Vascular Surgeons Performing Neurosurgery in US Military

[island doc]

From the March 15, 2007 Issue of Family Practice News, Page 45, article about Dr. John Liu, US Military Reserve Neurosurgeon:

"During that stretch of time, a reservist vascular surgeon, who was being deployed to Afghanistan, phoned him to ask him the basics of how to do a craniotomy. 'As a surgeon who does not normally do any type of brain operation, he would be called upon to do a brain operation should that need arise when he's in Afghanistan', said Dr. Liu.

Next, he will receive a call from a GMO for instruction on how to perform a craniotomy. And probably one that didn't even sleep at a Holiday Inn Express last night.

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[Galo]

From the March 15, 2007 Issue of Family Practice News, Page 45, article about Dr. John Liu, US Military Reserve Neurosurgeon:

"During that stretch of time, a reservist vascular surgeon, who was being deployed to Afghanistan, phoned him to ask him the basics of how to do a craniotomy. 'As a surgeon who does not normally do any type of brain operation, he would be called upon to do a brain operation should that need arise when he's in Afghanistan', said Dr. Liu.

Next, he will receive a call from a GMO for instruction on how to perform a craniotomy. And probably one that didn't even sleep at a Holiday Inn Express last night.

They showed us how to do this on a cadaver at the joke of a trauma refresher CSTARS. Of course we never went in to see a nuerosurgeon do it, not even at our own base. They always preface it by saying you would not be alone in any situation like that.

Hell, if you have not been doing trauma on a somewhat regular basis, alot of the basics are difficult to implement, and I am sure alot of soldiers have suffered for it. I know of 2 deaths that occured because Army reservist surgeons who were not current on trauma were the ones operating.

 

[Ex-44E3A]

I talked with a neurosurgeon who once found himself on the deployment list early in OEF... he was supposed to do a SWA tour, but his base didn't have the equipment for him.

So he went up the chain about his neurosurgical instruments, etc, and was told "Oh, you'll meet up with your gear in-theater." He advised them that he needed to contact the people who had the pallet-o-stuff so he could make sure a bunch of things were included in the load-out.

He didn't hear anything for a while, so he tried to follow-up on it.

Yeah... turns out the Air Force hadn't even purchased the gear for the EMEDS neurosurgical module. Yes, you read that right... they tried to deploy a neurosurgeon without the instruments or equipment to do his job.

 

[mitchconnie]

What's the alternative? Blanket the Middle Eastern Theater with neurosurgeons? An emergent craniotomy done by a vascular surgeon may be better than trying to transfer the patient to a larger center

This issue is not as simple as it sounds. There has also been debate in civilian circles over whether it is appropriate for relatively untrained physicians to perform advanced surgical maneuvers in emergency situations. Most notably non-neurosurgeons doing emergency burr holes, non-surgeons doing resuscitative thoracotomy in the ED, and EMT’s doing surgical airways. There are always a few cowboy types out there—some trauma surgeons, ER docs, or even pre-hospital personnel—who want to do stuff that is way beyond their training. The justification is usually, “well I have to do something, he’s going to die otherwise.” Unfortunately, the situation is never as simple as ‘drill a burr hole’ or ‘open the chest.’

For these advanced interventions to work, you have to
1. Diagnose the problem correctly—rarely as simple as it sounds
2. Know what surgical procedure is appropriate
3. Perform the exposure (thoracotomy or craniotomy) correctly
4. Address the underlying problem correctly—ie.fix the epidural bleed, repair the myocardium
5. Manage the patient perioperatively and post-operatively.


Any MS3 can be taught how to open the chest or drill a burrhole, but can he fix the cardiac laceration, address the underlying brain injury, or convert to a craniectomy if the swelling is diffuse? Chances of a successful operative course are probably nil. Virtually every neurosurgeon you talk to says exactly the same thing--patients have the best chance of survival by rapid evaculation to a higher level of care, not by random burr-hole placement.

There are a fair number of surgeons who think they are going to go to Iraq and suddenly be doing a bunch of complex subspecialty procedures that they have never done before or haven’t seen since residency. The fact is that in Iraq (don’t know about Afghanistan) advanced subspecialty care is virtually always within a 45min helicopter ride—at Bagdad, Balad, or Mosul. If you find yourself considering a surgical procedure that is clearly out of your league, do the patient a favor and put him on a chopper to Balad, where a real surgeon can do the right procedure and save their life. 99.9% of the time you will have done the right thing. Simple interventions—airway control, fluid resuscitation, control of bleeding, mannitol—and rapid transfer save way more lives then some surgical cowboy drilling random holes in someone’s head

 

[Ex-44E3A]

There are always a few cowboy types out there—some trauma surgeons, ER docs, or even pre-hospital personnel

Hey hey! Pleased to meet you... hope you guessed my name!

