For thousands of years it occurred in the comfort of one’s own home, surrounded by cherished family members and employing principles of ancient wisdom. I’m talking, of course, about ancient brain surgery, known as trephination.
Primitive cranial trephining, the surgical opening of the skull performed with primitive tools and techniques, is one of the most fascinating surgical practices in human history. It probably started in the Neolithic at least 7000 years ago.
Remarkably, it is performed yet today in parts of Africa, South America, and Melanesia.
That’s why it makes perfect sense for the NHS to take pressure off hospitals by encouraging home brain surgery.
[pullquote align=”right” color=”#333333″]There’s an unholy alliance between the NHS, desperate to save money regardless of who dies as a result, and the Royal College of Midwives, desperate to increase autonomy regardless of who dies as a result.[/pullquote]
Wait, what? The NHS is not encouraging home brain surgery? It’s not encouraging it because too many lives, including men’s lives, would be put at risk by brain surgery at home even though that’s how brain surgery was done for most of human history?
Oh, right, the NHS plans to “take pressure off hospitals” by encouraging home birth! That way the only people who will die are women and babies. That makes much more sense and is in keeping with the long time practice of the NHS to save money on the backs and through the agony of women.
According to The Daily Mail:
Officials want to encourage expectant mothers to have their babies outside hospital, either in small, midwife-led units or their own homes.
One proposal under consideration would see women offered vouchers to pay for their own private midwife for a home birth, if it could not be arranged on the NHS.
It has been put forward as part of a major review of maternity services being overseen by NHS England which is expected to report back next year.
Officials want to drive up safety and improve the overall birthing experience amid concerns that some labour wards are very understaffed.
Apparently officials of the NHS feel that it is too expensive to let UK midwives kills babies in hospitals when they could kill them cheaply at home.
1. At Morecambe Bay:
Frontline staff were responsible for “inappropriate and unsafe care” and the response to potentially fatal incidents by the trust hierarchy was “grossly deficient, with repeated failure to investigate properly and learn lessons”.
Kirkup [the author of the report] said this “lethal mix” of factors had led to 20 instances of significant or major failures of care at Furness general hospital, associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.
“Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies.
Indeed:
The midwives at Furness general were so cavalier they became known as “the musketeers”.
Of note, officials at Morecambe Bay attempted to short circuit investigations of the deaths and only relentless pressure by parents of babies who died ultimately led to an investigation.
2. At Royal Oldham/Greater Manchester, 7 babies and 3 mothers died in the space of 8 months:
Seven babies and three mums have died in two Greater Manchester maternity units in the space of just eight months – sparking an independent investigation.
Bosses at Royal Oldham and North Manchester General Hospitals called in outside experts to review the departments in light of the 10 tragedies …
It is understood the deaths took place between December 2013 and July last year – with four babies and two mums dying at Oldham, and three babies and one mother dying at North Manchester.
Once again, the hospitals themselves failed to investigate the deaths until a midwife anonymously reported them to the newspaper:
One Royal Oldham Hospital midwife, who contacted us anonymously … said: “It’s worse here than Morecambe Bay. It’s really bad, there have been lots of problems. Babies have died unnecessarily.”
3. At Milton Keynes:
History is repeating itself with the deaths of FIVE more newborn babies following staff failures at the hospital maternity unit…
Milton Keynes has now seen at least eight such deaths in two separate periods over the last eight years.
The latest five deaths happened over eight months between 2013 and 2014…
Most of the deaths involved staff failing to recognise or act upon warning signs of foetal distress.
All the babies were full term and previously healthy, and in each case parents claim speedier medical intervention could have saved their lives.
This is the second spate of preventable perinatal deaths:
Between 2007 and 2010 three babies had died due to midwife and doctor failures – a situation slammed as “scandalous” by coroner Tom Osborne .
As a result a CQC task force was put into the unit for a year. But in July 2013 problems recurred when staff failed to act after an unborn baby girl developed an abnormal heartbeat during labour.
The child was born with asphyxia and died two days later.
In November the same year two baby boys died shortly after they were born 24 days apart. Once again, vital clues from their deteriorating heartbeats during labour had been ignored for too long.
In all three cases the hospital admitted liability and offered a settlement – of around £20,000. The parents all refused and are now launching legal action.
Two more babies died between November 2013 and March 2014. In each case the hospital has admitted the care was “not good enough.”.
