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

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

Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (2 of 4)

Monday, November 7, 2011

In the morning, I toured the hospital with some of the visiting doctors. The hospital is addressing the medical needs of a large urban area (Mbarara has about 150,000 people) and of the surrounding rural areas, despite limited resources. It is basically a collection of low-rise buildings connected by pathways. The wards were built around 1950 and look as if they were meant to accommodate no more than 20 patients each, but at least 50-60 patients occupied each ward, many of them on the floor. There is an “ICU” that consists of 2 beds, with 1 working ventilator. A handwritten sign outside the OB ward listed supplies that were out of stock – sterile gloves, morphine, IV needles, and disinfectant. Care is supposedly free, but because of shortages of drugs and supplies, family members are often sent into town to purchase these items. Although there is activity everywhere – doctors, nurses, and students moving from place to place – there seems to be a lack of formal routine. Doctors are not checking on patients, and nurses are not taking vitals, nor do they appear to have blood pressure cuffs or stethoscopes for doing so.

Family members actually provide a lot of the care. Families cook for the patients and wash their clothes and linens, and often end up being the ones to notify the sisters (nurses) if there is a problem. When someone is in the hospital, families often travel hundreds of kilometers to care for them, losing valuable income.

I also learned that most of the surgeries performed at the hospital are emergent, not elective. However, most take place during the day (before 2pm), as staff are not always available to do procedures at night. In fact, much of the anesthesia is provided by “anesthetic officers,” who are technicians with variable training.

Finally, courtesy of Dr. Stephen Ttendo, an anesthesiologist who is our main contact in Mbarara, we get a tour of the new hospital building, which is under construction and should be finished by next summer. It will have more modern ORs, an 8-bed ICU, a CT and other imaging technology, and a chemistry lab. This expansion is greatly needed, and long overdue, since the hospital is already serving as a national referral center. I can already see that it is going to be a huge challenge to address the obvious needs related to head trauma. Without reliable ICU care, a way to monitor patients who are at high risk, or a social infrastructure to assist with aftercare for brain-injured patients, a surgeon can do only so much. I hope that the new facility can begin to address some of these challenges.

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

Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (1 of 4)

Saturday, November 5, 2011

My main goal for the 10 days I will spend in Uganda is to help scale up head trauma capacity at Mbarara Regional Referral Hospital in Western Uganda. I have brought along a cranial drill and plan on training the general surgeons and residents in its use. In addition, I plan to look at how the hospital is managing head trauma, and help set up baseline data collection so we can track outcomes and measure the effects of interventions. Finally, I want to contribute to scaling up ICU care, since it is so crucial to caring for head trauma patients, and help establish future collaborations.

Other than a brief visit to Cape Town 8 years ago, this is my first trip to Africa. My first impression is that Uganda is a very young country. During the 5-hour drive from Kampala to Mbarara, I see a lot of kids, teenagers, and young people. Almost no one appears to be over 50. Kampala appears to be a hotbed of economic activity, with a proliferation of every imaginable type of small shop:  mobile phone kiosks, hair salons, bars, convenience stores, produce and meat stands, and furniture sellers. There are goats, chickens, and cows everywhere, often grazing alongside the road. People are carrying enormous loads of wood, water, produce, clothing, and even gas cans on their heads or shoulders, or on the backs of bodabodas (motorcycles) and bicycles. Many of the women also have a small child or two slung over their lower back or stomach. A lot of people are cooking food outdoors on wood or gas stoves.

Before coming here, I already knew that head trauma was a huge issue for developing countries. Here, I get firsthand glimpses of the road safety problem. The road to Mbarara is now officially “paved,” but it often changes to dirt or mud when going through populated areas, with potholes capable of popping off tires on cars or swallowing bodabodas. It is also narrow with almost no shoulder. Nevertheless, it has to be shared by cars and trucks, bodabodas, cyclists, pedestrians, and animals.

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

Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara, Uganda

(2 of 3)

It has been a busy week in Mbarara.  Much of the first day in town was spent with introductions, meeting clinical faculty at Mbarara Hospital and academic administrators at Mbarara University (MUST) who help coordinate post-graduate training and the relationship between MGH and MUST.  The short meetings made me not only feel welcome but also gave me a better idea of the structure of collaboration here.  It is nice to witness the outstanding relationship that has been established between MUST and MGH by dedicated individuals from both sides.

On the first day in clinic, starting around 8 AM, the line of patients had already stretched a good distance outside the one-room clinic that has handwritten letters "ENT" on the door.  Multiple patients are seen in different corners of the room at the same time by the resident, attending, and clinical officer.  There is a nurse who directs traffic, calling in new patients when a seat opens up, handing charts or referral notes to free clinicians, recording all patient visits in the master log, translating when necessary, and seeing to it treatment plans are completed.  Patients carry in their own medical records, records that consists of a soft notebook in which clinicians have documented past illnesses and treatment plans.  The majority of patients have no records.  

