By Ciaran O’Donnell
A consultant at Letterkenny University Hospital, who performed a life-saving operation on a young Donegal man who was minutes from death, is calling for the protocol used to conduct the procedure to be rolled out across all remote hospitals in Ireland.
Dr Alan Howard, an emergency medical consultant at Letterkenny University Hospital, says many more lives can be saved if all hospitals are provided with the wherewithal to carry out the surgery. The procedure – known as pre-transfer cranial trephination – involves drilling a hole through the skull to release the build-up of pressure on the brain.
Dr Howard was on duty on Monday, July 1st, when he was called to the resus area to assess an injured driver who had just been admitted. The driver’s car had left the road and struck a wall around 8 am while en route to work along with his girlfriend.
“It was clear that he was in a critical condition and we took him for a CT scan,” Dr Howard told the Donegal News.
“When I saw the scan I knew from the first images it was a catastrophic head injury that he had. He had a bleed around the brain and we realised immediately that he would not survive. He certainly wouldn’t have survived the trip to Dublin unless we acted quickly and decompressed it,” he explained.
“This is a neurosurgical procedure not done in EDs. This is the first ED in the whole of Ireland able to do this procedure. It’s a procedure that I’ve been working on for six years. I’m realising we are losing a lot of these patients with hemorrhage around the brain before they are able to reach the neurosurgical facility in Dublin. So it’s an absolutely time-critical condition. Unless you can decompress that bleeding around the brain in time, the patient will die. Two hours seems to be the critical time frame to try and avoid that happening,” he added.
The same procedure has only been done once before in an Accident Department – that was two years ago, also at Letterkenny University Hospital. It was performed by a colleague of Dr Howard’s, Dr Vinaithan Krishnan, in August, 2017, after Dr Howard himself rolled out the protocol he had been working on and put in place the equipment necessary.
“That procedure was successful as well. The fellow survived and is now back at work,” Dr Howard said.
In consultation with the radiologist, Dr Howard had to map out exactly the best place was to drill through the skull and access the bleeding that was destined to kill the injured driver within a matter of minutes.
“We proceeded with the operation in the Emergency Department. We immediately noticed that his clinical signs, his vital signs, improved as soon as we drilled through the skull. You’re working very closely to the brain, so that’s why it’s something that would not have been done very often in Emergency Departments. There would be a reluctance on the part of doctors to do that,” he added.
“My ambition and my intention is to have this procedure rolled out to all the remote hospitals, because this is not an isolated case. This is something that happens on an reasonably frequent basis. Patients suffer what we call extra-axial hemorrhage or hemorrhages that are not within that substance of the brain. They occur on the outside of the brain because of the buildup of pressure. They compress the brain and patients die as a result of cardiorespiratory arrest as a result of this pressure on the brain. We’ve got to relieve that pressure – we can’t just put them in an ambulance and send them to Beaumont which takes three or four hours before they are on the table,” he pointed out.
“The injured driver in this case had a severe head injury and a lot of other injuries as well. The fact that he has survived and is able to talk is an absolute miracle. I knew he would not survive the roundabout at Tescso in the back of an ambulance. Death was imminent in his case in the Emergency Department. It would have happened within minutes if we hadn’t done this procedure. The miracle is the fact that we were able to get through all the red tape, that the proper procedures and protocol were in place over the six years, and that the patient held out until then to have his accident when everything was available. That’s the miracle.”
Dr Howard was high in praise of the neurosurgical team at Beaumont Hospital.
“The radiologist is also instrumental in guiding us through the CT scans to locate the right places to drill.”
“Our intention when we get these patients is for them to arrive alive on the operating table in Beaumont where neurosurgeons can work on them. The only chance we had to get him to Dublin alive was to do this procedure and drilling a hole through the skull. The procedure takes five minutes to do. I don’t want it to become a once-in-a-lifetime heroic procedure that doctors in remote hospitals do. I want it to be a reasonable standard of care for these patients that we know are not going to survive. It’s an intervention I feel which should be much more common place in remote hospitals.”
According to Dr Howard, the equipment needed “is not an expensive kit to put together”.
“But it’s having the willingness to extend your comfort zone to do what you know needs to be done in order to get these patients to survive. I have actually talked on this in Dublin and at a surgical conference in Letterkenny. We had a poster presentation at the IAEM conference (Irish Association of Emergency Medicine) last year. So we are trying to get the word out there that this something that can be done, and if it is done in the timeliest fashion it’s associated with a significant survival rate among these patients. But if it’s not done, the outcome is dismal. So the young man that was operated on in Letterkenny is living proof that it’s well worth moving outside your comfort zone to get these outcomes.”
“On any other day, at any other hospital and with any other group of people, there would have been a different outcome – that’s the reality of the situation.
“Our department is fully committed to adopting this procedure as a standard of care for patients who will benefit from it, obviously in discussion and consultation with Beaumont Hospital about each individual case. Dr Gerry Lane travelled with the patient in the ambulance to Beaumont and he also stands ready to do the procedure if he happens to be the only one available to do it,” he commented.
“We realise that so many outcomes will be changed through this. It’s dramatic.”
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“I just got the bad news that he was pretty much going to die”
Partner of driver recalls the worst day of her life
The partner of the young man whose life was saved by the intervention of Dr Alan Howard eight weeks ago, was told to prepare herself for the worst.
“It was the worst day of my life, but things have got so much better since,” she told the Donegal News.
“My boyfriend has some spinal bruising, but apart from that he is fine. I have so much respect for everyone involved. As I said to Dr Howard, he just didn’t only give my boyfriend his future, he also gave me mine too, because obviously we are planning our lives together. It’s just amazing.”
Monday, July 1st started as out as normal day. Having enjoyed a pleasant weekend, they were readying themselves for another week’s work. After an early rise and a coffee, the pair headed to Letterkenny by car.
“We know the road so well,” she commented.
“The car lost control and crashed into a wall on the driver’s side, so he go the brunt and the force of the impact. It was just before 8 o’clock. That was the start of the roller-coaster that was to follow.”
A van driver coming up the hill saw the collision unfold and he alerted the emergency services.
“The gardai, the paramedics and the fire brigades were at the scene very quickly,” she recalled.
She was taken out of the car first and sustained minor injuries.
Her boyfriend was cut from the carnage. The next thing she remembered was being in Letterkenny University’s Accident and Emergency Department. It was close to 12 noon when she was briefed about his condition.
“I was told he was being rushed to Dublin. Obviously I didn’t see what was going on behind closed doors – I just got the bad news that he was pretty much going to die,” she recalled.
After getting checked over herself, she got the all clear and was discharged around 2 pm.
“At that stage he was already on his way down to Beaumont Hospital in Dublin. I think I landed down there with my mum and dad around 7.30 and I got word that he had survived the ambulance journey and the operation performed on him on arrival.”
When she got to see him later that night, he was hooked up to various tubes and wires. The next 72 hours, she was told, would be crucial.
“At that stage we were just praying he’d pull through,” she said.
“Thankfully, he did and we are so grateful for all the people who played a part in saving his life. He wouldn’t be alive today if it wasn’t for Dr Howard. There’s no doubt about that.”