Meanwhile there is a sixth case, involving a baby boy born in January this year. An inquest will shortly decide whether failures by the hospital contributed to his death.
That’s dozens of preventable perinatal and maternal deaths in just 3 hospital systems. It may be only the tip of the iceberg.
Why has this happened?
I suspect it is because of an unholy alliance between the NHS, which is desperate to save money regardless of who dies as a result, and the Royal College of Midwives, which is desperate to increase its autonomy regardless of who dies as a result.
And I am sad to say, it reeks of gender discrimination. The NHS is trying to save money on the backs of women. They are willing to deprive them of state of the art obstetric care by replacing obstetricians with midwives, by allowing midwives to practice without appropriate oversight, and, in promoting homebirth, by letting them practice with no oversight at all.
I haven’t seen the NHS propose outsourcing to the home of any aspect of male medical care. How about home prostatectomies, or home vasectomies? Each of those procedures is far less dangerous, and far less painful than childbirth … but those procedures involve men, and apparently, the NHS believes that they shouldn’t save money by letting men suffer.
You have to credit the NHS with one achievement, though. In a masterpiece of marketing the NHS plans to take life saving services away from women and babies and pretend that allowing preventable deaths is improving “choice.” The fact is that more than 95% of women DON’T want to give birth at home. They’ve had the option for many years and they’ve rejected it.
But women, their needs, their desires, their very lives, pale when weighed against the NHS desire to save money and the RCM desire to increase autonomy.
The only issue going forward is how many babies and women are going to die as a result.
A private midwife in my area costs over 8k without the home birth bit.
I love the way the photo at the head of this article has the lobes colour-coded for ease of the non-expert operator!
That will be a great cheat-sheet for my CPN exam.
OT: More Hannah
https://theconversation.com/explainer-vaginal-birth-after-caesarean-48328#comment_807497
So glad The Conversation survived the gutting it got in the last budget.
Thanks for sharing this.
Yep – and the comments remain a good place to debunk the ideology.
This could be the catalyst to sign up-I’ve thought about it in the past but have resisted.
Did you look at the VBAC education ‘material’? All pink (well, lilac) and pretty so not bothering too much with the hard figures…
Yep – did you see my reply? I’m all over it. TC is one of my favourite haunts on health topics.
I did-assumed that was you but didn’t want to ‘out’ you if you didn’t mention it first.
TC gives voice to people on a range of interesting topics that get passed by in more mainstream media.
I’m public enough now to be widely considered arrogant, narrow-minded and “blinded” by my training!
My comment:
“Perhaps Dr. Dahlen can explain to us how a mother bonds with a dead baby.
The primary reason for repeat C-section is to avoid the risk of uterine rupture and perinatal death. Women who choose repeat C-section often do so because they’d rather carry the risk of surgery rather than foisting the risk of uterine rupture and death on the baby. It seems to me that mothers who choose repeat C-section for that reason have already bonded with their baby in utero.”
We could just put a defibrillator on each street corner and do away with the cardiac units, too…
Or teach everyone CPR and close those useless ICU. ICU’s have the highest mortality rate of all hospital departments, obviously you will be safer at home.
There are defibrillators all over the place in Japan-not necessarily every street corner, but a lot.
We speculated on who would use them-my knowledge is zero but I’m guessing you could do some intentional or unintentional harm with those paddles if you could get them going.
Are they the paddles that have a voice guide?
Never looked closely at one, but now you mention it that would be good, since having to read the instructions as you go would probably not be very practical.
Though written or spoken, in Japanese, would be no use to me or whoever needed it. Strictly tourist and staying fed language skills at this stage!
And come to think of it, how would a passerby know who needed shocking? Shocking
random passed out people doesn’t sound like something likely to have a
uniformly positive outcome.
Do the defibrillators analyze the patient first? All my knowledge of their use comes from movies but I remember them saying, “Shock advised! Clear!” Obviously movies are a terrible source of medical advice, though, so who knows?
You mean I can’t be a doctor even though I’ve seen every episode of ER?
I hope for the sake of all concerned that I never find myself in a situation where I have to make a decision on AED use!
Seriously, you young’ns and your learning defibrillation from ER and House. PCMs, of course, learned their defibrillation skills from a real show: Emergency!