The clinic flow is steady and efficient.  On a small table in the center of the room sit an assortment of medical instruments that are constantly being reached for; sometimes the absence of something needed is quite noticeable to me but quickly improvised.  When the power goes out, the head-mirrors used to look in mouths, throats, and ears can no longer be used.  I'm glad I brought several battery-powered headlamps so that the exams can continue.  

Most of the patients present with problems I've seen before; hearing loss, cerumen impaction, ear pain, foreign bodies in the ears or nose, hoarseness, trouble swallowing, tonsillitis.  Several patients are seen with more complex, less common issues, like a new presentation of laryngeal tuberculosis and several advanced head and neck lesions/cancers not yet fully diagnosed.  When clinic ends, I'm am eager to find Internet access to do some reading.  I have no idea how I would treat a suspected enlarging nasal dermoid cyst in a 4-year-old seen that day (a cyst that has about a 30% chance of intracranial connection) without access to MRI or a CT-scan, tests that would normally be used to exclude or delineate this possible central nervous system connection prior to surgical removal.  I am told that there is a CT scanner in the capital city of Kampala, a 5-hour drive away, but no one I ask seems too sure of the cost or wait time for a scan.  I am certainly, and perhaps predictably, being challenged to think in different ways some of the time here.

When I look back at the past week, I feel very grateful to my Ugandan colleagues for allowing me the opportunity to work with them.  As a junior resident in otolaryngology, I find no shortage of learning opportunities in Mbarara.  I also see opportunities to build surgical capacity in several areas related to otolaryngology here and am beginning to brainstorm the creation a few small projects with the outstanding MUST resident.  I hope to touch on these projects the next time I write.  

Kyle Chambers, MD - PGY-2 Harvard Combined Program in Otolaryngology-Head & Neck Surgery

Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara (1 of 3)

As travel goes, the trip to Mbarara, Uganda, had a bit of everything. There was delay in Kigali due to an airplane crash on the Entebbe runway, failure of my hotel shuttle to pick me up (with several taxi drivers unexpectedly unwilling to take me), and the theft of some of my medical equipment out of my checked luggage somewhere in-transit. But there was also the stunning 5-hour drive from Entebbe to Mbarara and conversations with the driver about traditional medicine in Uganda, the role of foreign mzungu doctors, and the Ugandan soccer team that barely lost a birth to the Africa Cup by 1 point to rival Kenya. The drive also gave me a chance to take in the warm, visibly tropical environment of southern Unganda as we crossed the equator and catch a glimpse of Zebras as we passed close to Lake Mburo National Park.

I've arrived in Mbarara as an otolaryngology resident given the opportunity to spend 2 weeks learning about ENT Surgery in Uganda and also with hopes of exploring possible future research and educational collaborations with Mbarara Univerisity of Sciences and Technology (MUST) and the affiliated Mbarara Regional Referral Hospital. Mbarara is home to approximately 150,000 residents with 500,000 people in the surrounding area. Mbarara Hospital serves as a major referral hospital for all of southern Uganda with an even larger catchment of unknown numbers that at times includes patients from northern Rwanda, Tanzania, and the Congo. As a hospital, it offers two operative theaters, two-four ICU beds, multiple over-crowded adult wards (by most accounts), and roughly 6000-7000 pediatric admissions to the pediatric ward each year. There are currently plans in place to build/open a new hospital that will reportedly offer 8 ORs and greatly improve the capacity to accommodate the large inpatient volume, expected to be completed next year.

By the numbers, otolaryngology in Mbarara is easily considered a needed specialty. Mbarara Hospital has 1 staff otolaryngologist, who has been a different cuban otolaryngologist every 2 years for some time now. This makes the ratio of ENT surgeons to population in Mbarara is very similar to that of the national average in Uganda of 0.06 ENT surgeons per 100,000 people (based on a 2009 study), which is remarkably lower than the 1:100,000 ration in the UK and the approximately 3:100,000 ration in the US.
Over the past several years, however, MUST has been trying to alter this deficit in ENT surgeons by starting a residency program with the goal of training and retaining otolaryngologists to serve southern Uganda. There is currently one resident in her post-graduate year three of four years with hope of bringing in a second resident soon.

Having arrived in Mbarara, with this background in mind, I am very excited about the days ahead.

Kyle Chambers, MD - PGY-2
Harvard Combined Program in Otolaryngology-Head & Neck Surgery