During the first few hours following an injury you can seldom forecast what is going to happen to a patient with a head injury. If he has fixed dilated pupils and does not respond to any stimuli, his prognosis is not good. If he is alert, he is going to live. But between these two extremes anything can happen. Children, especially, can recover remarkably from seemingly severe trauma.
You will find yourself caring for the following kinds of patient. Some will be children. Some of the adults will also be drunk. A few will have open head injuries.
The patients who are conscious, or are rapidly becoming so, when you first see them (Patients A, and C, in Fig. 63-5) Although a patient may seem normal after a head injury, he may not be fully aware of what has happened, or be fit to drive a car. Subdural or extradural haemorrhage may occur later, so warn him and his relatives that he must return immediately, if he becomes drowsy or his headache gets worse.
The 2% of patients who are unconscious when you first see them, but who have had a lucid interval at some time since the accident. An example is Patient D in Fig. 63-5 who is particularly precious, and whose life you may be able to save. Patient F, who did not lose consciousness at the time of the accident, but who has lost it since, is especially precious. If you remove his clot, his brain will probably recover completely.
The patients who are unconscious when you first see them, and who have never been conscious since the accident. These patients are of three kinds. Patient B is comatose; he shows no signs of improvement and dies. Patient C is drowsy, or even comatose, but his coma is lightening and his trend is towards improvement. Carefully nursed, he will recover. Patient E is important: he is unconscious, but his unconsciousness is deepening. His trend is to get worse—operate on him.
MANJI One Christmas Day a missionary doctor was called 40 kilometres to see a patient who had been beaten over the head with an axe haft. By the time that the doctor arrived the patient had such a severe degree of cerebral compression that he appeared lifeless apart from his pulse. It seemed that each breath he took would be his last.
Unfortunately, the primitive operating theatre had collapsed, so the operation was done in a little laboratory barely 4 metres square, with unglazed windows and no runing water. Light was provided by an electric torch and some hurricane lamps. No anaesthesia was required, the patient was so limp, but after the removal of some bone and a large blod clot, he had to be held down to be sewn up. LESSON While there is life there is hope.