Comment

Intubation offers new hope in treatment of brain trauma

Australia and Germany both pride themselves on their medical care but head injuries are approached differently in each country. What can be learnt from this?

Nicholas Stuart

It's incredibly difficult for a journalist to make "intubation" sound even marginally interesting, let alone to pretend it's fascinating enough to weave an entire column around. It's even more problematic once you know what it actually involves: inserting a tube into a part of the body (for example the trachea, or windpipe) to remove pressure or open an airway. This is the sort of thing we can normally leave, quite confidently, to doctors. That's fine. They're professionals. They do the best job of dealing with traumatic head injuries, whether as a result of a falling horse or a car crash.

Accept, however, that between 5 and 10 per cent more patients might survive similar injuries in countries that automatically intubate head injury casualties, and you might want to ask if the specialists have thought of etching this particular procedure on to their agenda. The medicos aren't ignoring best practice; it's something far simpler. We're trained to think inside the box. Sometimes, however, if we want a real breakthrough, it's worth reinterrogating our fundamental assumptions (even about things we think we "know" for sure).

Could routine intubation improve the recovery rates in brain trauma cases?
Could routine intubation improve the recovery rates in brain trauma cases? Photo: Michele Mossop

So, let's start at the beginning. Quite sensibly, doctors don't normally act unless there's a need: any intervention risks something going tragically wrong. That is why, in Britain for example, intubation is normally restricted to the most dangerous cases, where a failure to act will almost certainly result in death. But, as you'd suspect, because the procedure is reserved for the most serious patients, survival statistics aren't particularly brilliant. As a result, intubation has become a technique of last resort, restricted to the most dire cases.

Surprisingly, though, this isn't the case in Germany. Somehow or another, that country eventually came to adopt a very different standard operating procedure. A doctor is sent as a first responder (by helicopter) to where the patient had their injury. Secondly, every casualty is intubated as a matter of course. And so, bit by bit, utterly dissimilar techniques have come to be adopted as standard to deal with head injuries.

It could almost have been a planned controlled trial, except, of course, it wasn't. In fact, nobody even noticed the difference – until recently.

That was because a major technical company began focusing on and collecting information about this first stage of treatment. It was interested in introducing a new treatment and was hopeful a successful trial would provide firm back-up demonstrating the efficacy of its technique. In fact, however, the reverse occurred and the study was brought to an abrupt conclusion.

The only problem was there are important findings involved in the results. One of the researchers involved is convinced intubation does have a significant effect in keeping patients alive and that the early research was already proving there were dramatically different results between the jurisdictions, based simply on the background data.

Think about how important this is. If the assumption is correct, it means that releasing pressure on the brain at an early stage of the injury could have a massively significant effect on recovery rates. The findings were suggesting that adopting this method could result in a dramatic, 5 per cent, across-the-board improvement in the rate of recovery.

The difficulty is, of course, the findings haven't been made public, for obvious reasons. They represent an intellectual property investment by a medical company that has no desire to divulge what it's attempting to achieve. The results are also circumstantial, rather than conclusive. And this is the problem with knowledge. It's sticky.

Although there's a plethora of information around, something special needs to happen to translate understanding into knowledge. Recognising that an event is occurring isn't the same thing as acting on that information.

Creating change is about actively changing society – something that is far more difficult than just carrying on down the same path. These connections don't necessarily occur simply because someone has kept pushing steadily down a familiar route; it's often what appears to be a side detour that offers a new breakthrough, because an old problem has been suddenly seen in a different way.

As alert readers will be aware, I'm fortunate enough to be travelling through Europe at the moment. That's how I found out about the intubation study. Obviously, it hasn't yet been published and so the only way I found out about it was when someone in the know offered to discuss what they believe are the critical findings.

Physical contact encourages trust that cannot be brokered electronically; speaking allows the sort of unfocused chat that can lead from one revelation to another. The internet is a blunt, unfocused way of curating knowledge. The reality is that we will continue to require human contact to really progress our understanding.

I've been lucky enough to receive a Churchill Fellowship, which has given me the opportunity to investigate the different ways we treat brain injury. Hopefully, I might be able to bring some of this knowledge back to Canberra. What's really terrific is that this scholarship isn't about (directly) extending your own skills: the idea is very firmly focused on the community. It's about creating change and making a difference in your local area.

I'm still finding out more detail of the intubation study and if it might offer any insights to us. However, the initial indications are positive. People who know far more than I ever will say the hypothesis seems to stack up: the critical questions and issues lie elsewhere (resources, training and cost). It will take a long time to work through, but imagine if a life could be saved ...

Nicholas Stuart is a Canberra writer.