Nurturing Neurosurgery with basics and compassion …Some thoughts
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.217972
Source of Support: None, Conflict of Interest: None
Neurosurgery is one of the most arduous of all the medical specialties. It mostly requires a close monitoring of the patients at the bedside by doctors and nurses, rather than performing this task remotely by using solely the electronic surveillence systems. Although the developments in the investigative, intensive care unit, and monitoring facilities have improved the care of neurosurgical patients over the years, the basic principles of their care and observation remain unchanged in the pre- and post-computed tomographic [CT]/magnetic resonance imaging [MRI] era. The outcome of these patients is highly dependent on a good clinical observation and their meticulous care.
Even though tremendous progress has been made over the years in the investigative facilities like the CT and the MRI scans, one should not underestimate the importance of history-taking and a proper and detailed clinical examination of a neurosurgical patient. Proper documentation should be carried out at the initial stage of the patient examination. Even today, an initial accurate neurological assessment is fundamental for the correct management of the patient. If baseline history and neurological examination are not properly undertaken then the clinical presentation may be wrongly interpreted later on. These processes help, to a large extent, in understanding the disease process, the course of the disease (whether progressive or remising) and its nature (acute, subacute or chronic). To some extent, the history and clinical examination of the patient help in analyzing the possible pathology of the disease processes as well. Many neurological illnesses can be diagnosed just by observing the patient. The patient's general mannerisms, mood, posture, gait, facial expressions and speech may all provide vital clues to the final diagnosis. A proper history and clinical examination are also helpful in the vital decision-making on whether to treat patient conservatively or by surgery. Therefore, one should not be under the erroneous impression that it is not necessary to retrieve the details of the patient's history and clinical examination in today's era, where a plethora of diagnostic facilities exist.,,,
In the management of neurosurgical patient, an important sign to observe is a changing consciousness level; and, this clinical feature cannot be accurately assessed by any modern instrument. When a conscious patient lapses into coma, the fact that something is wrong with him and the situation requires an urgent intervention, is fairly obvious; when an already unconscious patient worsens in his neurological status, the change is less striking and its recognition may be delayed unless regular monitoring of the conscious level, a sequential assessment of the focal neurological signs and a regular recording of the vital signs is undertaken. Although time consuming, changes in the patient's clinical condition may be identified early by a vigilant observer's frequent clinical assessment and regular monitoring of the patient's status.
A proper initial evaluation of the patient also helps to understand the basic nature of the disease process, involvement of the area, the cells, the tracts, and the location of the lesion. This may be substantiated by the CT/MRI findings; and, the entire sequence of examination and investigations may also help in providing prognostication of the disease to some extent.
The surgeon, along with his/her team members, should study the investigations at least a day before surgery, and plan the surgical approach, thinking of the likely problems that one is likely to encounter during surgery and of the ways required to tackle them. The alternative surgical approaches, if deemed necessary, may also be discussed in detail. It is very important for the surgeon to decide how much of the lesion to remove and when to stop surgery to ensure safety of the procedure.
Post M. Ch experience
After completion of an exhaustive training program, and having obtained a degree, one should spent some time under the tutelage of a senior faculty member, a process that helps in gaining further experience. This is the time when one can decide the subspecialty in which one wants to gain further experience and training, and the departments where the best facilities for obtaining this training are available. This is also the time when one should work in the experimental laboratory to acquire and enhance surgical skills.
Once a person starts feeling confident in working independently, he/she may have to work alone in a particular setup. In such a situation, while treating patients, sometimes, one may face a dilemma regarding the choice of the proper line of management with respect to the patient's illness. The young doctor may want a second opinion to reinforce his/her thoughts regarding the treatment to be offered to the patient. Therefore, it is better to be a part of a group practice instead of working alone. In a group practice, one can discuss the cases with one's colleagues, and help each other in the operative procedure and in establishing various management protocols.
Every member (including junior or senior faculty members, senior residents, nursing and paramedical staff) of the team is important for imparting patient care. The complete involvement of each member of the team is desirable for delivering an optimum level of care. The chief of the team should include all members of the team in the decision-making process regarding the patient and should always make an attempt to bind members of the team together. The observations and suggestions of various members of the team should be properly considered and discussed. A close observation of the patients by residents and the nursing staff is very important as these members of the team spend the maximum time with the patient. Their appropriate training is, therefore, desirable for the benefit of the patient.
Interaction with patients and their relatives
It is very essential to work ethically, honestly and sincerely. One should always explain to the patient and his/her relatives details regarding the disease, the present clinical condition, the available mode of treatment, the alternative procedures available and the most appropriate treatment under the given circumstances. The health care provider should always consider whether or not alternative procedures are available in that particular setup. If the patient or his/her relatives wish to go for an alternative procedure that is not available in the hospital, one should not hesitate to refer the patient to the appropriate center.
The patient and the relatives should be explained the patient's clinical condition from time to time and all their queries should be answered. In patients who are suffering from a serious clinical condition, the doctor may have to explain the patient's status to the relatives several times. This creates a trust between the doctor and the patient's relatives thereby reducing chances of dissatisfaction amongst family members.
It is also essential to explain the steps of surgery as well as the probability of developing post-operative deficits. One should never consider any neurosurgical procedure to be minor or without any problem. Occasionally, one may even have problems during a so-called simple procedure like a ventriculo-peritoneal shunt that may require one or more revisions.
Care of fine instruments and equipment
Any center is only as good and advanced as the properly functioning medical equipment and instrumentation that are present in it. Almost all neurosurgical procedures require fine and delicate instruments and expensive equipment. It is the cardinal duty of the surgeon to take good care of them. In fact, the instruments should be cleaned and packed under the close supervision of the surgeon himself.
Training of junior medical and nursing staff
It is the duty of the senior doctor and the leader of the team to properly and regularly train the junior doctors, nursing staff and technicians regarding the neurosurgical care of a patient as well as the care of the equipment and instruments in the operating rooms and wards. They should be taught how to closely observe and monitor the patient. Even the ward and operating room attendants should be taught the method of properly shifting and positioning of patients. All these maneuvers help in providing better medical care to our patients.
Whatever progress we make in developing facilities for patient care, there is no short-cut to the proper evaluation as well as observation of the patient. The advances in investigative facilities as well as monitoring equipment are only additive to the basic clinical management of the patient.