(actually, haven't opened a chest since residency, and that's just fine with me)

 

[g293]

ENT is doing emergency neurosurgery (craniotomies) at Bagram. They had him stop in theater and get some OJT, then presto-chango.

 

[mitchconnie]

It’s hard to argue with hypothetical situations and citations of medieval medical practices, but as long as we’re speculating…help me conduct a little hypothetical randomized control trial. (Ex-44E3, I need your assistance since I’ve only seen 200-300 posttraumatic intracranial bleeds and you’ve probably seen 1000+).

Take 200 patients with elevated ICP and intracranial bleed of some type. Randomize 100 to random bur hole by untrained personnel, and 100 to definitive neurosurgical care after 45 minute helicopter ride. Which group do you think will have the highest survival rate?

Remember that most intracranial bleeds are managed non-surgically and that only very isolated cases will be effectively treated by a burr-hole: probably a fronto—parietal epidural. Most will be subdural or intraparenchymal bleeds, a subset will be massive bleeds which are unsalvageable, and a subset will be minor bleeds requiring ICP monitor/mannitol only. Maybe one out of 100 would benefit AT ALL from a burr hole. The rest of the patients will get an unnecessary procedure and an hours-long delay in care.

Or let’s assume that the vascular surgeon, based on zero clinical experience, can actually pick out that one patient in a hundred who would benefit. Would he really be able to get him to the OR and open his head in less than 45 minutes? No way. He’ll spend an hour just trying find the drill, figure out how to work it, spend a few minutes dithering about whether it’s appropritate, calling neurosurg in Landstuhl, etc. The shortest path to decompression is virtually always transfer.

I don’t mean to be too argumentative on this specific issue, because 99% of military physicians know their limitations and are not practicing way outside their training. I just don’t see it as being a gigantic problem. (I DO see problems with medics attempting non-indicated surgical airways and mangling the neck—but that’s different topic).

 

[Ex-44E3A]

Mitchconnie speaks the truth.

Let's understand what we're doing with skull trephination... and why (I'm just an ER doc, not a neurosurgeon, so don't take this as medical advice, or the establishment of a physician-patient relationship, blah, blah, blah, etc).

You usually pursue a burr-hole when you're faced with a rapidly-deteriorating patient, a specific pattern of injury, a specific set of physical findings, and mandatory consultation with a neurosurgeon (remember, there is no imaging in the field). Typically some mixture of:

1. blown pupil (implying uncal herniation and third-nerve compression)
2. cushing's reflex (implying increased ICP and cerebral ischemia)
3. rapidly decreasing GCS

The burr-hole is usually drilled on the same side as the anisocoria... but the bleed can be on the contralateral side in 5% of cases (so you may end up drilling two holes). Fronto-temporal epidural bleeds are the fastest bleeders, and the compressed time interval makes them potentially benefit from this procedure more than any other ICH (subdurals tend to accumulate much more slowly). Once penetrating the inner table of the skull with the drill, you can tap into the hematoma directly (remember, it's an epidural bleed). Epidural bleeds in that location are almost always (80%+) caused by a temporal fracture and subsequent meningeal artery tear.

You can also partially decompress a subdural with a burr-hole, as some of the blood can be removed once you incise the dura. This procedure will do absolutely nothing for any sort of diffuse intra-cerebral edema, intraparenchymal bleed, intra-ventricular blood, or classic coup/contra-coup petechial hemorrhage.

I concur that few patients would benefit from this procedure in the field, and you'd be hard-pressed to justify delaying their emergent transfer to do one. Consider that blast injury (probably the lion's share of our casualties) is unlikely to cause a focal epidural bleed in that location, and that the overpressure is much more likely to cause a DAI-type of injury pattern.

This study from WRAMC would seem to validate that suspicion. 433 patients seen at WRAMC with traumatic brain injury over a 27-month period, and only 1.5% had epidural bleeds (18% had subdurals, which are often observed rather than rushing to do a crani). By my math, that's only a half-dozen epidurals over a two-year period. Now ask if any of that half-dozen might have been sufficiently decompensating at such a rapid rate in a remote location that a 45-minute helo-ride would be too long, necessitating an emergent skull trephination.

I'd bet the number of times this would be needed is extraordinarily small.