It also taught us to give IVs with D5W-TKO, but the most important lesson we learned was to transport as soon as possible. Oh, and that Dixie McCall and Joe Early were married in real life.
They do actually analyze, looking for a pulse first. What happens with most of those corner AEDs is that you stick one pad high on the chest and then just above the hip on the opposite side.
Then the machine checks for a pulse and if none is detected it will do the “Shock advised, stand clear!” Which basically means remove yourself from all contact with the patient.
I only know this because I have recently done a first aid course and they actually walked us through the use of an AED.
They’re designed with in-built, pretty clear instructions so laymen with absolutely zero medical training can use them.
So I’m ideally qualified as it turns out. Good to know.
And hopefully the ones in Japan have nice clear pictures…
Well, if The Business of Being Born makes you more qualified on obstetrics than an actual obstetrician, then a season or two of House or ER would qualify as an advanced medical course in a wide range of specialties.
Zap away! You’re now a certified professional emergency cardio-pneumo-neuro-ortho-psycho-gastro-optho-wife.
In general one pad is red, the other white. The pictures wil show ou where to place them, but it is white over red. Or as we remembered it, smoke rises over fire.
There are also AEDs in most Westfield shopping centers now.
I often lose the will to live at Westfields, if I stay too long-more than about 45 mins-so if an AED can fix the results of that…
All the better to empty your purse woth! Mwahahaha
We do have AEDs scattered about (restaurants, gyms, etc). But as a way of getting people to the cardiac unit, not as a replacement for cardiac units.
Yep. I have to be up-to-date on my first aid certification for a side job, and they always emphasize – if more than one person is present at the scene, at least one person should 911 for real help while the other(s) try to keep the person alive. If only one person is present, call 911 and _then_ try to keep the person alive.
Disgusting. And I can see that this proposal will be used as an argument by people in my country who peddle for homebirths to be paid by government, just like all hospital births. They use the NCB trope that it’s safer at home because women who are relaxed during labor never ever develop any problems and thus interventions won’t be necessary. Until this moment, there haven’t been any disasters in assisted homebirths (few unassisted HB deaths in this year, though, and it’s for a population roughly 2 million people) but it’s due to pure luck and strict risking out policies by homebirth midwives themselves (in our small country any deaths or severely adverse outcomes will get into news soon, and it will ruin the illusion of HB safety).
You know what’s gonna fun? When someone convinces American insurance companies that this is a reasonable cost saving measure.
My health insurance barely acknowledges my need for asthma medication. I shudder to think
I had my first in a freestanding birth center, covered by employer health insurance. My husband requested a review after the fact, and they were dropped, but still, they were covered. I think they were also a Medicare provider.
The liability insurers are unlikely to let the health insurers get away with it. And even the health insurers probably aren’t going to be too keen, since the healthcare costs for a birth-injured child are astronomical usually from day 1.
My state’s Medicaid program already pays for home birth or birth center birth with CPMs. The state midwifery association presented it as a cost saving mechanism.
What do the NHS obstetricians have to say about this malarkey? And is the NHS planning to force women to homebirth? If most of the women want a hospital birth, how is this suggestion going to make any difference anyway?
I’m not sure that most first time Mothers do want hospital births because of the way the NHS guardedly hands out information. Here we have a choice of a midwife led unit miles away from the nearest operating theater, the labour ward staffed by Obstetricians/Midwives, a midwife led unit attached to the hospital (literally about 10 feet from the labour ward) and home births and most women I know wanted either the MLU away from the hospital or home births. It’s not helped that unless you want an epidural, you have zero chance of getting on the Labour ward as “low risk” because of all the people being induced, augmented or “high risk”.
Not surprisingly I know a lot of women who have been transferred from birthing pools in the back of ambulances but because if you’re “low risk” you never see an obstetrician until either you hit 41 weeks or something goes pear-shaped so with your first child you only hear the community midwife perspective which goes something like ” Doctors are mean horrible people who want to ruin your experience, scar you for life and make you doubt in your own body’s ability”.
For example my son was born 81 hours after a premature rupture of the membranes and I didn’t meet an actual Doctor until hour 68 (By which time I was away with the fairies, running a temperature, dehydrated and briefly and very frighteningly seeing snakes.. and it got worse). At around 12 hours after my waters broke, a hospital midwife told me I’d be an ideal home birth candidate, despite this being my first time in labour, having a baby who wasn’t properly on the cervix and the sort of random contractions which caused my thigh muscles to spasm. I ignored her, luckily as it turned out given that my son was eventually born by emergency c-section because the combination of my pelvis and the fact that my husband’s family produce baby’s with big heads is not a match made in heaven.
