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A Long-Distance Guide
Neurosurgeon David VanSickle was assisting in an operation at the Children's Hospital in Denver when his pager went off. From the description, he realized how desperate the doctor's patient was. VanSickle agreed to help. Leaving the primary neurosurgeon to finish the surgery, he found a quiet spot, clear of distractions, and prepared to guide Bergin's hands long-distance.The speakerphone was on the wall of the OR not far from the operating table. Listening to the spectral voice that issued from it, Bergin began. First, cutting through skin and muscle tissue on the shaved left side of Carter's head, he exposed the skull and prepared to enter the delicate world inside. Guided by the CT scan and VanSickle's advice, Bergin estimated the clot's location by measuring with the width of his fingers. But he could not be certain until the holes were drilled.
Hospitals equipped for neurosurgery have specially designed instruments, some with drills fitted with footplates and guards to prevent penetrating the dura and the brain. Bergin would be working with a standard orthopedic drill, an electrically powered stainless steel apparatus about the size of a hair dryer used more frequently on bone spurs and shoulders than skulls. He had to be careful not to go too deep and risk irreparable damage or death.
The moment had come, however. Bergin took the drill and bored into the bone. His goal was to cut two one-centimeter-wide holes, and then check his position with the clot. With only his sight and the feel of the drill in his hands, he needed to go just far enough to pass through the skull without puncturing the dura, and not a millimeter more.
It took five minutes to drill two vertical holes above Carter's ear. The crucial step was done.
VanSickle then instructed Bergin to cut the bone between each hole, connecting them like a connect-the-dots puzzle. This would create a two-centimeter-wide window between the holes and allow Bergin to look inside the skull, find the hemorrhaged clot and remove it. If things worked well, they would be near the clot's location. If not, he would have to drill new holes until he found the hemorrhage.
Bergin looked at his tools. He had nothing that would allow him to cut through the bone while protecting the brain beneath. Forced to improvise again, he selected an instrument used to file bone spurs and carefully sawed away the bone between each hole.
Finally, with the window successfully created, Bergin looked in on the dura -- the tough, fibrous membrane that wraps the brain. Relief filled him. He had drilled directly above the clot. They would be able to remove it through this aperture.
Now the neurosurgeon directed Bergin as he and his team began to remove pieces of clotted blood. Using forceps and suction, they scooped the mass from the hole, but as the clotted blood came free, Bergin's nerves tightened. "There's fresh arterial blood," he told VanSickle.
Because more of the heart's pumping force is behind it, an arterial bleed applies greater pressure on the brain and it can be harder to stop. It was a nerve-racking moment. Yet, in calm voices, the two doctors conferred on a plan of action. To slow the leak, Bergin selected a common adhesive sponge called Gelfoam.
"Use it," VanSickle told him. They both hoped it would work.
Taking small forceps, about the size of eyebrow tweezers, Bergin inserted the sponge into the area and pushed it against the pulsing artery. He held pressure on the ruptured vessel, and hoped the sponge would adhere and seal the leak.
After a few moments, Bergin carefully relieved pressure, watching the point where the sponge was lodged. "The flow is slowing," he said.
"Tell me what the dura looks like," VanSickle asked. The dura's appearance would indicate what was happening to the brain. The brain's covering, VanSickle explained, should be lax, not tense and under pressure, not bulging like a balloon somewhere.
Bergin looked at the dura. It pulsated regularly, appearing soft and relaxed.
"That's a good sign," VanSickle responded. The pulsating meant blood and oxygen were entering the brain. The soft, lax appearance meant pressure had been alleviated. Bergin's efforts seemed to be working.
There was still the long flight to Denver. Worried that jostling during the flight might restart the bleeding, VanSickle advised Bergin to insert a drain through a separate incision in the scalp near where the clot had been. If the sponge patch broke, the drain would give the medical crew a way to draw blood to prevent another hemorrhage.
Working carefully, Bergin positioned the drain. Forty minutes after he first entered Carter's skull, he closed the incision and prepared the boy for transport. Only minutes after Bergin finished, the Denver plane touched down in Sidney, and an ambulance took Carter to the airport.
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