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t m c » p u l s e | o c t o b e r 2 0 1 7 23 23 Askenasy called a friend who's a neu- rosurgeon and told him the scenario. His friend said, "You go, buddy. You've got to do it." He also went back downstairs and deliberated again with Vierling and the attending physician, Stephen Hecht, M.D. They wanted to make sure they could give the patient the best possible care under next-to-impossible circumstances. "After an hour, we finally got the last call from CMOC, who said the Coast Guard cannot fly in these wind conditions, that it would be dangerous to land," Philip said. "CMOC did say they could get a heli- copter in the following morning. We said, okay. Next? What do we do now?" By this point, the patient was in decline. He had grown nauseous and had started throwing up, signs of a neurologi- cal deficit. It was time to talk to the patient's family, most of whom were assembled in the hospital. Askenasy, who is Colombian, communicated with the Hispanic- American family in Spanish. He told them in straightforward terms what they were facing. Under ideal circum- stances, he explained, the patient would be transferred to a facility equipped for neurosurgery. Since that was impossible, they were left with two choices: wait and hope for transport, or proceed with sur- gery to remove the blood clots and relieve the pressure in the patient's brain. "I'm a very direct person," Askenasy said. "Families deserve honesty. I told them I am not a neurosurgeon and that apart from very extreme circumstances, I would never consider doing this surgery." The patient's family responded: "Are you good?" Askenasy chuckled at the memory. He reiterated to the family: "I think I can do this, but I am not a neurosurgeon." The family asked: "Can you give us some time?" Askenasy gave them 10 minutes, then returned. The family told him to go ahead with the surgery, that they believed this was the right decision. The OR team prepped and intubated the patient, shaving and sterilizing the area of his head that was protruding, which took close to 30 minutes. Then, Askenasy prayed. "I'm a person of faith," he said. "In a situation like this, I pray. Absolutely I pray. God give me wisdom, understanding, peace and clarity of mind to help this gentleman. And it wasn't just me. It was everybody—this was a total team effort." • • • The surgery began around midnight and lasted close to two hours. Throughout the drilling, Askenasy had to be very careful not to disrupt the brain. Ordinarily, instruments for this type of procedure include a drill that stops automatically when it bores through the bone. The drill Askenasy was using had no such feature, so he had to proceed slowly, stopping to make sure he wasn't going too far. After drilling the four burr holes and sawing lines between them, Askenasy had some trouble wedging an instrument under the scalp to pop out the mass of bone. He called his neurosurgeon buddy who recommended that he make the burr holes larger. That worked. "We were able to remove part of the skull and visualize the clots on the brain," Askenasy said. "We were able to remove the clot that was compressing his brain as well as the one in one of the lobes. We closed his scalp and placed the bone flap we removed in his abdominal tissue—that goes with him and doesn't get lost in a freezer somewhere." Members of the OR team said one of the clots was huge—the size of a fist. • • • Elsewhere, another piece of the drama was unfolding. Midway through the surgery, the Coast Guard called LBJ Hospital to say they could collect the patient within the next few hours. Vierling ran upstairs and asked the OR team if the patient would be stable enough to transfer. The team said yes. Then, hospital staff had to find a place for the helicopter to land. Ordinarily, Memorial Hermann Life Flight and other choppers land in front of the hospital, but that was impossible because the area was underwater. "We had a couple of our guys that are military who went out and found an area in the physician parking lot where the helicopter could land," Philip said. "There were three cars parked there, though, and no one knew who they belonged to. We took pictures of the license plates and asked the Houston Police Department to help us find who owned these cars and where they worked in the facility. Ultimately, they were all able to move their cars." Once the surgery was complete, the patient was taken to ICU. Askenasy showed the post-op team how to take care of him, then went back to the call room, turned on his PlayStation 4, and reflected on what had just happened. "Without Dr. Askenasy, we don't know what we would have done," Philip said. "There's no other general surgeon who would have been able to do what he did. Without the surgery, if the patient had not died he would have been brain damaged, absolutely." And the child that the patient had gone out to rescue in the first place? He was found, safe, and was waiting anxiously with the rest of the family at LBJ to learn the fate of his loved one. Nearly two hours after the surgery, an LBJ staffer went out in the rain with a basic flashlight to help guide the Coast Guard to the improvised landing area in the physician parking lot. Within a matter of minutes, the chopper lifted off with the patient on board, bound for Memorial Hermann Hospital. Today, the patient is doing well. "My understanding is that he's fine," Askenasy said. "He woke up, asked to go home and was discharged within a few days." • • • One week after the surprise craniot- omy, Askenasy took the entire OR team out to eat at Pappasitos. A week after that he headed out to Guatemala for mission work with a group called Faith in Practice. "We will typically perform 80 to 100 surgeries the week we are there," he said. Mission work helps Askenasy think on his feet, a quality that came in handy during the craniotomy. "In the field, you have to think outside the box," he said. "We have so many lux- uries in the U.S., but you can provide well for patients with much less." Askenasy also believes that no one's life experiences are accidental. "I did two extra years of medical train- ing because of my time in neurosurgery," he said. "Sometimes you don't get to see the reason you've gone through what you've gone through. But I did." — Maggie Galehouse The craniotomy team at LBJ: Kevin Ibarra (anesthesia tech), Renee Crooks (OR RN), Jorge Iniguez (PACU RN), David Roife (MD, general surgeon resident), Denisse Salas (surgical tech), Ashley Acosta (OR RN), Alberto Cortez (OR RN). Credit: Facing page and right: Courtesy photos S T O R I E S