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AANS Neurosurgeon | Volume 28, Number 2, 2019

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Neurosurgery in Tanzania: Lessons Learned from a Recent Graduate

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As part of a global neurosurgery fellowship, I recently spent six months at the Muhimbili Orthopaedic Institute (MOI) in Dar es Salaam, Tanzania. My goal was to build on the infrastructure established by former fellows (Andreas Leidinger, MD; Maria Santos, MD; and Albert Lazaro, MD)3,6 and faculty, (Roger Härtl, MD, FAANS)1-2,5,7 to implement a spine trauma protocol that reduced the time to surgical intervention. Along the way, I learned many lessons and ultimately was able to have a meaningful impact. 

This fellowship was sponsored by Dr. Härtl and the Weill Cornell Department of Neurosurgery. MOI is a major neurosurgical referral center in East Africa and one of the few centers in the region that routinely performs spinal stabilization procedures. Previously, the median time from admission to the OR for spine trauma patients was 23 days.4 Although the reasons for delay were multifactorial, the primary impediment was financial, as patients were forced to pay for cost-prohibitive screws. This delayed surgical treatment. Working with the local neurosurgeons, orthopaedic surgeons, anesthesiologists, nurses, technicians and hospital administration, as well as armed with a generous grant of implants from Depuy-Synthes, we were able to significantly reduce this delay. The result is a time to surgery average of 2.5 days (all patients,) and 1.8 days (incomplete spinal cord injury patients). These early, promising results could only be accomplished through a persistent, sustained effort from many individuals, most notably the local Tanzanian neurosurgeons who welcomed me, recognized the importance of our spine trauma protocol and treated me as one of their own.

The six months spent in a low-middle income country (LMIC) were, in many ways, the most formative of my neurosurgical training. Below are some of the most impactful lessons I learned during my time in Tanzania that I believe are relevant to any neurosurgeon with an interest in global neurosurgery.

Figure 1A-E. (A) operating team during O-C fusion; (B) (left to right) junior residents Denis, Albert, Silvery and Juliet; (C) closed traction; (D) OR team; (E) (left to right) outgoing and incoming chief residents, John Mbwambo and Alpha Kinghomella.

Assuming Multiple Roles

During spine trauma cases, I would:

  • Get to the theatre early;
  • Set up the bed;
  • Grab necessary sheets;
  • Find enough tape;
  • Secure the Mayfield for posterior cervical fusions; and
  • Make sure the entire room was prepared for an efficient operation.

Compared to what I had become accustomed to during my residency, where the surgeon works with an experienced OR team, a new level of investment was required. One key component of this role was to involve a junior resident in the setup process, making sure they learned the nuances of room preparation. Equally important was preparation of spinal implants. Before every case, I would think through what screws were definitely needed and what screws we might need as a backup plan, often without a CT/MRI to measure pedicles and lateral masses. Having wires/cables available also proved useful. However, a new variable to consider was the need to judiciously conserve implants. For bilateral cervical facet dislocations, I would have always preferred to fuse longer, yet almost never did, to save screws for future patients. While stabilizing more levels might allow for a more robust construct, was that worth the tradeoff of not being able to use these implants on another patient?

One of the most important details was making sure we had enough set screws, often the limiting piece of equipment. And I learned from my mistakes. While doing an occipitocervical stabilization on a patient with a fracture, the case proceeded uneventfully with enough lateral mass screws, set screws and an occipital plate. However, after instrumentation was complete, what did I realize was missing? The unique set screw to secure the rods to the occipital plate. With the help of a visiting medical student, tray after tray was opened in search of the smaller set screw, to no avail. We were forced to exchange the occipital plate for rods with occipital fixation at the proximal ends. Every step, no matter how small, had to be rigorously thought through prior to incision to optimize outcome.

Flexibility without Compromising Care

I learned how to handle missing, overused or broken instruments, without options for replacement. I would ensure we had a backup plan if certain instruments were not available. Such is the reality of operating in a limited-resource setting, something the Tanzanian surgeons know well. I also learned (the hard way) to recognize which operations required certain instruments in order to ensure patient safety. For example, for every anterior cervical surgery, at least a 2 mm Kerrison was critical. For any posterior cervical case, a 2.8 mm sharp tap was needed. While flexibility and adjustments were routinely required, some requirements were non-negotiable. The task of communicating these explicit instrument needs in a multilingual setting also brought challenges.

Resourcefulness

Instrument trays in a resource-limited setting are often missing the most commonly used screws and plates. Within a few weeks of my arrival, I realized the perfectly fitting titanium cage or cervical plate were rarely, if at all, going to be available. Examples of newfound techniques – things I had never done in my seven years of residency – were numerous. With no appropriately fitting cervical cage, we routinely used tricortical iliac crest autograft to fill cervical corpectomy defects (Figure 2A-D). CT or MR imaging would sometimes take days to complete due to cost, closing the window for neurologic improvement. So we often went to the OR with x-rays only. During a cervical corpectomy, one of my colleagues asked for a rod cutter. Why on earth would we need a rod cutter during a cervical corpectomy? We only had >22mm screws, far too large for the vertebral bodies of the 16-year-old boy we were operating on, so we cut the anterior cervical screws with a rod cutter to make them bicortical (Figure 3A-D). Learning to be resourceful and deferring to those with more experience functioning in this environment was routine.

Figure 1C-D. (C) Cervical corpectomy defect with (D) tricortical iliac crest autograft in place.

Figure 2C-D. (C) Cervical corpectomy defect with (D) tricortical iliac crest autograft in place.

