WHAT'S INSIDE

Providing Anesthesia for Neurosurgery in Uganda as Part of the 2016-2017 ASA International Residents Scholars Program

Benjamin H. Cloyd, MD, MIPH
Department of Anesthesiology
University of Michigan
Ann Arbor, Michigan, USA

Colby Simmons, DO, MBA
Department of Anesthesiology
University of Colorado
Aurora, Colorado, USA

Editor’s Addendum:  Dr. Benjamin H. Cloyd is the newly announced recipient of the 2017 ASA Resident Humanitarian Service Award.  Congratulations!

Figure 1: Dr. Justin Onen, staff neurosurgeon at CURE Uganda and Dr. Emmanuel Wegoye, CURE's current neurosurgery fellow performing a procedure at CURE Uganda.

Figure 2: From left to right Dr. Fred Musana, CURE Hospital staff anesthesiologist, John Kahwanga, CURE anesthesia technician, and Dr. Colby Simmons,ASA scholarship recipient, induce anesthesia at CURE Hospital in Uganda.

We were both fortunate to be recipients of the 2016-2017 ASA International Residents Scholarship. Established in 2015, the scholarship has been previously described and advertised in the ASA Monitor.¹ Organized by the ASA Global Humanitarian Outreach Committee, the scholarship provides the opportunity for several residents a year to experience firsthand the issues facing the development and delivery of anesthesia in developing countries around the world.

During our one-month rotations we each spent time at the CURE Children’s Hospital of Uganda (CCHU) and the Mbale Regional Referral Hospital (MRRH), both of which are located in Mbale, a city in the eastern region of Uganda. CCHU itself is one of ten hospitals operated in developing countries by CURE International (CURE), a Christian nonprofit organization based in Pennsylvania. CURE's efforts are focused on providing medical care to children suffering primarily from orthopedic and neurological conditions. MRRH is the local public hospital serving the Mbale region. These two hospitals, CURE and MRRH, are staffed by the only two Ugandan anesthesiologists in the region. Supported by a British anesthesiology specialty registrar and a team of anesthetic officers (Ugandan equivalent of CRNAs), they provide care to an area that encompasses more than four million people.

CCHU is a neurosurgery subspecialty hospital, primarily performing surgeries on children with hydrocephalus, neural tube defects, and brain tumors; founded in 2000 by Dr. Benjamin Warf, MD, a pediatric neurosurgeon and the Director of Neonatal Surgery at Boston Children’s Hospital. Following the recognition that shuntless procedures were not only more effective at treating the particular etiology of hydrocephalus presenting in Uganda, which is primarily post-infectious, the endoscopic third ventriculostomy and choroid plexus cauterization procedure (ETV-CPC), was developed at CCHU by Dr. Warf.² This procedure has been shown to significantly improve long-term morbidity and mortality in children in low-income countries with the capability of being taught to providers caring for children with hydrocephalus not only in developing countries, but in developed nations as well.^3,4 Owing to these endeavors, CCHU has become a global leader in the minimally invasive treatment of children with hydrocephalus.^5,6

CCHU has expanded over the years to include two permanent neurosurgeons on staff, thirty general care beds and ten intensive care unit beds. Other improvements since its inception include a CT scanner and a variety of necessary diagnostic and supportive treatment facilities such as physical therapy available on site. In the process, the hospital has become an international teaching center for surgical treatment of children with hydrocephalus and has trained twenty-five neurosurgery fellows from around the world in these techniques on site in Mbale. CCHU has become a key part of the Mbale community, employing almost exclusively local Ugandans to provide care for an impressive number of patients, totaling 1,110 surgeries and 5,774 outpatient visits in 2016. Continually seeking to enhance their capacity, current and future potential exists to expand, particularly in the intensive care unit where personnel such as respiratory therapists are needed along with equipment such as infant warmers and mechanical ventilators. Intraoperatively, the ability to provide neuromonitoring for spine and posterior fossa procedures along with staff education of these techniques is another potential area for collaboration.

