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t m c » p u l s e | o c t o b e r 2 0 1 7 22 The Craniotomy Crew In a life-or-death situation, a general surgeon performed brain surgery H eading into work at Lyndon B. Johnson Hospital on Friday, Aug. 25, Erik Askenasy knew he wouldn't be leaving anytime soon. "I packed a duffel bag," said Askenasy, 37, a general and colorectal surgeon who spent five days riding out Tropical Storm Harvey at the northeast Houston hospital. During that time, LBJ became an island. Surrounded by five feet of water, it also succumbed to the same punishing winds that the rest of the area endured. And smack in the middle of the epic storm, a worst-case scenario unfolded. Askenasy and other members of the ride- out team—staffers assigned to ride out the storm at work—were called on to perform a surgery that the hospital is not set up to do, that Askenasy and the operating room team were not prepared to do, and for which there were no designated tools or instruments. A craniotomy—brain surgery. LBJ is a Level III trauma center, which provides comprehensive medical and surgical services with the exception of neurosurgical care. In other words, they don't do brain surgery. • • • Around 8 p.m., a middle-aged man arrived at the hospital on the back of a dump truck with a large bump protruding from his head. "The story that we had received from his family was that a son or grandson had gone missing in the middle of the flood and he went out on an ATV to go look for him," said Merry Philip, administrative director of nursing at LBJ's emergency center. "During the time he was out, he hit something and got a head injury. As soon as he got here, we started doing our scans and we found out he had a subdural hematoma." Time to activate the trauma team. Askenasy, a trained trauma surgeon, examined the patient's scans. "I saw he had a significant bleed in his brain, as well as a large bleed between his brain and his skull," said Askenasy, a UTHealth assistant professor. "Normally, we'd send this guy to Ben Taub Hospital or Memorial Hermann, both Level I trauma centers. But no one could get in by ground or air." The hospital was eerily quiet at this point. Although the storm raged outside, the flood of people who were hurt or displaced had not yet begun to arrive. As Askenasy hurried to talk to the patient, he had a sneaking feeling he might need to operate to relieve the pressure building inside the man's head. He started to play out the scenario in his mind. "I run in and talk to the dude," Askenasy recalled. "I can tell he's altered. He's confused, searching for words. He's not there." Askenasy called Tien Ko, M.D., chief of surgery and chief of staff at the hospital, and said: "I don't see how we'll be able to get this man to Hermann." Ko, in turn, communicated with Alan Vierling, exec- utive vice president and administrator of LBJ Hospital, who was on site, and got him up to speed on the situation. Meanwhile, hospital staff did what they always do in cases like this: hustled to find a way to get the patient to a Level I trauma center. "We called CMOC [Catastrophic Medical Operation Center] and said we have a patient who is critically ill; we need to get him out," Philip said. At the same time, Askenasy went upstairs to the operating room and spoke to the nurses. "We may have to do a craniotomy," he told them. "I need to find some instruments.'" "Dr. Askenasy explained step by step what he was going to do and that really helped," said Alberto Cortez, an OR nurse clinician and the charge nurse. "He was really calm, too," said Ashley Acosta, an OR nurse clini- cian. "He made us feel really comfort- able, because we had never done this. We all talked about what we needed and kind of ran around to get supplies. We asked Dr. Askenasy what tools we should use, and the anesthesia faculty gave me a number to a neurology nurse at Memorial Hermann to ask about what we needed. Most of the stuff we didn't have because we don't do neuro, so we kind of just had to improvise." Cortez found drill bits used by ear, nose and throat surgeons that would work to bore burr holes into the patient's skull. The team also got their hands on a Gigli saw—a flexible wire saw used to cut bones—that would allow Askenasy to per- form the surgery he had planned: Imagine a game of connect-the-dots, except the dots are burr holes and instead of drawing a line between them, a surgeon cuts the bone between them. Once that's done, a piece of the skull can be removed. "The bone pops off and you're staring at the brain," Askenasy said. • • • A busy general and colorectal surgeon, Askenasy spends three days a week at UTHealth and two at LBJ. He operates on Mondays at LBJ, and on Fridays he typically sees patients in clinic. Twelve years ago, though, he began his medical career in neurosurgery. "I was at Baylor for two years in the neurosurgical program and then I decided I enjoyed general surgery because there was more opportunity to do mission work," Askenasy said. During those two years at Baylor College of Medicine, however, he did have some surgical responsibilities. "As a resident, I was assisting and taking part in surgeries," Askenasy said, "but I had an attending with me in the room. I was never unsupervised." He had been present for craniot- omies, but he had never been the person in charge. And the last time he'd been involved in any type of neurosurgery was a decade ago. • • • Askenasy and the OR team waited to hear if they were headed to surgery or if there was any way to trans- port the patient. Essentially, hospital personnel were planning for two potential situations at once, waiting for definitive word on which way it would go. Erik Askenasy, M.D. W H E N H A R V E Y H I T