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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 September 8; 335(7618): 501.
PMCID: PMC1971188

Outside the comfort zone

Peter J Revington, consultant maxillofacial surgeon, Frenchay Hospital, Bristol

I realised that there might be more to this Afghanistan trip than I had supposed when my “dog tags” arrived. For several months, I had looked forward to it with all the anticipation of a trip to the car wash: it was simply an unknown, and I was therefore neither excited nor apprehensive at the prospect. That changed the moment those shiny metal discs fell from the envelope.

Only a few weeks later I found myself facing something of a challenge, both surgically and ethically. My six week deployment as a Territorial Army maxillofacial surgeon began uneventfully enough. The multinational team of doctors were all suitably eminent and charismatic individuals. The hospital proved remarkably well equipped for a war zone, and, despite the dust and occasional rocket attacks by the Taliban, it functioned with the quiet efficiency of a banking house. If you imagine the film M*A*S*H* but set in a high altitude desert surrounded by fairly impressive mountains, with occasional glimpses of the snow capped Himalayan foothills, and add the incessant beat of helicopter engines and the roar of high speed jets, then you may begin to conjure the atmosphere of the place.

A knock on the door of our billet at 6 30 one morning served to jolt us into action and to announce the imminent arrival of casualties from the crash in the mountains of a helicopter that had been carrying 22 men. The first five off the rescue helicopter were in body bags, apparently a feature of the loading priorities; they had put the sick on board first and the dead last.

One patient, a 29 year old, presented in the first wave of casualties at 7 30. He had been thrown clear of the wreckage and was deeply unconscious, with a Glasgow coma score of 4, but apparently otherwise uninjured. He had been intubated at the scene, and his initial clinical examination was unremarkable, although he had bradycardia of 50 beats/minute. Computed tomography, however, showed considerable bilateral intracerebral haemorrhage, with bleeding into the fourth ventricles, and extensive cerebral oedema.

Unable to monitor the patient's intracerebral pressure and without a neurosurgeon on site, we sought a neurosurgical opinion by telephone. A bleary voiced colleague, roused from sleep four time zones away, advised against decompressive craniotomy. We therefore managed conservatively, by means of intravenous 20% mannitol infusion and cooling by means of wet towels and ice. This dropped his temperature to 34°C. With head elevation and inotropic support to maintain his mean arterial pressure, he was maintained until 3 30 pm, by which time he had developed profound bradycardia at 35 beats/minute and had blown one pupil, although inotropic support meant his mean arterial pressure remained at 100 mm Hg.

At this point, some 14 hours after injury, the patient's evacuation flight was still not due to land for some two hours; after which, he could expect a flight time of a further seven and a half hours. Given this scenario, we felt that he was unlikely to survive without some form of surgical intervention. As the next best thing to a neurosurgeon, and having a degree of familiarity with the anterior cranial fossa acquired through working in a regional neurosurgical centre, I could scarcely shirk the responsibility.

He was a young, fit man. His outcome looked bleak without surgery; could it be any more bleak with it? If we knew anything, it was that serious head injuries often had unpredictable outcomes. Would it be better to allow him to die here in a foreign land with dignity, rather than preserve him, only to live out a vegetative existence? Or should we do what we could to keep him alive long enough for him to reach a neurosurgical centre and take his chances from there? After some discussion, the medical team agreed to adopt the latter course.

We performed a bifrontal, decompressive craniotomy relatively uneventfully—after a fruitless initial search to find a non-existent craniotome—and replaced the bone flap on the unopened dura to allow the already tense brain to expand further. After the procedure, the patient's pulse rose to a range of 50-65 beats/minute (my own pulse was considerably higher). The patient was finally evacuated by air, in a ventilated state, at about 10 pm, a journey which he survived.

At the time of writing, some two weeks after the event, he is still alive, but his outcome remains uncertain. At leisure again, we found support for our approach in the literature: bifrontal, decompressive craniotomy is recommended in cases of refractory intracranial hypertension (Bullock et al, Neurosurgery 2006;58 25-31).

As my return to the humdrum, target ridden, comfort zone of the NHS looms, I find myself once more unexcited. War surgery is a mixture of boredom alternating with frenetic activity; but, regardless of one's views on conflict, there can scarcely be a more needful or deserving group of patients than the courageous men who put themselves in harm's way for a living. As a doctor, waiting safe in hospital for the fruits of conflict, I found this contrast rather humbling.

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