Figure 1A-B. (A) Incision over right anterior iliac crest in preparation for C5 corpectomy and (B) tricortical iliac crest autograft.

Figure 2A-B. (A) Incision over right anterior iliac crest in preparation for C5 corpectomy and (B) tricortical iliac crest autograft.

Figure 2A-D. (A) C5 fracture; (B) using rod cutter to shorten anterior cervical screws; (C-D) postoperative lateral and AP x-rays.

Figure 3A-D. (A) C5 fracture; (B) using rod cutter to shorten anterior cervical screws; (C-D) postoperative lateral and AP x-rays.

Gaining New Colleagues

Hands down, the best part of my experience was meeting and working with the Tanzanian neurosurgeons who are some of the most ambitious, practical, resilient, selfless and team-oriented surgeons I have operated alongside. Tanzanian people are positive, upbeat, friendly, warm and welcoming at all times, always treating each other with respect; this was inspiring. During challenging moments, their sense of calm set a new personal bar for me on how to stay even-keeled at all times in the OR (Figure 1A-E).

Embracing the Complexities of a New System

With fewer resources comes a slower pace and this slower pace leaves time for reflection. The more I compared all aspects of the two medical systems – OR environment, surgical resources, structure of training, hospital infrastructure and the concept of work ethic – I was left more confused than when I started. One example is the schedule of residency. In the U.S., most residents get to the hospital between 4 am and 5 am to start rounds, but that is usually after a relatively convenient commute. What if the commute to work involved three packed buses that are unreliable and can take more than two hours? What if roads were closed due to incessant rains? Also, how do you round without a patient list or knowing where the patients are? One quickly sees how simple comparisons breakdown.

Another example is the concept of “work ethic,” the principle that hard work is intrinsically virtuous or worthy of reward. Having the right work ethic is intrinsic to success in the U.S., but that definition is predicated on us having a warm, comfortable house or apartment, with water, electricity, internet and a safe place for our loved ones. What if that secure home is not available? How does that change how we approach a day’s work? What do we look forward to at the end the day? Grappling with these questions lead only to more questioning, an appreciation for the unknown and a retreat from any snap judgments.

Practicing neurosurgery in a resource-limited setting is not for everyone, but if you are on the fence or have even an ounce of interest, I would encourage all trainees and recent graduates to step out of their comfort zone and go for it. The chance to work abroad only gets harder as one’s career progresses. You will be challenged and rewarded in ways you did not previously imagine. Dr. Härtl’s Global Healthy Neurosurgery Fellowship provides an outstanding international experience and is actively looking for postgraduate fellows.

 

References

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1. Budohoski, K. P., Ngerageza, J. G., Austard, B., Fuller, A., Galler, R., Haglund, M., … Stieg, P. E. (2018). Neurosurgery in East Africa: Innovations. World Neurosurgery, 113, 436–452. doi: 10.1016/j.wneu.2018.01.085

2. Coburger, J., Leng, L. Z., Rubin, D. G., Mayaya, G., Medel, R., Ngayomela, I., … Härtl, R. (2014). Multi-Institutional Neurosurgical Training Initiative at a Tertiary Referral Center in Mwanza, Tanzania: Where We Are After 2 Years. World Neurosurgery, 82(1-2). doi: 10.1016/j.wneu.2012.09.019

3. Leidinger, A., Kim, E. E., Navarro-Ramirez, R., Rutabasibwa, N., Msuya, S. R., Askin, G., … Härtl, R. (2019). Spinal trauma in Tanzania: current management and outcomes. Journal of Neurosurgery: Spine, 31(1), 103–111. doi: 10.3171/2018.12.spine18635

4. Magogo, J., Lazaro, A., Mango, M., Zuckerman, S. L., Leidinger, A., Msuya, S., … Härtl, R. (2020). Operative Treatment of Traumatic Spinal Injuries in Tanzania: Surgical Management, Neurologic Outcomes, and Time to Surgery. Global Spine Journal, 219256821989495. doi: 10.1177/2192568219894956

5. Maier, D., Njoku, I., Schmutzhard, E., Dharsee, J., Doppler, M., Härtl, R., & Winkler, A. S. (2014). Traumatic Brain Injury in a Rural and an Urban Tanzanian Hospital—A Comparative, Retrospective Analysis Based on Computed Tomography. World Neurosurgery, 81(3-4), 478–482. doi: 10.1016/j.wneu.2013.08.014

6. Santos, M. M., Qureshi, M. M., Budohoski, K. P., Mangat, H. S., Ngerageza, J. G., Schöller, K., … Härtl, R. (2018). The Growth of Neurosurgery in East Africa: Challenges. World Neurosurgery, 113, 425–435. doi: 10.1016/j.wneu.2018.01.084

7. Smart, L. R., Mangat, H. S., Issarow, B., Mcclelland, P., Mayaya, G., Kanumba, E., … Härtl, R. (2017). Severe Traumatic Brain Injury at a Tertiary Referral Center in Tanzania: Epidemiology and Adherence to Brain Trauma Foundation Guidelines. World Neurosurgery, 105, 238–248. doi: 10.1016/j.wneu.2017.05.101

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Silvery Mwesige | March 19, 2020 at 7:35 pm

Constructive remarks.This writing will motivate more postgraduate to come and work with us.I never knew you are a soldier hahaha

John Stephn Mbwambo | March 21, 2020 at 5:02 am

It was really wonderful moment to work with you Scott, i was impressed by the fact that you did more than what your mission required you to do. You surprisingly fitted to the environment that most people get serious troubles to fit in, YOU FITTED LIKE A GLOVE.

Keep your African MISSION alive and we will work with your team any time. Karibu tena.