Brain surgery, or at least anything more complex than drilling burr holes, was out of the question at Haydom Lutheran Hospital in Tanzania. The theaters had no operating microscope. The suckers barely worked. The operating light was too dim. Patients under anesthesia were ventilated by squeezing an oxygen bag with your hands. Instruments were scattered across a storeroom that looked like a teenager’s closet. Here, Dr. Dilan Ellegala would be limited to the most basic forms of neurosurgery, which was fine with him. Just a few easy cases in the morning to keep his surgical skills sharp, and then maybe a nap or a book or a run, whatever. He would let his mind wander.
As he neared the wards, people nodded and smiled. Word had gotten around quickly that he was a neurosurgeon. As far as he knew, he was the first brain surgeon to visit Haydom for any length of time, perhaps ever. Prior to his arrival, Tanzania had just three practicing neurosurgeons. Three for an entire country of forty million people. And all three were in Dar es Salaam, the country’s biggest city, five hundred miles away.
The United States had 3,700 neurosurgeons — not enough to keep up with the demand in either country. He didn’t know it at the time, but twelve countries in sub-Saharan Africa had no neurosurgeons at all.
* * *
The morning radiology meeting broke with the sounds of moving chairs. A clinician he’d met earlier approached. His name was Emmanuel Mayegga.
Mayegga had a round face, almond skin, a wisp of a mustache, and a high hairline that made his forehead stand out. He’d been on call during the night when a patient with a head injury arrived. The man was barely conscious. Mayegga wasn’t sure if the injury was a subdural or epidural. Either way, the man was in a bad way.
“Dr. Dilan, please, is there something you can do for this man?”
“Sure, let’s go,” Dilan said.
Dilan followed Mayegga through Radiology outside to a breezeway between the hospital’s buildings. To their right, patients waited next to a window to pay their bills. The surgical ward was on their left, and they entered through a heavy wooden door. Inside, patients spilled out of rooms lining both sides of a dark hallway. They found the farmer in a room with a window view of the hospital’s dirt driveway. Like the other rooms, it had about twenty beds and at least as many patients. Family members stood and sat nearby. The salty and slightly metallic smell of blood mixed with the scents of soiled sheets. An open window let in dust and flies. Dilan squeezed past other patients to reach the man, who lay motionless under a maroon blanket.
He was a farmer in his early fifties. The circumstances of his injury were vague. Mayegga had heard that he’d fallen while in a stupor and bashed his head. Dilan leaned toward the man, who appeared to be unconscious. He would need to do some quick tests to calculate the farmer’s Glasgow Coma Scale, a rough way of measuring the severity of a brain injury. To do that, he would need to inflict a bit of pain. He looked at Mayegga.
“Please tell him that I’m sorry.”
Mayegga said a few words in Iraqw, the farmer’s language and Mayegga’s. Dilan clenched his fist and placed it on the farmer’s sternum. Quickly, he rubbed hard, knuckles to bone. If the farmer reached for Dilan’s hands to stop the pain, then his brain was in reasonably good shape. But the farmer moaned and barely moved his arms. Dilan checked his eyes. Nothing. The Glasgow Coma Scale’s range is three to fifteen, with three being the worst. The farmer was a four.
“This means he’s in a deep state of unconsciousness,” Dilan said.
He leaned closer to the farmer’s head and noticed cerebrospinal fluid dripping from one ear, another bad sign. The brain is sealed tight in the skull, and cerebrospinal fluid is part of the protective buffer between hard bone and soft brain. A leak was a life-threatening condition in itself, a vector for infections. But the drips revealed a bigger drama playing out inside the farmer’s cranium. The blow to his head had breached the meninges — the brain’s outer defenses — and blood and fluid had begun to pool. He could see it in his mind: the dura would be hard, stretched tight from the pressure, and purplish, like a bruise on a pale person’s skin. The brain itself would have an angry red tint, like a bloodshot eyeball. Under this assault, the farmer’s brain was saving energy by shutting down less vital functions: speech, movement, consciousness. His brain was probably burning glucose like crazy in a last-ditch attempt to buy more time.
“Time is brain.” Dilan said this often to his surgical teams. Every minute counts when someone’s brain is damaged. Fix it quickly and you might save the memory of a first bicycle ride or a family camping trip; you might save the ability to move the legs, urinate, or breathe. He could save this man. It was a simple operation. He just had to get inside his head and stop the bleeding. Except for one problem. He had no way of opening the guy’s skull.
More:
http://www.salon.com/2017/04/08/brain-surgery-with-a-tree-saw-how-one-neurosurgeon-changed-the-game-for-a-tanzanian-hospital/It's about a ten minute read - and well worth the time.