Should I decide I want to do it all again… despite having a c-section scar, I probably wouldn’t see a Doctor until week 21 ish. They have to keep those nasty Doctors locked up and away from pregnant women you see.. in case they encourage you to have a c-section or proper pain relief because that all costs money.
That is absolutely horrible. The snakes alone (my worst fear, pretty much a phobia) would have me explaining firmly to my OB that we’d be doing a C-section at 38 weeks or the very first sign of labor, whichever came first. As to the rest…*shudder*
In England, are you required to try for a VBAC, or can you opt for one from the start if you’ve already had a CS?
I am so sorry you went through all that.
“Luckily” I was diagnosed with PTSD as I ended up with flashbacks to being raped on the operating table and they’ve very kindly agreed in principle to what ever I want (at the moment repeat c-section under general anesthetic) should I get pregnant again although before trying to conceive I want them to put it writing (because I used to work for the Government and I’m horribly horribly cynical).
Plus I’m helped by the fact that my son was only six pounds nine ounces albeit with a very big head but I keep forgetting to mention that last bit and the midwife who wrote up his stats has handwriting which looks like a series of ants were murdered on the page so hopefully no one else will bring it up either. I want my taxes back in the shape of lots of drugs and surgery.
NICE guidance is clear that you can have a repeat section if you don’t want to VBAC. I’ve never heard of anyone not being able to get a date agreed for their section, the problem can come if you go into labour before that.
I was told that I would be expected to make a vbac plan for a premature baby even if I got to the hospital in plenty of the time because I fully dilated last time and my pelvis shouldn’t present an issue to a smaller baby. I can understand that if you turn up with the baby pretty much falling out of you they have limited options but will not find that acceptable should I turn up only partially dilated.
The onus here though seems very much unless you can produce a concrete reason you will be strongly encouraged to try vbacing (call me a cynic if you wish but our hospital has low vbac stats and I can’t help but they are under pressure to increase them any way they can).
How is it you are qualified to make a vbac plan? Honestly this is insane behaviour on the part of your ‘carers’.
With “help” from midwives of course. Apparently it’s the PTSD talking and once I’ve completed therapy, I’ll want a vbac. Got to love being patronized…
I’m guessing that I know the answer to this question, but…I don’t suppose you’re allowed to fire the midwives?
As epically screwed-up as the US system is, one thing it does have going for it is the ability for most (albeit, sadly, not all) patients to be able to tell these sort of carers precisely what they can do to themselves before walking away from any chance of having to be seen by them again.
Fraid not. When I had my debrief with a Midwifery Manager she was very sympathetic and agreed that I had cause to be unhappy with the care I received but said she didn’t think anyone did anything off script apart from the hair stroking Doctors. Which is sad really because they’re the ones I don’t have an issue with because the midwives never mentioned the fact that I had been raped and didn’t like people touching me to them and according to my husband alarms were going off every couple of seconds in the OR, my blood pressure was doing “interesting” things, I had a rather high temperature, they knew I was worried about the baby and I guess they thought I needed reassuring. If I go for round two, going to make sure that if people want to reassure me that they know I respond better to words rather than touch.
They are willing albeit unhappily to refer me to another Trust if I insist though. However I would apparently need to sit down with Consultants and the peri-natal mental health team to ensure there isn’t anything they could try to make another experience “better”. When I explained that first they needed to deal with my concerns they would make repeat worse.. the room went quiet.
I think it’s the whole NHS though, everything seems a bit “wing and prayer” ish, my father is undergoing chemo at the moment and was sent home with a leaflet telling him to take paracetamol and come back if his temperature got above 38 degrees. Everything seemed fine, he kept taking the pain killers as advised until he collapsed and now he’s back in hospital having just had three litres of blood transfused, no white blood count to speak of and a temperature which without the paracetamol is spiking all over the place.
What a nightmare.
