In Bed With the Boss

Georgie was just coming out of the gym at seven-fifty-nine the next morning when her mobile phoned beeped, indicating an incoming message. She checked the screen and saw that she had a missed call from A and E. She quickly called the number and the registrar on duty answered. ‘Dr Willoughby, we’ve got an MVA down here. Two victims, husband and wife, both middle-aged. The husband’s got some bumps and bruises, but I think the wife’s got an extradural. She had a GCS of 12 on arrival, with equal pupils, but she’s gone off to GCS 9 over a matter of minutes and her left pupil’s blown up. Can you get down here now and look at her?’

‘I’m on my way, Drew,’ she said. ‘Can you get Anaesthetics down now? I’ll phone Theatre on my mobile while I’m coming down.’

‘Right.’

Georgie raced to her car and, pushing aside all thoughts of Madame Celestia’s predictions, drove with care but haste to the hospital.

When she arrived in A and E, Drew Yaxley, the registrar, quickly filled her in on the patients’ conditions.

‘The wife’s pulse and BP have just hit the floor, Dr Willoughby. The anaesthetics registrar has intubated her. The general surgical registrar is just about through the secondary survey now but it looks like it’s pretty much an isolated head injury. Husband’s got minor general surgical trauma—no neuro injury.’

Georgie came over to where a middle-aged blonde woman was lying on the emergency trolley, intubated, with Kevin Chase, the general surgical registrar, completing his examination.

‘Georgie, this looks like a neuro emergency,’ Kevin informed her. ‘She’s got a clinical left skull fracture, and very little else. ABCs were pretty good when she got here, but her GCS went off in front of my eyes when I was doing the primary survey, and she’s blown up her left pupil. They were equal when she first got here. Jane has intubated her, but she’s become bradycardic and hypotensive. I’m pretty sure she’s got an extradural.’

‘Dr Willoughby, if this is an extradural, you’re going to have to do something now,’ Jane said, looking stressed as the beeps on the ECG showed a slowing pulse, now down to 40. ‘She’ll arrest before we get her anywhere near Theatre, let alone CT.’

Georgie examined the patient, noting the boggy haematoma over the left scalp, the dilated left pupil, the hypotension and bradycardia. ‘Are you sure she’s not hypovolaemic, Kevin? Are there other injuries?’ she asked.

‘A bit of bruising, but nothing serious, Dr Willoughby. Like I said, she seems to have an isolated left head injury. The ambos said the car ran into a tree on her side.’

‘Georgie, if you can do anything here, you’d better do it now. Her pulse is 25 and no BP,’ Jane said.

‘Kevin, get Ben Blackwood on the phone, tell him what’s happening and ask him to come in straight away. Tell him I’m doing an emergency burr-hole in A and E. Drew, get your staff to bring the emergency neuro tray, gown and gloves.’ She turned to the hovering nurse and instructed, ‘Get me some gloves, goggles and a couple of razors to shave the scalp.’

Quickly Georgie turned the woman’s head to the right a little and shaved the left scalp. While nursing staff opened up the emergency neuro tray, she quickly gowned and gloved and injected 1 percent xylocaine with adrenaline into the scalp over the left parietal region. She then prepped the scalp with Betadine and used a section drape to isolate the area. She made a 5 cm incision over the scalp down to the periosteum and inserted a self-retaining retractor. She then took the hand-brace with attached skull bit and started drilling into bone at the site of the now visible skull fracture.

Georgie could feel her skin breaking out in fine beads of perspiration, her tension levels rocketing second by second as she concentrated on the boring. After two or three minutes the centre of the bit breached the inner layer of the skull. She continued to drill for a few more turns to enlarge the hole and then removed the brace. From the hole in the centre of the conical skull defect she had created, fresh arterial blood rapidly flowed out under pressure. She took bone nibblers and enlarged the burr-hole, from which at least 100 ml fresh blood emerged under pressure, slowing to a continuous ooze and revealing the depressed dura underneath.

‘You’ve certainly done something, Dr Willoughby,’ Jane said. ‘Her pulse has come up to 100 and her BP’s now recordable at least.’

Just then the emergency room doors burst open as Ben came in.

‘Dr Willoughby, what the hell’s going on in here? What the hell are you doing, drilling burr-holes in A and E?’ he asked.

Georgie refused to be put off by his overbearing manner. She had done what she had done in the best interests of keeping the patient alive, and so far her actions had worked. ‘She was about to arrest, Mr Blackwood,’ she said a little coolly. ‘She would never have survived a CAT scan or the transfer to Theatre.’

‘She’s right, Ben,’ Jane said. ‘Dr Willoughby had to do something there and then or we would have lost the patient. As it is, there’s been an instant rebound in her parameters. At least now you’ve got a live patient to take to Theatre, thanks to your registrar.’

Ben inspected the patient over Georgie’s shoulder, his body touching hers from behind. ‘It’s very uncommon to have to do burr-holes this urgently. But it looks like a good call in this case, Georgie,’ he said after a momentary pause. ‘That’s a decent-looking emergency burr-hole, too. Have you ever done one before?’

‘The first burr-hole I’ve done was in my first theatre list with you two days ago,’ Georgie replied, stepping away from the heat of his body.

‘Well done, then. That was not only a good call but a brave piece of rare emergency neurosurgery,’ he said. Turning to Jane, he asked, ‘How are her obs now, Jane?’

‘Pulse 100 and BP now 120 over 90. A vast improvement. Her left pupil has come down a bit, but it’s still dilated,’ Jane answered.

‘Georgie, you need to put a suction drain over the burr-hole and staple the scalp closed, get the wound dressed, and get a CT stat so we know what else we’re dealing with, then straight up to Theatre,’ Ben instructed.

‘Theatre’s ready—I called them half an hour ago—and CT has been cleared and is waiting for us,’ Georgie informed him, still glowing inside from his unexpected praise.

‘Well, then, there’s nothing left for me to do here. Seems you pretty well have things under control. I’ll go and get changed and come down to CT in fifteen minutes. When we take her to Theatre, I want you to do the decompressing flap and I’ll assist.’

Georgie opened her mouth to say she wasn’t ready to be the primary surgeon but he’d already pushed through the swing doors.

‘You’ll be fine,’ Jane said as she cleared away the used instruments. ‘You have to start somewhere, and you’ve done a good job so far.’

‘Thanks,’ Georgie said with a weak smile.