Because two heads are better than one
Traumatic brain injury surgery is staple for India's neurosurgeons, given our rash driving tradition and top spot in head injury stats. But, it's an 'honour' we'd rather do without
I walked into the emergency department at 3 am and was given the brief. "This is a 24-year-old man who rammed his bike into a tempo while turning into a no-entry road at 1.55 am. He was under the influence of alcohol at the time of the incident and was brought to us unconscious and gasping. He had to be intubated and ventilated. There was a 15-cm scalp laceration that was bleeding and has been sutured. The CT scan shows several areas of haemorrhage with severe brain swelling and multiple fractures."
I did a quick neurological examination to find that his pupils were reacting to light, a sign that he wasn't brain dead. Yet.
A colleague and I glanced at each other. When a long silence precedes a course of action, it is because we both understand the gravity of the situation. We spoke to the family and suggested an operation called a decompressive craniectomy. Here, we remove a large portion of the skull and allow the swollen brain to expand outward instead of pressing on vital structures within. The bone is preserved in the abdomen and can be replaced when the swelling subsides a few weeks later.
Sometimes, when we don't preserve the bone for a reason and discard it, we replace the defect with a pre-contoured titanium mesh. This sort of operation is the "bread and butter" of neurosurgery, especially if your hospital is close to the highway. I must have removed hundreds of bone flaps while training. I remember preserving several of these bones; washing, sterilising, and autoclaving them; and drilling the words, Happy Birthday, to gift to my then girlfriend, now wife. They continue to be her most 'crowned' possessions. At least, that's what I think. I'm a thrifty and innovative spouse.
"There is a very high chance that the outcome is not going to be good. But because he is young, we have to do whatever we can," I said. I tried to explain that the condition of his brain was akin to having dropped a glass from a height and then trying to put the pieces back, but I wasn't sure if they got it.
His parents listened in silence, staring in denial. In these situations, relatives either ask a lot of questions or none at all. "Aap bhagwan hai, aap ko jo sahi lagta hai kijeye". When patients refer to you as God, it's actually disconcerting. You're expected to perform like the divine, which, sometimes, if you're lucky (and the real God is on your side), you may be able to pull off. But in this situation, it seemed impossible.
We drilled a few holes in the skull and connected the dots with a cutter to remove 16x12 cm of the bone. The underlying covering of the brain, which is usually leathery and lax, was stretched and thin. The brain in its regular condition is soft and pulsates gently; his was like a rock. We made a nick in the dura and opened it up swiftly only to have the brain bulge right into our faces. Small blood vessels on the surface, not able to withstand the stretch, began rupturing. We managed to enter some of the crevices and release cerebrospinal fluid, opening up pathways to reduce pressure. We were able to perceive some pulsations, but the brain gnawed angrily back at us. It was time to close rapidly. "You think he's going to make it?" I asked my assistant, usually the optimistic one. His silence was answer enough. The brain oozed out like toothpaste through our skin sutures.
If you browse through the Indian Head Injury Foundation website, you will see that a person dies every three minutes from traumatic brain injury in our country; that's 25 times higher than in the developed world. Most of us believe that a serious road traffic accident is unlikely to ever happen to us, and hence the callousness and indifference.
Ram, a carpenter who worked for my family, was plump and used to ride a black Yamaha Rx100. He was extremely adept at his craft and would come home for the smallest of fixtures. As kids, when we arrived from school, we'd know he was home if we saw his bike parked under the building with a turquoise helmet strapped on the handle. In the 20 years of him having worked with us, the image that has stayed with me is him strapping on his helmet. One day, when I saw the helmet missing, I enquired with him. The strap had broken and he had given it for repair. It was to be back the next day. That was the last I saw of him.
India is the head injury capital of the world, a distinction we cannot be proud of. Ever so often, we see our youth, die in horrific road traffic accidents, and while saving them can be exhilarating, losing them is devastating. Head injuries generate business for neurosurgeons, but it's one source of income I'd rather not have.
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals. You can reach him at firstname.lastname@example.org
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