Learning to place an external ventricular drain (EVD) has long been considered a rite of passage for those training to become neurosurgeons. Although I have placed many EVDs in my career, I can still recall placing my first one as an intern. Before me in the emergency department lay a moribund patient with a large ventricular hemorrhage from a ruptured intracranial aneurysm. My nervousness translated to ice-cold fingers that felt unable to perform the procedure correctly and made me think I was not moving fast enough. My ears rang with the hum of monitors, alarms, the ventilator, and the medical staff around me talking. My mind raced as I reviewed the steps of the procedure and the equipment checklist.
At this point, a crowd of onlookers had gathered in the emergency department. Nursing students and battle-hardened critical care nurses alike had congregated to watch the neurosurgeon “save the patient’s life.” For many, this experience would be the closest that they would ever come to seeing what we do as neurosurgeons in such a dramatic fashion. With so many eyes upon me, I wondered if they realized that I felt like an imposter. This person who had been sent to save the patient had minimal experience and practically no idea of what he was doing. Could they not see my hesitation and my every blunder?
As I made the first cut, blood gushed from the scalp feeders. This incision, which I had been taught was more than sufficient for the entire procedure, seemed grossly inadequate because the pool of briskly flowing blood offered no glimpse of the underlying bone. Two gauze pads later and with no progress yet in controlling the bleeding, I felt the eyes of the onlookers burning into my forehead while a cold sweat enveloped me. Despite the bleeding, I decided to press forward with the drilling.
To this day, the push-pull routine of the drill feels unnatural. It requires all the strength in your hands, yet must be gentle enough at just the right moment so that you do not plunge into the underlying brain. The “release” of the drill as the inner cortex opened was my first small victory in what seemed to be an eternity since the procedure had started.
After the dura was opened and placement of the EVD began, the moment of truth arrived. For the first time in my life, I felt the parting of brain tissue at the tip of the drain. The resistance from the density of the white matter and the wall of the ventricle engendered self-doubt that I had completed an accurate trajectory. Was I just blindly wandering around in this patient’s brain? But I summoned the fortitude to press forward, never more in tune with the pads of my fingers, until I felt the unmistakable “pop”—the ultimate victory. Blood-tinged cerebrospinal fluid began emanating from the end of the drain. Without a word, everyone watching understood that the procedure had been successful.
The EVD bedside procedure, like the placement of the lumbar drain (LD), is one of the most frequently performed procedures conducted by neurosurgeons and neurosurgery residents, often in life-saving circumstances. Having performed more than 100 of these procedures myself, I believe that placing these two types of drains is also the most common point of contact between neurosurgeons and the practitioners of other medical specialties. Many of the neurosurgeon’s daily interactions with other members of the medical team involve troubleshooting and managing EVDs and LDs.
This book is intended to be the definitive manual for the placement and management of both types of drains. In its chapters, my coauthors and I enumerate the planning and procedure stages for each drain and then examine the problems that arise and how to troubleshoot them. Relevant examples from our training, experience, and background are provided to enhance the lessons we aim to teach.
Our goal is not to remove neurosurgeons from the equation and allow other members of the medical team to place and manage EVDs and LDs independently but instead to convey the rationale of their management. Therefore, this book is intended for more than junior neurosurgery residents who are just learning how to place these drains. It has also been written for emergency, critical care, interventional radiology, anesthesia, and neurology residents, fellows, advanced practice providers, and attendings, as well as for critical care nurses, transport medics, and medical students who may be assisting with patient care.
The three of us hope you will both enjoy and learn from this book. We welcome your feedback on how to improve its content in later editions.