Because two heads are better than one

I walked into the emergency department at 3 am and was given the brief This is a 24yearold man who rammed his bike into a tempo while turning into a noentry road at 155 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 15cm scalp laceration that was bleeding and has been sutured The CT scan shows several areas of haemorrhage with severe brain swelling and multiple fracturesI did a quick neurological examination to find that his pupils were reacting to light a sign that he wasnt brain dead YetA 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 laterSometimes when we dont preserve the bone for a reason and discard it we replace the defect with a precontoured 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 thats what I think Im a thrifty and innovative spouseThere 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 wasnt sure if they got itHis 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 its actually disconcerting Youre expected to perform like the divine which sometimes if youre lucky and the real God is on your side you may be able to pull off But in this situation it seemed impossibleWe 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 hes 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 suturesIf 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 thats 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 indifferenceRam 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 wed 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 himIndia 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 its one source of income Id rather not haveThe 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 mazdaturelmiddaycomCatch up on all the latest Mumbai news crime news current affairs and a complete guide from food to things to do and events across Mumbai Also download the new midday Android and iOS apps to get latest updates MidDay is now on Telegram Click here to join our channel middayinfomedialtd and stay 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