Use of telemedicine for an emergency craniotomy in a pediatric trauma.

THE CASE: In late March 2002 a private vehicle with 3 passengers was involved in a rollover accident on a highway in a small northern BC town. The vehicle occupants were transported to the nearest medical facility by the provincial ambulance service. The only passenger with significant injuries was a 10-year-old girl. She had an unclear history of loss of consciousness, was found to be “stable” overall, but had a significant scalp laceration and was “restless.” Despite a Glasgow Coma Scale (GCS) score of 15, a head CT scan was considered necessary, and arrangements were made to transfer the child to a facility with CT capability, which was about 1 hour away by road. En route, the patient experienced a profound decrease in consciousness, and she arrived in the emergency department with a GCS score of 3. Her blood pressure was 60/28 mm Hg, her pulse was 123 beats/min, and her pupils were fixed and dilated. Mechanical ventilation was started immediately, and the patient was given vigorous fluid resuscitation intravenously and sent for a head CT scan. An abdominal CT was not performed. The general surgeon on call, the only surgeon in this community, was immediately involved in her care. Upon viewing the CT, he activated the telemedicine pager, reached one of the emergency physicians on call at the Vancouver General Hospital and described the case. The consulting telemedicine emergency physician then contacted the neurosurgeon on call. Fortunately, the on-call neurosurgeon was in the Vancouver General Hospital’s emergency department seeing a patient. He came immediately to the telemedicine communication room, and real-time video contact was established with the general surgeon in the rural community. The CT scan was reviewed, and the neurosurgeon confirmed the diagnosis of an epidural hematoma. It was determined that the patient required an emergency craniotomy. The air travel time from the rural location to Vancouver — about 2 hours — made transport to the centre unfeasible. There is at least 1 centre with neurosurgery capabilities less than 1 hour away from the rural location, but a snowstorm had moved into the area and made any air travel and most road travel impossible. It was decided that an emergency craniotomy would be performed in the rural emergency department. The 2 cameras at the rural site were optimally positioned, and lighting was arranged while the patient was prepped and draped, all of which took less than 5 minutes. Under guidance from the consulting neurosurgeon, a frontotemporal craniectomy was performed, and the hematoma was identified and drained. Small vessels were tied off prophylactically, and no major bleeders were found. The surgeon at the rural site and the neurosurgeon in Vancouver were satisfied with the operation, and the wound was closed and dressed. There was no change in the status of the patient immediately after the procedure, with her pupils staying fixed and dilated and her systolic blood pressure now hovering in the 90–100 mm Hg range. The 3 physicians agreed that a conference including the patient’s family, the surgeon and the neurosurgeon would be useful. The family was brought into the emergency area at the rural site and were able to talk “directly” to the Vancouver neurosurgeon about the operation. The videoconferencing technology allowed visual and voice communication for all parties involved in the discussion. The patient remained in the local intensive care unit for the next several hours. No seizure activity occurred, and no anticonvulsants were used. Unfortunately, she had no recovery of central nervous system function overnight, with her pupils remaining fixed and dilated and a GCS score of 3. Arrangements were made for air transfer by fixed-wing aircraft to Vancouver as soon as the weather cleared. She arrived the next day, was pronounced brain dead by the critical care physician in conjunction with a neurologist and became a multiple organ donor. View of the patient’s head with scalp defect.