I had my kids in the UK, many long years ago, the midwives and doctors worked respectfully together, and all this kind of nonsense would never have happened. We had turn about gp and midwife for the entire pregnancy, with one ob visit about 30ish weeks and maybe 2 scans-very low risk, I was. The labour ward was as you describe, with midwives leading the care but the docs very much in evidence, popping their heads in the door regularly. It’s shocking to me that all that seems to have gone out the window.
I am so sorry you went through that and it’s great you are recovered so well. But that whole idea of going first to a birth centre-particularly for a first baby-is just ridiculous.
I think that is absolutely barking mad. If they are hell bent on pushing this sort of asinine behavior on the public, they should require all first time mothers to have a hospital birth so they know how things go. Or have some sort of screening for pelvic size and shape, estimated baby weight, placenta placement, etc. You know, try and account for some of the variables that can cause issues in a first time mom. If you have the first one in a hospital and there are no major issues, then you should be considered a good candidate for any subsequent home births. You should have to prove yourself a good candidate for home birth instead of it being the automatic default setting and everybody just assuming that you are a good candidate. And I think it should be required that there be sort of screening/testing/evaluation a couple of times during the pregnancy, and maybe an ultrasound, possibly two, before birth. One at 20-ish weeks and one closer to the due date to check for size, placement of baby ( breech, transverse, vertex, face up or down, etc) and nuchal cords.
If people are bound and determined to do the home birth thing, they should have to meet minimum screening standards to have that “privilege”. I don’t think that is unreasonable. Others, I’m sure would disagree, vehemently and violently,
“a hospital midwife told me I’d be an ideal home birth candidate, despite this being my first time in labour”
and yet – in the UK Birthplace Study, babies of first-timers at home had 3X mortality.
I have to admit my experience has left me questioning the point of Midwives even with the training they receive in the UK. When I had my PROM I phoned up the hospital and they didn’t want me to go in but I persisted because I wanted checked.
Then I had other such awesome examples of professional standards as walking into a room and being told I wasn’t in pain because I was sat on a birthing ball reading a craft magazine despite being actually stuck on the ball because with every contraction my thigh muscles gave up the ghost. Oh and being told that despite the fact that my waters had been broken for 67 hours, I wasn’t a high priority for the Labour ward and that it would probably be another 12-24 hours before I got a bed. (It wasn’t but only because I asked for my first exam since my waters broke because I felt my contractions had really sped up and much to their surprise I was 5cm dilated which for someone who apparently wasn’t in pain or in labour came as a bit of a shock to the midwife).
What annoys me the most about the whole experience though, not the flashbacks, not the fact that I was running a fever for a while or that I needed bags of saline pumping into me but that they let my son get to the stage that they admitted they thought his condition would be much much worse than it was when they finally got him out of me. It doesn’t matter that to everyone’s surprise he came out with apgar scores of 9… it’s the fact that they were so determined that I should have him naturally they pushed us both to the brink.
I won’t go into details of the Post-natal ward but I’m pretty sure the staff of the local budget hotel chain could have offered better “care” than most of the midwives on duty. Again I only saw one Doctor post-natally and that was after I had a major emotional and mental breakdown.
Thanks for sharing this. I am so sorry that happened to you.
Midwives claim to care for women but this lot seems to have missed the memo.
UK midwifery seems unrecognisable from what I experienced.
The postnatal ward was worse than bootcamp and most of the advice, such as you can use a bottle of RTF formula for 24 hours, was just wrong. You can use a bottle of rtf for 24 hours, but not if you are feeding it straight from the bottle. We were in for five days and they totally missed my baby wasn’t feeding at all and was heading towards serious dehydration.
I definitely liked the idea of MLU for my first. Visited both, it seemed a lot nicer than the CLU and it’s only down the corridor in the event of problems. Thought I’d labour at home for a bit, go to the MLU, and transfer for an epidural if I felt I needed one. Got the distinct impression that was what they wanted to hear from low risk women.
Of course, getting transferred purely for pain relief can be rather difficult, but this isn’t something that tends to get mentioned. As a system, that one wouldn’t be so bad if women could be assured of transfer if they wanted it. It doesn’t always work out that way, though. In the event, PROM meant I wasn’t allowed even to set foot in the MLU first time round.
So….. they are concerned that their maternity wards are understaffed and that this can be dangerous. So instead of staffing their maternity ward properly, they send people to birth at home?
