Saturday, 24 October 2009

On the issue of burr holes done by general surgeons

Since having some interaction with general surgeons who have on occasion had to manage patients with head injury in Abuja, I have come to realise that there is more to this than meets the eye.

Many of the surgical interventions are actually unnecessary and frankly dangerous with more harm than good being done. The interventions are often inadequate and increase the morbidity and mortality for the patient. I wont advocate for a stop to the performance of such procedures but I will insist that anyone hoping to perform such procedures must be properly informed, educated and taught how to do it before embarking on this. At least in Abuja. I cannot influence what happens elsewhere.

The key problem at first glance is 'wrong' diagnosis. It is imperative to relate the clinical history and the clinical examination to the imaging. All three: history, examination and imaging results must tally. The diagnosis must be correct. The importance of any imaging feature must be interpreted in the line of the patients clinical presentation and the condition. There have been patients in good clinical condition and those in extremis who have had burr hole performed unnecessarily. In those cases who were going to die anyway, it was a waste of time and resources, BUT in those who were good grade patients, it led to increase morbidity and eventual mortality. A real waste of life.

The problem I have seen in a few cases is the radiological diagnosis. The radiologists report what they see. They often fail to relate it to the clinical condition of the patient. Often in acute cases, the reporting radiologist was not actually there when the patient was being scanned and is reporting the scan hours later. Its not their job to then prescribe treatment or advice on such an issue.
Let me give you an example. Young woman with mild to moderate head injury.. gcs 12 to 13/15. Scan reported as showing an acute subdural hematoma. Surgeon decides to offer burr hole to remove subdural. Patient then had to be ventilated in ITU post operatively. Patient died of complications of treatment: surgical and anaesthetic. I review scan and note a thin film of subdural.... not surgical..... no need to have had a burr hole.... maybe patient may still be alive if left alone?? The radiologist did not inform about size of the clot and its significance just that there is a subdural clot. Surgeon did not relate size to clinical condition of the patient.

Another example. Young man with head injury..gcs 3/15 right from the start. Intubated for a scan which shows an acute subdural clot and temporal lobe contusions. Surgeon offers burr hole drainage of the subdural. Patient died in ITU days later. I review the scan and note a small film of subdural but more important significant lobar contusions. Patient may have benefited from a decompressive craniectomy and removal of the contusions if anything needed to be done. I actually would not have offered any intervention given the poor clinical state at presentation. Radiologist did not emphasise the small subdural and the more important contusions. Surgeon failed to appreciate what was really important in the clinical presentation and imaging.

May I finish this diatribe by saying categorically, that burr holes are for chronic subdural collections only. They cannot be used to treat an acute extradural hematoma, an acute subdural hematoma or an intracerebral hematoma especially in untrained hands.

The teaching of general surgeons will commence in Abuja in earnest working with these basic principles: Know the patient, read the scan, discuss with the radiologist and then ask advice of a neurosurgeon before making any attempts at a burr hole drainage. Do burr hole ONLY for a chronic subdural hematoma or perhaps for a brain abscess. Burr holes cannot treat an acute subdural or an extradural hematoma. Certainly not with a Ghajar guide.

Sunday, 4 October 2009

poverty is a big issue

The one thing that is creating a problem at the moment is poverty and the inability of some patients to afford the costs of investigations and treatment. Radiology especially CT and MRI scans are expensive and surgical treatment is also very expensive for many. Real patients with real problems and significant risks of increased morbidity and mortality are seen without ability to pay for treatment. It saddens.

What can we do and how can one help? How many free treatments can one afford to give out before you stop being able to help even anyone? What ways can we device to help? Because we do have to do something. And fast.

First, we perhaps should encourage the development of charities, the involvement of charities in care and establish specific foundations and endowments to fund some investigations and operations. We should also perhaps encourage and set up support groups for conditions such as stroke, tumours and trauma. The charities and groups could seriously help to inform, educate and generate much needed funds for particular projects.

Involving well meaning members of the public in specific projects for hospital development and endowments is important and should be actively encouraged. All hands need to be on deck especially in preventive measures to reduce the incidence of many conditions. We need to actively educate doctors and nurses and then the general public on ways to prevent some preventable diseases.