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

Thursday, November 10, 2011

Today I was finally able to demonstrate the drill to Gerald and the residents. Since there had been no appropriate cases during the week, we bought some fresh goat heads from the market and performed burr holes and craniotomies on them. Fortunately, the electricity cooperated. The residents had a great time learning to put the drill together, practicing with the different attachments, and working on the goat heads. Among other things, we discovered that a goat’s frontal bone is very thick under its horns! We also discussed basic head trauma management, and the residents showed an excellent grasp of the relevant anatomy, physiology, and critical care despite having few opportunities to practice it. I reviewed the technique of exploratory burr holes, which I have never actually performed – because CT and angiography have been widely available for so long, few if any practicing neurosurgeons in the US have performed this technique. The residents helped me get a sense of what they try to do for head trauma patients in the ER. Since imaging is not available, they rely on the history and exam. Any loss of consciousness warrants 24-hour observation. They use the Glasgow Coma Scale, vital signs, and pupillary asymmetry to decide whether to give mannitol (intermittently available in the ER) or explore. However, even at MGH, by the time a patient exhibits the classic Cushing response or “blows” a pupil, it may be too late. Also, once a patient is admitted to the ward, such monitoring no longer occurs. It is common for patients to come in with a GCS of 13 or 14, then suddenly decompensate and die on the ward – presumably because of a rapidly expanding epidural or subdural hematoma that could have been addressed if an accurate imaging diagnosis had been available.

Through this discussion, I gained a much better understanding of the situation in Mbarara. This urban hospital is caring for head trauma patients every day, and the doctors have an excellent knowledge base – but they lack the resources to effectively triage and monitor patients. My sense is that the primary obstacle is inadequate monitoring on the ward - ongoing assessment of mental status, hemodynamics, chemistries, etc. – things that we might expect to occur in an ICU or stepdown unit. Thus, scaling up ICU care in Mbarara might go a long way toward improving head trauma outcomes. It will also be crucially important to have a CT scanner in order to diagnose intracranial hemorrhage in patients who have not already decompensated. But even without imaging, ongoing assessment of clinical exam will help capture more patients who require neurosurgical intervention.

Although I was only in Mbarara for a short time, I plan to return in the next few months – and to establish ongoing collaboration between my department and the surgeons there. Since they are used to a high-cost, high-complexity system, neurosurgeons in the US often take a fatalistic attitude toward global health, believing they cannot possibly contribute. I hope to help demonstrate the opposite – that neurosurgeons can and should help build up local resources to care for head trauma patients, reducing its worldwide burden of death and disability.

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