Tuesday, December 6, 2011

Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (3 of 4)

Wednesday, November 8, 2011
We arrived on Tuesday morning only to find that the electricity had been out for several hours. The hospital has two ORs dedicated to obstetrics, and this area has its own generator. However, the two general surgery ORs do not have a generator, so all surgeries were being postponed. In the afternoon, I met Gerald Tumusiime, a general surgeon. We found him in the ER where he was in the process of admitting 6 surgical patients – about half the patients in the ER. Most of them were children, and most were ill enough for ICU admission had they been seen at MGH. The surgical problems included blunt abdominal trauma, appendiceal abscess, and a neck abscess in danger of causing airway obstruction. Gerald explained to us that there have been no potentially salvageable patients with severe head trauma this week.

Gerald has a work ethic that would embarrass the average American surgeon. He plans on getting all the surgeries done overnight, then a full day of teaching, patient care, and research – even though he gets no support for his research and only a small stipend for teaching.

On Wednesday morning, I met with Gerald, who amazingly had managed to operate on all the ER patients overnight, Paul Firth (MGH Anesthesiology), Mark Preston (MGH Urology/Oncology), and Dr. Lopez, a visiting Cuban general surgeon. We spent a couple of hours discussing both challenges and opportunities. Gerald has been compiling several sources of data to try to establish a baseline for tracking outcomes. There is an anesthesia case log tracking the surgical cases, indication, type of drugs used, and immediate outcome. This demonstrates the astonishing variety of surgical cases performed in Mbarara even in the absence of what we would consider adequate preop testing and imaging. Gerald has also been tracking all the ER and ward surgical cases with 14-day outcomes and mortalities, and has begun abstracting information on head trauma from this data. This is very difficult for him since there is no infrastructure to help with longer-term follow-up, and he has to do all the data entry in his limited spare time. So far, Gerald’s work has demonstrated that 35% of mortalities in surgical patients are due to head trauma – an astonishing fact. In addition, advanced presentations of metastatic cancers, particularly GI cancers, are very common, reflecting a lack of access to primary care and screening services.

The surgeons would like to have some administrative support to help with data collection. A longer-term need is laboratory, imaging, and pathology services to help them make an adequate and timely diagnosis, and thereby improve outcomes.

Considering neurotrauma, there is no CT scanner, invasive blood pressure monitoring, or protocol for expectant observation on the ward. So neurosurgery here is always exploratory, and is usually done as a last resort. Dr. Lopez explained the informal “Mbarara protocol” for head trauma, based on current guidelines and the unique resources of the hospital. It relies on neurologic exam, Glasgow Coma Scale, and vital signs to decide whether or not to explore. Unfortunately, by the time patients with rapidly expanding hematomas develop focal neurologic signs, they may not be salvageable even in a developed country with full OR/ICU resources, so this is discouraging. Many patients die shortly after surgery, and many die on the ward a few hours after being admitted. High spinal cord injury is almost invariably fatal because these patients need immediate ICU care and extensive long-term rehabilitation, which is not available here. However, this represents a huge opportunity for improvement. If we can direct some resources toward scaling up ICU care, we may be able to make a difference in the head trauma statistics.

In the afternoon, Mark and I met with Gerald again and lay the groundwork for future collaboration. Our goal is to establish a baseline for data collection and outcomes tracking. The more we talk to Gerald, the more we admire what he is able to accomplish with what we would consider very limited resources. We learned that part of what it means to be a doctor here is to be able to advocate for yourself and your patients to government officials and force them to live up to their responsibilities to provide those resources – a daunting task.

Anna R. Terry, MD, MPH
PGY-5, MGH Department of Neurosurgery

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