Friday, 22 May 2009

Did you hear about the one with the GP, the Black & Decker drill and the boy with a hole in his head?

 No, this is not some macabre tale from a horror film, but about a story that broke earlier in the week about Nicholas Rossi, a boy who fell off his bike and bumped his head. He developed signs of severe bleeding into his brain (similar to that which killed Natasha Richardson), and the GP, saved his life by drilling a hole through his skull with the only drill he had available.

 This story has made me stop and take note for a couple of reasons. Firstly, I deeply admire Dr. Carson, the GP involved, for what he did. Making the diagnosis of an intracranial haemorrhage in these circumstances is not actually very difficult for a trained doctor to do. We also know that to save a patient in these circumstances, you need to relieve the pressure in the skull and this can be temporarily achieved by drilling a burr hole into their skull. Actually doing it is a different matter. It doesn’t take a great deal of imagination to realise that you can do untold damage to someone by drilling into their brain. It takes a cool head, a steady hand and, most importantly, you need to be convinced that you are doing the right thing for the patient on the other end of the drill bit.

 Dr Carson is, quite rightly, being lauded as a hero but – here’s the irony – if Dr. Carson had been working as a GP in Britain, or even as an A&E doctor a district general hospital in Britain, he would be being hauled over hot coals right now.

 Reading this story in the press, you’d think that these events happened in the deepest, darkest outback and infer that if Nicholas had fallen off his bike in the UK he would have got to a big hospital quicker, making the Black & Decker unnecessary. You’d be wrong, very wrong indeed. Let me explain.

 Dr Carson’s rural hospital was 105 miles from the nearest Australian neurosurgical hospital. I work in a hospital about 60 miles from the nearest British neurosurgical hospital. 105 miles by helicopter and 60 miles by road have roughly the same journey time, if anything the chopper will get you there slightly quicker. What I’m saying is that my hospital is effectively just as isolated as Dr Carson’s. We are no closer to the neurosurgeons and their expertise here than he is in Australia. Admittedly, we have some posher drills here, but I don’t think we have a proper craniotomy kit and I’m certain that even if we did, there’d be nobody here that knows how to use it.

 My point is that a 13 year old boy with a head injury coming through the A&E doors at my hospital is effectively in the same situation that Nicholas Rossi was in Australia, and, I’ll tell you this much, this sort of scenario isn’t uncommon. In the last 18 months or so, I have seen three people come through into A&E resus with similar symptoms to Nicholas (head injury, altered consciousness and a blown pupil) when I’ve been on call. The difference is that not once have I or any of my trauma colleagues got the drill out. Not once has anybody even suggested getting the drill out.

 All three of them died.

 I find it quite shocking when I see it written down in black and white like that, but it’s true. (edit - to be fair, two of them had other, severe injuries elsewhere)

 The reason that we don’t drill into people’s skulls in my hospital is not because we don’t know what to do, it’s because we’re not allowed to do it. Trust me, if I attempted a burr hole in a patient like Nicholas in our A&E, I would undoubtedly be in huge trouble - even if I managed to save the patient’s life. I would have had the book thrown at me. I would have been accused of “acting outside my clinical competence” of “being arrogant and without insight” of “putting the patient in danger” etc… etc… etc…

 I would have no doubt been suspended from working as a doctor and referred to the GMC. And this would be if the patient survived. If the patient died (which, lets face it, is by far the most likely outcome in circumstances like this), I could be struck of the GMC register and possibly put up for a manslaughter charge. Regardless of whether or not the patient lives, very few would be lauding me as a hero. I would be at best a pariah, at worst a prisoner.

 I seriously doubt that anyone would have stuck up for me either. Not the anaesthetic consultants, not the A&E staff, not the neurosurgeons, certainly not the lawyers and, if the boy died, probably not even his family would have done.

 It’s a sad state of affairs that here, in the UK, we’d rather let someone die than attempt to save them by doing a procedure that we know is required. Once again, my hat goes off to Dr. Carson.


rosiero said...

In the good old days you would probably got away with it. But political correctness and the fear of being sued these days leaves a lot to be desired.

Anonymous said...

Increased litigiousness is definitely a contributor; you could also blame protocol-driven medicine as Dr. Crippen does. But what does "political correctness" have to do with anything?

2nd Year Medic said...

I think the difference between your hypothetical scenario and the one in which the Australian Doctor found himself was that he was in contact with the neuro-specialists via the phone.

If they advised it, then surely he could never be in trouble for performing it?

I reckon that if it where you and you had been in contact with the specialists 60 miles away and they advised it then you would be safe from all the consequences you mention.

Jo said...

It is very sad - if I were in the situation of possibly dying with the procedure and definitely dying without it, I'd rather have the procedure done!