As a new medical director, I thought to myself, “What is the worst that could happen at our rural, 12-bed ED?” The scenarios we all know came to mind: pericardiocentesis, thoracotomy, lateral canthotomy, resuscitative endovascular balloon occlusion of the aorta, and skull trephination (burr hole). At our monthly departmental meetings, we reviewed all of these procedures so we would be ready. I ordered the necessary kits so we would have the tools on-site. Our hospital had never even had a skull trephination kit before. The one I ordered arrived the day before a 2-year-old patient arrived at triage.
A 2-year-old male was brought to the emergency department by his mother after falling out of a shopping cart seat and striking his head. He initially appeared well and was running around the triage room. After a period of observation, he became increasingly somnolent, and on repeat exam, his pupils were slightly unequal. A head CT revealed a large epidural hematoma with midline shift. His pupils quickly became significantly worse at 6 mm and 2 mm, and he became unresponsive. I intubated him and called the nearest pediatric trauma center (one hour away) to begin arranging for helicopter transport. During the conversation with the trauma surgeon at the major academic center, I told him I was planning on doing an emergent burr hole. He said, “I’ve never done one of those—it’s up to you.”
I had seen one of these in residency and went to the supply room to find the newly arrived burr hole kit, took a deep breath, then started to prepare for the procedure by reviewing the CT.