R.D. Kasumov, E.D. Lebedev, S.A. Kravtsova
(Polenov Research Neurosurgical Institute, Saint Petersburg)
Saint Petersburg has a large number of beds for neurosurgical patients (2.5 per 10000 men), which is two times higher, than an average index, typical of Russia (1.01 beds per 10000 men). Despite this fact, casualties with craniocerebral trauma (CCT) are often admitted to other and first of all traumatologic departments. Every year about 25-30% of such patients are brought to medical establishments, having no neurosurgical departments. Among them one can mention hospitals N 1, 15, 28, 33 (Kolpino), N 36 (Kronshtadt), N 38 (Pushkin), N 40 (Sestroretsk) and medical-sanitary units of different enterprises. Some of these hospitals have some neurosurgical beds in traumatologic departments (N 15, N 37, children’s hospitals N 1 and N 2) and permanent neurosurgeons, working during day-light hours only. Primary examination of patients with CCT should be carried out by doctors on duty during the first hour of their admission. All necessary diagnostic examinations (including CT and MRI), making primary diagnosis and decision on expediency of surgical intervention are the problems, which should be solved during the first three hours. According to existing indications, patients with CCT trauma are immediately sent to a surgical block or to a resuscitation department or an intensive care unit, where they are followed up by experts in resuscitation, neurosurgeons and other specialists. In case of necessity casualties with CCT, admitted to non-specialized medical establishments without neurosurgical departments, are examined by a consulting neurosurgeon from the Polenov Research Neurosurgical Institute, hospital N 17 or children’s hospital N 19. Some of examined patients are transferred to neurosurgical departments for further treatment, others are subject to life-saving operations just on the spot. The rest undergo recommended conservative treatment. According to data of the Bureau of Medical Statistics, there were 2952 patients, operated in neurosurgical departments of Saint Petersburg in 2000; 591 cases died. Thus, the rate of average postoperative mortality in the city was 20%. As for traumatologic departments, consulting neurosurgeons performed intracranial operations in 229 patients; 89 of them died. The rate of average postoperative mortality was 38%, i.e. 2 times higher in comparison with neurosurgical departments. The rate of postoperative mortality in some traumatologic departments varied from 64.7% (hospital N 33) up to 71.4% (hospital N 37). It is explained by absence of permanent neurosurgeons and neuroresuscitation wards in them. Doctors of general resuscitation departments lack profound knowledge in the field of neuroresuscitation. Besides, one more important factor is absence of neuroanesthesiologists in these hospitals. Casualties with minor CCT (minor concussions and contusions of the brain) are often admitted to therapeutic (neurological, etc.) departments. For example, in hospital N 26 such patients can be admitted to an allergologic department because of absence of free beds in a neurosurgical one. Use of expensive neurosurgical beds is often irrational from the economic point of view, as patients with brain concussion account for 70% of all cases in some neurosurgical departments (hospital N 3). Absence of twenty-four-hour mode of CT and MRI operation has a negative effect on quality of diagnosis and treatment of cases with CCT. The results of our study make it possible to think, that improvement of timely and qualified medical care of casualties with CCT demands carrying out the following measures:
1. Patients with severe CCT are to be admitted only to expert neurosurgical departments of the city, which are equipped with CT and MRI, operating 24 hours, and have specialists, who can use these technical devices skillfully.
2. Cases with severe CCT are to be transported in ambulances with teams, consisting of experts in resuscitation and surgeons.
3. Casualties with minor brain concussions and contusions are to be admitted to special departments, created for such patients, or to neurological departments of multi-field hospitals, which have neurosurgical units.
4. The results of treatment of patients with CCT, obtained in the Polenov Research Neurosurgical Institute during the last 10 years, demonstrate necessity of creating specialized wards of intensive care in neurotraumatologic departments.
5. A number of hospitals, which admit patients with CCT but have no conditions for rendering timely and effective medical care, should be reduced.
6. Hospitalization of patients with severe CCT should not be based on the principle of the nearest hospital; it especially concerns those situation, when there are well-equipped ambulances with teams, consisting of experts in resuscitation and surgeons.
7. In our opinion, it is more expedient to use a differentiated approach, while admitting casualties with CCT to municipal hospitals. Patients should be distributed among the main hospitals (N 1, N 3, N 16, N 17, N 26) on the basis of a character of craniocerebral trauma (associated or isolated injury). Science-and-practice assistance in treatment of such patients should be a responsibility of the Polenov Research Neurosurgical Institute, Dzhanelidze Research Institute of Emergency Care and Medicomilitary Academy.