One of the true challenges of neurosurgical care is that
small details can have a big effect. In short, the central nervous system is
one of the least tolerant organ systems in the body to irritation, injury,
infection and other ill effects.
While I was training in general and then pediatric
neurosurgery, I was troubled that despite careful attention, very delicate and
important drains in the fluid spaces of the brain sometimes fell out. This
often happened at night, required an additional procedure to replace the drain,
and in the worst cases caused a temporary leak of cerebrospinal fluid (CSF) out
of the drain site, resulting in infection. In some cases, with small fluid
spaces, called ‘ventricles’, replacing the drain could also be tricky, and
involved a small but important amount of risk.
So, throughout my career, whenever I worked with a new
colleague (resident, fellow, or faculty member), I paid careful attention to
details of how they liked to secure their CSF drains. I asked questions. I made
notes.
When I started as the head of pediatric neurosurgery at
Doernbecher Children’s Hospital, I combined what I found to be the best tricks
and techniques into a very systematic way of stitching in CSF drains. I stuck
with it. I taught every one of our residents how to do it, and I insisted they
use my system. The method spread within our Department, but no further.
That was until 2011, when a senior and respected colleague
of mine wrote me an email from Africa. He was running a neurosurgical service
at a mission hospital in one of the poorest countries on earth. He had very
little nursing support. His drains fell out all the time. His nurse
practitioner had years before worked at Doernbecher. She mentioned to him that
our drains “never fell out”. He did not believe it, but he sent me the note.
I told my friend how I do it. A month later, he sent another
note. Not a single drain had fallen out. He insisted I describe the technique
as an official scientific report. Moreover, he recommended that I send it to
our top ranked journal. I wrote back to him complaining that this was just a
curious way of securing a drain stitch. I would be a laughing stock for trying
to publish a scientific paper on that. But my friend reminded me that
scientific papers are there to improve patient care, and that drains falling
out may not be fancy science, but are a real problem harming children literally
all over the world.
So Nathaniel Whitney, one of our terrific OHSU neurosurgery
residents, and I wrote the paper. With help from our world-class medical
illustrator, Andy Rekito, we included detailed diagrams showing how to do it.
To my surprise and delight, the Journal of Neurosurgery:Pediatrics accepted the
paper immediately. Here is the link:
My friend soon sent a wonderful congratulatory note, and
thanked me for following through. He deserves thanks for a suggestion that did
not occur to me, and for keeping a sharp eye as he always does on the welfare
of our patients and new ways to promote it.
A month later, I got another wonderful note about this project.
A friend and colleague in the Midwest, another pediatric neurosurgeon whom I
used to work with, saw his resident tying in a drain exactly as I do it. He
asked the resident who taught him that. “I just read it in the Journal of
Neurosurgery” was the answer.
Helping children in Oregon & SW Washington is
Doernbecher’s primary mission. By working with our colleagues around the world,
in this case from Africa to Minnesota, we also strive to advance the welfare of
all children.
This may be some of the least fancy academic work I have
ever done. In some ways though, I think it may turn out to be some of the most
impactful.
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