When I was in Afghanistan in 2010 I served as an intensivist at two different combat support hospitals (CSHs) – one was in Kandahar (Kandahar Air Field), the other in Helmand, Province (Camp Dwyer). Both CSHs had modern ICU capabilities, but only the CSH at KAF had a neurosurgeon. We cared for military and civilian patients with traumatic brain injury (TBI).
At both locations my fellow intensivist had been trained in neurocritical care at Johns Hopkins. I recall his having a conversation with the neurosurgeon at KAF, a well-respected physician from the United Kingdom, about the value of intra-cranial pressure (ICP) monitoring. The neurointensivist had more confidence in its value, based on experience and existing guidelines (J of Neurotrauma 2007; 24: S1-106), than did the neurosurgeon.
A recent randomized controlled trial (RCT) cast doubt on the need for invasive ICP monitoring (N Engl J Med 2012; 367:2471-81). For patients with severe TBI, a South American group achieved equal outcomes whether the trigger for intervention was monitored ICP > 20 mm Hg or changes to exam and/or CT scan. An accompanying editorial discussed the study limitations (N Engl J Med 367;26: 2539-2541), and my buddy from neurocritical care pointed out that the clinical and radiographic management group received more hypertonic saline and mild-hyperventilation (pCO2 30-35 mm Hg). Still, the results are provocative.
While at the CSH in Helmand we were forced to manage many Afghan military and civilian casualties without neurosurgical support. I was fortunate to have a neurointensivist with me who could pull this off using methods similar to those described in the NEJM trial. Otherwise, I was terrified to practice without a monitor. Maybe this terror was unfounded. In light of the recent NEJM trial, perhaps the neurosurgeon from the UK had been right to express skepticism about invasive ICP monitoring. It wouldn’t be the first time advice from an expert, based on extensive hands-on experience, proved more valuable than guidelines.