moment. They will need time to digest their impending loss. Any time is a lot more than none.
"We're doing everything possible to protect his vital functions of circulation and breathing. We are getting a CT scan of his brain to find out exactly what we're dealing with. This will tell us the best thing to do next. All right? Do any of you have any questions? I'm sorry this has happened and I will keep you informed of any changes and I will tell you everything that I'm doing. We will also be making arrangements to fly him down to Santa Rosa where there is a neurosurgeon who can take care of any treatable brain problems which, of course, we're not equipped to do."
The CT obtained, having decided to put a hole in his skull, I again approached the family. "OK, we have the CT scan results. I'm afraid he does have quite a serious brain injury. There is blood inside his skull that is putting pressure on his brain. He may not recover from this injury but one thing we can do here and now is to drill a hole in his skull to let some of the extra blood out to relieve the pressure. It's not a cure but it may buy him some valuable time. We have special surgical drills made for this." They encouraged me to proceed.
"Do whatever you can for him doctor. Do you know which hospital he will be sent to?" I told them and returned to our patient. The intention of my words were to let them know that he was mortally wounded but also that it was not yet over and great effort was going into his treatment. This makes it easier for loved ones to accept the end when it comes and it gives them a critical period during which to start the process of coming to grips with this sad reality.
The time had come. Working from training done years ago, I quickly rehearsed the technique in my head. Vertical incision about two inches above the ear, about five cm. long, raise periosteum (the membrane which covers all bone) with elevator (the periosteal elevator is a chisel-like tool), spreaders, drill with brace and bit, all on the tray. Simple. In my thirty some years doing carpentry, wood and metal work, tools have been natural extensions of my thoughts. Inappropriate or inadequate tools make difficult or even simple jobs impossible. As I began to bore the bit into the outer surface of the skull, the tip walked around, failing to purchase into the bone. I wondered if surgeons had a special centerpunch for this purpose, but there was no time to find out. I leaned hard onto his head. His cranium inched away from me. My heart rate accelerated. I called out to my nurses, "someone grab his head and push towards me. Now."
Finally, the burr caught bone and nearly effortlessly, bone chips crept up the bit on its way to a bloodied brain. The bit stopped cutting and spun freely, by successful design, as the brain cavity was entered. Pulling it out, I saw no free blood, only an intact membrane. Where was the epidural bleed? What's going on, I wondered. For lack of anything better to do, I slit open the dura (the outer tough membrane covering the brain) and out oozed the currant jelly consistency mass of clot. I was elated. I did it. We did it. His body changed from total flaccidity to decerebrate posturing (movement seen in brain injury). Not exactly purposeful movement, but movement nonetheless. We place a large gauze pack over the oozing hole, turban wrapped his head, and paralyzed him with Pavulon (modern day curare - the paralyzing poison for the blow dart of primitive jungle tribesmen), as his newly active motor state was interfering with ventilation.
I didn't give much more thought to his diagnosis at the moment. I was confused about the epidural bleed that was actually a subdural bleed (the burr hole, in this type of situation, is done to relieve high pressure bleeding from a ruptured artery on the outer surface of the brain, not the lower pressure bleed from a ruptured vein on the inner surface), but went on to finalize arrangements and let the family know what had transpired.
Finding the most familiar face in the group, evidently the closest family member, I told her, "We have a helicopter ambulance on its way now and everything went well. I was able to put a hole in his skull over the bleeding and let out some of the pressure. He started moving a little bit after that but we gave him a medicine to stop his muscles from fighting the breathing machine. So far, everything is as good as it can be in view of his injuries, so we're just waiting for the transfer crew to arrive. We have been checking his blood for oxygen and other important things to make any adjustments if needed. Do you have any questions? If you want to see him, that would be OK now but I want you to know that he doesn't look so good. We have bandages on his head and his face is very swollen and bruised. There is the breathing tube in his neck. If you can handle this and feel strongly that you want to see him before the helicopter gets here, we'll have two or three of you at a time come in."
If their loved one is never going to come back, they should see the reality when it is happening. To emotionally and spiritually metabolize the loss, the more real the event, the sooner the grieving process becomes effective. If grieving is based on some degree of fantasy (was he really that badly hurt?) progress may be impeded. When the family sees his badly bloodied head, a part of them may even wish for his death to avoid further and future suffering.
After arrival in Santa Rosa, in the hands of an excellent neurosurgeon, Mr. Lucas’ ventilator was turned off when evidence of cerebral circulation was absent. He died without further suffering. It turned out that his subdural bleed looked like an epidural because his prior brain injury and surgery had altered the dural membrane attachments and made the shape on the CT deceptive.
For the next couple of days, our hospital staff greeted me with the ‘slap on the old back’ congratulations and hints of slight envy. I had done something they never had and probably wouldn't have wanted to. In fact, none of them would have placed themselves in this position of risk, except for the surgeon who works for me, and he would have done an excellent job. As with many things in medicine, most events that get you high, most triumphs of skill and intellect over disease, I can enjoy a few minutes of greatness, a few hours of self-satisfaction, and then it is back to ordinary reality and hard work. I looked forward to the next days off, away from medicine and patients.
One of my healing meditations for the next few days was to finish construction
of an amplifier cabinet for one of my guitar amps. Building things in
my workshop is therapy, the only side effects being the occasional abrasion,
contusion, or laceration resulting from fatigue or lapse in caution.
With blues in the background, I work and create and fix and I am at peace.
The world of medicine is far away. Except, when I used the countersink
bit on the drill to prepare the pilot holes for screws. This bit looks
much like the burrhole bit I had just used on the skull and the images
flood back, just as the scent of stearic acid (from crayons) brings back
childhood memories. I never got around to checking on whether neurosurgeons
use centerpunch tools to indent the skull for the drill bit. Musing and
chewing on little fragments of work residue, I am interrupted by the
garage door opening. Kathryn asks my opinion on dinner and I have a little
shudder of ecstasy knowing that I will go to bed tonight and not have
to get up at the crack of dawn to go to work. With a few days off, I
am free for a little longer. The contrast is dramatic. The warrior may
sit squarely in the saddle but his mount must walk and graze. The healer
must dream and gaze.
All Rights Reserved © 2004 Jon Sterngold