A 4-month-old child was brought to the emergency department at 7 a.m. with active seizures for the past two hours, refusal to feed since the previous night, and decreased responsiveness for the last 4–5 hours. The child was immediately assessed by the on-duty emergency doctor, and the ICU team was informed. Given the patient’s critical condition, he was sedated and placed on a ventilator. On pupillary examination, the left pupil was dilated, suggesting an intracerebral bleed.
The ICU doctor called me to inform me about the patient’s condition. After reviewing the history and examination findings, I advised the team to send blood samples for laboratory analysis, reserve blood and blood products, administer antiepileptics and antiedema medications, and perform an urgent CT scan. I informed them that I would reach the hospital shortly.
I arrived at the ICU within 20 minutes. The child was sedated, the anterior fontanelle was bulging, and the left pupil remained dilated. The CT scan revealed a large blood clot in the left side of the brain. We called the parents to discuss the child’s condition and the treatment plan. I explained the critical nature of the situation and the necessity of surgical intervention to remove the blood clot, which would require temporarily removing the skull bone to allow the brain swelling to subside. I also detailed the risks, including the possibility of death, weakness on the right side, speech impairment, prolonged hospitalization, and other potential complications. The parents requested some time to discuss the matter privately.
After 10 minutes, they returned and informed me they were ready to proceed with the surgery. However, during that interval, we received the blood test results, which revealed severe abnormalities in clotting function as the cause of the brain hemorrhage. I informed the parents that we could not proceed with surgery that day due to the high risk of excessive bleeding, which could result in the child’s death on the operating table. I explained that the bleeding parameters needed to be corrected first. Clotting factors were transfused, and the blood abnormalities were addressed.
When the brain is injured, it is crucial to treat it promptly to prevent further damage. It took us two days to stabilize the child’s bleeding parameters. I spoke with the father again, reiterating the increased risks, including the possibility of death, even with surgery. However, the father remained resolute, insisting that we proceed. “The child has fought for two days,” he said. “You should do your part and hope for the best. Don’t worry about other things; I will take care of them.”
The child underwent decompressive craniectomy. The skull bone was removed, and the blood clot was successfully evacuated. The surgery was uneventful, with minimal blood loss. After the procedure, the child was transferred back to the ICU on ventilatory support. Over the next two days, the child showed signs of improvement and was eventually weaned off the ventilator. He began feeding through a nasogastric tube. A few days later, he was transferred to the ward, where physiotherapy was initiated.
During follow-up visits, the child appeared healthier and more active. A month later, the skull bone was replaced. However, due to poorly developed skull bones, there were concerns that the bone flap might not survive. The parents were counselled about the possibility of requiring a revision surgery with artificial material. Again, the father’s confidence shone through. “We have come so far and will face whatever comes ahead,” he said.
The revision surgery was performed, and the child had an uneventful hospital stay, being discharged after five days. During subsequent follow-ups, bone absorption was noted, but we opted for continued observation. Three months later, the child returned with signs of developing bone over the skull, good limb movements, normal feeding, and a cheerful demeanor.
This case highlights the complexities of managing critically ill patients, especially children. As surgeons, we consider all possible outcomes—both good and bad—and communicate them transparently to families. A doctor always strives for the best for their patients, understanding that their name and career are on the line. In this case, the father’s unwavering positivity and confidence inspired our team, boosting our morale and giving us the courage to push boundaries and achieve the best possible outcome.
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