Our time in Mbale provided what will certainly be an unforgettable experience. In contrast to short-term mission trips, which often involve a team of practitioners travelling from the same institution or country, this scholarship allowed us to travel alone and work within the existing healthcare system at a specialty referral center alongside Ugandan anesthesia providers. We encountered novel challenges for us, but issues Ugandans deal with on a daily basis such as Halothane inductions and providing anesthesia for children with advanced neurosurgical pathology who were fewer than three days old. In particular, living onsite at the CURE Hospital allowed us to become known and trusted members of the team and allowed for cross-cultural communication that likely would not have been possible otherwise.

Another enjoyable aspect about being on site in Mbale for such a long period was that it allowed us to take part in the education of medical students at the nearby Busitema University Medical School, and work with the local anesthesiologists to develop the specialty in Uganda. Generous donations from organizations and hospitals around the world have helped to develop an anesthesia simulation learning center in Mbale. This center is used on nearly a daily basis to help train medical students and other healthcare providers in a manner which previously would have been impossible. Dedicated, long-term efforts by multiple local and international societies, to improve both education and retention of providers have so far been successful, as the number of anesthesiologists in Uganda has increased from two in 1986 to a total of eighty having completed training. Of these, more than sixty remain practicing in Uganda today. While developing educational plans, it was noteworthy to see how frequently American protocols and guidelines are utilized and referenced in Uganda and it served as an important reminder that the research we perform and guidelines we develop in organizations such as SNACC and others help to set the standard and can even guide practice throughout the world.

Since the inception of the ASA International Residents Scholarship, the program has drawn increasing interest as residents seek to find means to satisfy their desires to participate in global health initiatives. A characteristic of modern residents is that they seek the opportunity to put into practice the technical skills they have honed in educational programs to serve societies and populations that lack access to advanced medical care.⁷ Undoubtedly, many will ask, “Why go?” The short answer, “How can we not?” Indeed, the need is great, and perhaps when viewed as a whole, overwhelming. However, the sense of accomplishment and the reward of seeing a child and family healed, an anesthesia provider trained, a friendship formed, is, to put it succinctly, life changing.

In a world that seems to be drawing inward, this scholarship serves as an important example of the need to engage with those with different experiences and circumstances than our own. The ideas exchanged, friendships made and partnerships developed will influence our careers and broaden our horizons for our entire lifetime.

We would like to thank the ASA, the people of Uganda, CURE International, our respective institutions and our families for helping to make such an incredible experience possible. The people of Uganda, in particular, were incredibly welcoming and generous, and did everything they could to make our experience the best it could possibly be. We each miss them dearly.

Disclosure: Both our service trips were funded by the ASA’s Global Humanitarian Outreach Committee’s International Anesthesia Scholarship Program. We have no other institutional or commercial affiliations or associations that might pose a conflict of interest in connection with the submitted material.

References:

1. Drum ET. Resident International Anesthesia Scholarship Program 2017-18. ASA Newsletter. 2017;81(1):32-.
2. Warf BC. Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy. Journal of Neurosurgery: Pediatrics. 2005;102(1):1-15.
3. Warf BC, Tracy S, Mugamba J. Long-term outcome for endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization for congenital aqueductal stenosis in African infants. Journal of Neurosurgery: Pediatrics. 2012;10(2):108-11.
4. Warf BC. Educate one to save a few. Educate a few to save many. World Neurosurgery. 2013;79(2):S15. e-S. e8.
5. Sims-Williams HJ, Sims-Williams HP, Kabachelor EM, Fotheringham J, Warf BC. Ten-year survival of Ugandan infants after myelomeningocele closure. Journal of Neurosurgery: Pediatrics. 2017;19(1):70-6.
6. Prabhu VC. Neurosurgery Initiatives in Global Health. World Neurosurgery. 2015;84(6):1544-6.
7. McCunn M, Speck RM, Chung I, Atkins JH, Raiten JM, Fleisher LA. Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions. Journal of Clinical Anesthesia. 2012;24(1):38-43.