Date of Medical Observation
April 2008

A 45-year-old  male sustained a severe closed head injury  secondary to vehicular accident. He was referred to our institution  by Calamba Medical center.

Patient arrived at the referring hospital with a GCS of 15/15 where immediate ct scan was done and initially interpreted as epidural hematoma on the left temporal area.  During his 12-hr hospital stay, his GCS declined to 10 and was then intubated.  This deteriorating condition prompted referral to our institution.

Upon arrival at OMMC TRAUMA-ER, patient's GCS was 10/15.  I reviewed the CT scan plates and  found no epidural hematoma but instead a huge subgaleal hematoma and a diffuse cerebral edema. His neurological presentation was also consistent with diffuse cerebral injury as manifested by signs and symptoms of an increased intracranial pressure. There were no lateralizing signs noted.

I explained to the relatives the condition of their patient. My plan then was to conservatively control the increasing ICP. In approximately 8 hours after admission patient's GCS markedly fell down to 4,  He had anisocoric pupils and kausmaul's breathing.

 Relatives were primed with the patient’s condition but they were very aggressive in pushing that an operation be done no matter how great the risks were. 

Since my initial assessment was only  a diffused  cerebral edema, I moved that patient be subjected to craniectomy.  However, As I relay my evaluation to my neuro-consultant he told me that a localized lesion may be present as manifested by anisocoric pupil despite its  absence on the CT scan. We then formulated our plan and  agreed to subject the patient to an emergency operation. 

During the OR, as I was burring holes on the cranium, blood was found flowing out the holes. This confirmed my consultant’s suspicion. there was an accumulation of epidural hematoma on his left temporal area. Cranial CT may have been done earlier than the development of the hematoma  that is why it was not seen on the plates.

The operation went well. We were able to evacuate approximately 3 tablespoons of clotted blood.

Patient is now on the 6^th post operative day showing signs of improvement. We are waiting and hoping for his full recovery.

INSIGHT

n  Physical, Ethical, Psycho-social

n  Discovery, Stimulus, Re-inforcement

We have been taught by our mentors the what, why and how of patient’s  management process.  Little by little we gain knowledge, we acquire skills. Everyday indeed is a learning experience.

A few words from the experience of our consultants or senior residents, is worth a month of reading books.

For us to make the right decisions for these life changing choices, we must take into account to get information on our options and consult a person with experience and knowledgeable in the field. 

The prognosis of this patient was grim even at the start. However we are doctors expected to do our duties. We do not wait for patient to die in front of us. However we must train hard to be able to save one.

 This story taught me another lesson.