Yup! To me, it sounds like an (any idea, really) floated by Mayor Quimby on the Simpsons – such a bad idea that you are amazed it ever passed the basic “are you nuts?” test.
It seems to me that any process will be more efficient when performed at a centralized location. Why on earth would childbirth be any different? It seems to me that the push to move people home is less about efficiency and more about people being annoyed that women are taking up resources.
Isn’t there supposed to be two midwives at a home birth? That means tying up two medical practitioners for up to a few days on one birth.
I have to imagine that the cost save comes into play when the birth progresses “too quickly” for the midwives to attend.
To be fair, if it lasts that long you’d be transferred. The reason the UK homebirth system has pretty good stats is because the women doing it are so very low risk compared to the general population. They do tend to send people into hospital at the first sign of enhanced risk, which is why primagravidas have something approaching a 50% transfer rate.
Even if all the staff working at these affected units are great and it was no fault of their own that babies & women were harmed, we know that NHS units are understaffed. Assigning more MWs to homebirths, which requires two MWs, won’t help.
I would also hazard a guess that it would place more stress on ambulance services. Who is more in need of an ambulance, you may ask? A woman who *chose to give birth at home knowing the risks and problems with understaffing*, or a bloke who has a heart attack through no doing of his own?
We also know that most people quote the Birthplace study about the safety of homebirth…well the women in that study were much differen than women getting homebirth services with significant risk factors, like HB with a history of 3 CS
http://www.onetoonemidwives.org/_stories/home-birth-after-three-c-sections
I’m a fan of Patrick O’Brian’s Aubrey-Maturin novels, Jack Aubrey being the captain of a ship, and Stephen Maturin being his ship’s surgeon/English intelligence asset/general all-around Smart Guy. Maturin won the awe of a number of the crew by actually doing brain surgery on the deck of a 19th-century ship with a carpenter’s drill. Back in that time and place, of course, that was the best they had to offer. You know, much like home birth.
On the bright side, both obstetrics and neurosurgery have improved since then. Furthermore, if you told Stephen Maturin that we could do all the amazing things that we can in either field, he’d be stunned into a rare and impressed silence.
While it’s true enough that most of the time, even back in the old days, babies were born just fine, when the crap hits the fan I want someone skilled in dealing with disasters to be right there with all the paraphernalia s/he needs. That and *I* don’t feel a need to experience more pain than necessary. An epidural is hardly likely to derange your thinking any more than being in that much pain would do. Plus, if you’re one of those oddballs like me and don’t get an oxytocin rush from bf’ing or exercising, you probably won’t get one from natural childbirth either.
Right. I don’t want an expert in normal birth at the birth of my kids. I want one who’s seen every variation of obstetrical WTF and who knows what to do about it without having to think twice.
It completely blows my mind that an epidural is considered a negative outcome. In my mind an epidural is the best possible outcome. Preferably administered somewhere in the seventh month.
I can see it as a proxy measure for extreme pain, but in other metrics, effective pain relief is considered a key measure of quality care.
Remarkably, it is performed yet today in parts of Africa, South America, and Melanesia.
And occasionally in the US and elsewhere in the “developed” world: If you’re out in the middle of nowhere with someone with a bad subdural hematoma, no help coming for hours, and you have a pocket knife, digging a hole in their skull is probably a better move than not doing so. (/things you probably didn’t want to hear.)
Sounds about right. Could sterilize that knife with some vodka, one of those weeny-size bottles.
Surely they wouldn’t need the whole pint… 😉
The extra is for the patient. 🙂
Or as my husband would say, “Cook’s prerogative.”
*hiccup*
That actually happened at my smal community ED this year. Acute head bleed in a kid. Neurosurgery NOT in house 24/7. ED doc was in Afghanistan and kicks ass, but even he had never done anything like that. It ended up being a bariatric surgeon (“any available surgeon the the peds ed stat!”) who did it. Saved the kids life!
I shit you not, I came across a few “Alternative medicine” practitioners who still use trephining. Complete with fools gullible enough to actually do it.
How would you know where to put the hole though? Somewhere near the injury/bump, if it’s visible (after a fall for example)? Or doesn’t it matter too much?
I’m not an expert on this, but I think that you would be guided by signs on neurological exam (such as blown pupils).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28750/ This article seems pretty relevant!
Yay! I’ve read about neurosurgery on the Internet and am now prepared to do my first trepanation!