ER doc, rescue celebrated; Drilled hole in patients’ head with Power tool

I’m late to this story, but as I Googled around it hadn’t gotten much press, so it might be news to you, too.
Idaho Mountain Express : ER doc, rescue celebrated: Improv procedure saves the day

St. Alphonsus Life Flight paramedics Tammye Erdmann and Blaine Patterson first met Ben King on Dec. 5, 2003, as he was dying on a stretcher in a church parking lot in Shoshone.

The next time they saw him was Friday, April 23, at a reception at St. Luke’s Wood River Medical Center in Ketchum. The event was organized by the hospital to recognize Dr. Kieth Sivertson, St. Luke’s emergency department director, and the extensive medical effort that went into saving King’s life.

King was suffering an inner-cranial [sic] bleed caused by the trauma of falling down a flight of stairs in their Hailey home. Despite the heroic efforts of his wife Melissa, who found him, and hospital staff, King needed a neurosurgeon. The nearest at the time was in Boise.

Standing around the stretcher in Shoshone, the medical personnel were preparing Melissa King for the worst. Then Sivertson decided to take a drastic measure: He relieved the pressure on King’s brain by drilling a hole in his skull with a Makita drill, a power tool found on most construction sites.

“It sounds like an outrageous cowboy move,” Sivertson said. “But, it was a calculated risk. We will risk a lot to save a life.”

“Idaho is one of the last places you can find (where) you’re entitled to do yourself harm,” he said, explaining that medical attention, especially emergency medical help can not reach victims here as quickly as it might in a large city. “If you’re counting on getting a second chance, forget it. You don’t get to choose how you die. You get a chance to choose how you live. Your life can change just that quickly,” he said, snapping his fingers.

Sivertson said, for example, if a person who is allergic to bees gets stung at the blinking light at the intersection of State Highway 75 and U.S. 20. and has a systemic reaction, he or she will die. Emergency services would not be able to get that person to a hospital in time.

As part of the reception, Makita T-shirts were exchanged, and Sivertson received a Makita drill with a plaque attached to the box for his efforts. …

In addition to a Makita T-shirt with autographs of everyone who contributed to saving King’s life, Sivertson also gave the survivor a Makita baseball cap with a bull’s eye by the temple for any future emergencies.

“I owe my life to everybody here,” King said, including his wife, the first person he saw when he awoke. “I owe my life to you. I feel fantastic.”

First off, the patient is alive, so this is a win! I don’t know enough of the circumstances to know if this was “an outrageous, cowboy move”, but clearly it worked.

I have never, and really pray I never need to, perform an emergency burr hole to relieve the pressure on a brain; this was a bold move, and Dr. Sivertson is to be commended for cool thinking and the fortitude to act.

During my training we had one of those ‘around the desk’ educational chats about emergent burrholes, and it went “three fingers above the ear, two or three fingers in front of that, and make a hole on the side of the first pupil that blows“. (This seems backwards from what you’d expect: pressure on one side of the brain should shove it away, causing the opposite side pupil to blow when the nerves gets compressed on the tentorium, you’re thinking, as did I; however, we’d be wrong. The pressure is causing an uncal herniation syndrome that starts to compress the nerves on the side nearest the lesion first; the opposite pupil dialates as a very late finding).

The article is very oddly written, and it’s not clear whether this patient was being transferred from a hospital to another when this happened (which I think is the case), or whether this was a prehospital move. If it was an interhospital transfer, Dr. Sivertson may have had a CT scan to show the hematoma, but maybe not. I’ll try to find out more.

In the mean time, here’s an article entitled, appropriately enough “The occasional burr hole“. I like their #1 under the procedure heading:

You need:
(1) A sense of historical proportion. Drilling a hole in the head is just the boring (sorry) start to most neurosurgical days. Trephination was practised safely in the Stone Age. So relax.

I wouldn’t be very relaxed, but that’s just me.

hat tip: LizDitz


Comments

  1. One of our resident lectures last year (lectures given by the residents) was about emergnecy burr holes. After a nice slide presentation about the history & precedent’s for Emergency Room docs performing burr holes prior to transfer (happened in Montana, I think), he left the room & came back with a picnic cooler & a large unweildy duffle bag. The bag had drills of all sorts. Hand drills, power drills, burr hole drills & an neursurg OR drill. The cooler had…you guessed it…pig skulls!

  2. John Schedler says:

    Read the book they made the movie “MASH” from. Duke uses a chisel to make a whole in a cranium of a soldier w/ a head injury. Afterwards he comments: ” He may live — even if all I did was hit him in the head with an ax.”

    When I was in college, I worked in an ER in Seattle. A pt came in from some some remote place with head trauma. Some doc had done much the same.

  3. The article was oddly written because it was from the local paper and expected the readers to be familiar with the geography and letters.

    To translate: the injury happened about 6-10 miles south of the hospital, to which Ben King was transported. The SOP for severe injury/illness is helicopter transport (“Life Flight”) to Boise or Salt Lake City (depending on the patient’s illness/condition). I think it is about 80 air miles from the hospital to Boise. Shoshone is about 50 miles south of Ketchum. I’m not sure why or how Dr. Sivertson met up with the ambulance in Shoshone, but he could have been driving back from Twin Falls and got the call…

    The night of the injury the weather was truly bad, with poor visibility, blowing snow, ice on the roads. As you know, ambulances are poor vehicles for such adverse conditions…and I think even flying from Shoshone had a pretty high pucker factor under those conditions.

    So was it a cowboy move? Well, it sounded like the choices for the patient and the flight crew weren’t good in any direction.

    The other part of the deal is that they got the local law enforcement to uhm, open the hardware store without a key, to obtain an unused drill… I can’t find the article that had that little detail in it.

  4. Anonymous says:

    The pupil may dilate ipsi or contra to the mass lesion: when contra, it’s known as Kernahan’s sign, a false localizing sign. More commonly ipsi, so without head imaging, knowing it’s a gamble, go ipsilateral. .

  5. Or go bilateral. Recommended without imaging.

  6. Even more update. I was in Ketchum with a pal, she banged up her shoulder skiing, so off we went to the ER. Who should be the physician on duty but the good Dr. Sivertson. It was a sunny March day, so ER load was light, so we got a chance to chat.

    He cannot afford to live close to his ER — the S. homestead is about 40 miles south of the hospital, which is why he met the life-flight group in Shoshone. He didn’t want to talk much about the Makita incident though, we talked more about what happens when a geographically compressed area (like the north end of Blaine County) becomes so expensive that support staff (including physicians) can’t afford to live in the region.