In the mid-1980s Alastair Coutts was the surgeon for the Solomon Islands. In 1999 he described one of his more interesting cases in an article published in the BMJ.

The story starts with a telegram he received from Dr Bob Eason (who if I remember correctly, taught me clinical physiology back in medical school):

Fifty five year old lady. Acute extradural haemorrhage. Ipsilateral pupil up. Unconscious flexor pain responses. Boggey haematoma over left middle meningeal area. Any chance you can come plus equipment to evacuate clot. Helena Goldie Hospital would refund fares.
Dr Bob Eason

An adventurous 400 mile trip from Honiara to Munda, and its landing strip with no lights, ended with Alastair jumping on the back of Bob’s moped as they sped to the hospital. This is what he found when he got there:

The patient was deeply unconscious and both pupils were dilated; she made extensor movements to pain with only her left arm and had a large swelling over the left side of her head as a result of being hit by a falling coconut. Her Glasgow coma score was about 4, but at least she had a clear airway and was breathing.

Scan or no scan, it didn’t take a brain surgeon to figure out what was going on: an extradural hemorrhage and a coning patient. First Bob got the consent:

No operation—100% chance of dying, operation—99% chance of dying.

The family deliberated for ages, then agreed to proceed with a craniectomy. The operation was swift.

As soon as the clot had been evacuated the patient woke up, tried to get off the table, and promptly hit her head on the lamp, exclaiming, “The Lord be praised.” She lay back and the previously quiescent middle meningeal artery started spurting everywhere.

The patient was no longer coning — she was bleeding to death. Bob grabbed four bystanders and bled them, assuring Alastair that everyone in Munda was O positive.

Under the flickering lamp with minimal equipment in a small wooden hut, Alastair simply could not stop the bleeding. His patient was going to die. Then he looked up and saw Jesus.

Opposite me was a large Roviana male nurse who was chewing gum… he announced his name was Jesus.

Coutts had to think fast:

“Jesus, please could I have some of your chewing gum?” “Of course,” he said reaching into his shorts pocket for a fresh stick. “No, not that stuff, the stuff in your mouth,” I retorted. Incredulously, he opened wide and handed me his gum. With thumb and forefinger I skillfully rammed it into the left foramen spinosum. The bleeding stopped.”

Bob administered the new antibiotics that had been recently donated from New Zealand. Six months later Alastair reviewed his patient:

“She had a minor right sided hand weakness but wanted the bone back in her head.”

Reference

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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