New Place, New Neurosurgery Needs

Today marks just over five weeks in Uganda. After spending nearly four weeks in Kampala at Mulago National Referral Hospital and taking the weekend to go on safari, this past Monday, I arrived in Mbarara, the second of three sites I will visit here. Mbarara is about four hours to the west of the capital city of Kampala, and far more rural. I am staying with the kind family of my research assistant and you can see here I’m living on top of a hill surrounded by banana trees and gorgeous views—fieldwork can be awesome.

My first week here has already revealed substantial neurosurgical needs at the Mbarara Regional Referral Hospital, but they are actually quite different from the ones I saw in Mulago. At Mbarara, the hospital had a renovation a few years ago that included a brand new building and beautiful facilities for the ICU and the Operating Theater. The ICU includes eight fully equipped rooms with isolation capability and each room has A/C and a sink for infection control.

The operating theater includes eight large rooms with all the supportive infrastructure one could ask for. They actually look very similar to an operating room in the US; the new building has equipped this hospital well for exciting potential.

But appearances can be deceiving. Although the physical space is there, Mbarara suffers from serious equipment difficulties. For example, the ICU has NO WORKING VENTILATORS. Anyone in the medical field with surgical experience can understand just how imperative it is to have the ability to support patients post-operatively with ventilators, especially neurosurgical patients.

The hospital used to have at least four working vents, at least ten working ESUs (electrosurgical units), and many more suction machines. Now, the operating theater has just one working suction machine and just one working ESU. I understand not all of us reading this are surgeons (myself included) but most surgeries cannot be safely conducted without these two machines. Neurosurgeries are particularly dependent on these, as I mentioned a few weeks ago—the brain bleeds quite a lot and the loss of blood will be substantial without an ESU to stop the bleeding. In part due to this lack of equipment, and in part due to a shortage of staff resources, only four of the eight available operating rooms are used. Each room will prepare their patients and continue to the point that they need the suction or ESU to continue, and then wait for the other room to bring it over, causing both delays in the surgery and risk to the patient, but there is no other option.

Another issue at Mbarara is the use of the CT scanner. It has been inoperable for nearly a year, and the hospital is waiting on an $80,000 (USD) replacement part. I’m not sure, but I think they will be waiting for quite some time. While this scanner has been broken, when patients need surgery, they are sent to local private clinics where they will need to pay for the CT scan if they have the money. Without a scan, the surgeon is basically flying blind and frequently will not want to put the patient at risk in that way. Take an emergency case of traumatic brain injury (TBI), for example. These are so common in Uganda due to the high use of boda-bodas (motorcycles that commonly have as many as four people on them) without helmets. Police will find a TBI victim roadside, pick them up and take them to the hospital, but the patient will not have family around them to help coordinate their care. As I mentioned a few weeks ago, it is not nurses and hospital staff that coordinate patient care in Uganda, but rather the family members that act as their attendants that will fetch their drugs, take them for testing, pay for imaging, etc. So when the emergency patient arrives at the hospital and has no attendants and the CT scanner is not operable, there is also no one to take them for an outside CT scan at a private clinic (and no one to pay for it). Without this, the doctors must wait for symptoms to manifest in order to have a clue where to open the patient up; but at this point, once symptoms manifest, it is frequently too late to intervene and save the patient. They are lost waiting for their CT scan.

So why is the equipment situation at Mbarara in such dire shape? They have no biomeds on staff. These are people like myself (my bachelor’s degree is in biomedical engineering) that are trained on medical equipment that can perform preventive maintenance as well as troubleshoot and attempt to fix this sophisticated equipment. Of course this is what brought my interest to global health in the first place—recognizing the need for biomedical experts in low-resource settings. It is what my undergraduate professor (Dr. Robert Malkin) in Duke’s Developing World Healthcare Technologies Lab (DHT) has dedicated his life’s work to. And here you can see the need for his investment. The ventilators have not worked for over two months and there is no hope for repair any time soon. The same is true of the many ESUs and suction machines that are stacked on shelves and in corners waiting for attention and repair.

Probably what is the most disturbing about this need at Mbarara is that there is no promise for change any time soon. Everyone on staff acknowledges this lack of biomed staff as a problem, but no one is aware of any change in the works to hire someone local with expertise on medical equipment. So during this time, if you have an emergency like a road traffic injury at Mbarara … I pray for you. I hope you have enough money and someone around to take you to get your CT scan, or that you have enough time to travel the four-hour journey to Mulago Hospital where the resources are a bit more and better affordable. Of course that is part of the purpose of this research that I am conducting now: to put into scientific evidence the needs and barriers to patient care in the surgical setting, in hopes that it gives enough justification to make a change. I am concerned for how long this transition will take, but along with the medical staff at Mbarara, I am hopeful.

Things I learned this week:

1. Mbarara is beautiful and less congested than Kampala (read: much more my style).
2. The hospital has beautiful facilities based on a recent renovation, but many of them are underutilized based on equipment and staff shortages.
3. The equipment situation in Mbarara is dire and there is no promise of change any time soon without a biomed on staff.