Global Health Neurology Program - Elena Sherman

The first patient came to our attention from a resident who caught us on the stairs requesting help reading a head CT.  The patient was a 23-year-old man presenting with 4 weeks of worsening headaches and now encephalopathy.  His neurological exam was markedly abnormal with the patient having difficulty maintaining wakefulness and with his eye movements darting in multiple directions.  The latter is what neurologists would refer to as nystagmus and is a sign of a problem in the posterior fossa.  His imaging revealed problems of an alarming nature, namely a large mass causing compression of the fourth ventricle and marked hydrocephalus proximal to this blockage.

This is a finding which must be addressed with neurosurgical intervention urgently.  In the US, one might place an extra ventricular drain (EVD) while awaiting definitive surgical resection of the mass.  In this setting, ventriculoperitoneal (VP) shuts are placed, but patient’s families must personally obtain them from a medical supply store since they are not covered by health insurance.  Unfortunately, the cost of these shunts can be prohibitive and it may take families multiple days to raise the funds to purchase them, if they are able to purchase them at all.

Our patient was transferred from the medicine ward to the neurosurgical unit and when we went to check on him the next day, he looked worse.  He was more somnolent and had some dried vomit on the side of his mouth, likely from increasing nausea from the mounting pressure in his head.  We went to find the surgical resident who was busy with paperwork and after inquiring as to our patient’s status it was clear that he had no idea who we were talking about or the urgency of his clinical state.

We took the time to examine the patient together so that this resident would be alert to any deterioration of his exam that would prompt more urgent intervention.  He shrugged his shoulders and told us family had still not returned with a shunt so a change in his exam would be irrelevant.  I cringed at his defeatism and calm complacency, struggling to understand.

Indeed, this patient presents one of many ethical challenges that physicians face on a routine basis at KATH.  If someone could just pay for this patient’s shunt, then why wouldn’t a physician, either local or visiting, just purchase the item for them?  Relatively speaking, it might not be a great cost and it could save someone’s life.  I have, on occasion, seen residents or attendings chip in to pay for glucose strips or an important lab test for a patient that cannot afford these items, but overall, paying for a patient’s care is not a frequent occurrence.  The truth is that it becomes an issue of justice, I think, as well as sustainability.  You might be able to meet one or two patient’s needs, but truthfully they are all worthy of assistance and since you will be unable to provide for the needs of all current and future patients it seems arbitrary to select a small sample to assist financially.

I checked on our patient for the next few days and still no shunt had arrived.  After that, I am ashamed to say that I stopped checking on him as aggressively, not because I didn’t care, but because I worried that he would die despite my best efforts.  After witnessing multiple other patient’s deaths that week, many of which could have been prevented in a setting with additional resources, I couldn’t bear watching him slowly die from something treatable.  So I left him alone and let myself be distracted by the work of seeing other patients, silently feeling rather useless.

I later heard from the neurosurgery resident that eventually this patient underwent successful shunt placement---a full two weeks after we had referred him for the procedure!  It is by the grace of God that this man survived; I know that many will not be as lucky.

I am telling you this story, not because it has a happy ending, but because it captures a feeling that I felt among my physician colleagues and that I myself experienced in seeing this patient.  After years of intense training these young physicians are providing the best care they can for their patients and watching so many of them experience poor outcomes.  It is not surprising that they carry a sense of heaviness and express frustration with their powerlessness to help their fellow man.  I believe that the effect of this chronic sense of powerlessness is profound and that it is the major contributing factor to the brain drain that impacts Ghana as well as other developing countries.

Indeed, during my visit, I helped multiple residents prepare for upcoming interviews at US residency programs as well as answer questions about fellowship opportunities.  Many trainees seek international medical training because they are aware of the limitations in their own country and are hoping to train in settings where they will be exposed to additional therapeutic interventions and have access to greater resources to care for their patients.  Although many may initially intend to return to practice in their home country, the vast majority will establish practices abroad.  This is concerning as countries like Ghana already are struggling to train enough physicians to keep up with patient demand.  I am excited for these young physicians as they seek out additional training experiences, but I worry about who will be caring for the patients that they leave behind. 

The second patient was the first consult that I received in Kumasi: a 27-year-old man with tetraparesis with a concern for cervical myelopathy.  The team was planning to order an MRI of the spine and wanted our opinion on potential etiologies.  I took a group of residents to the patient’s bedside to obtain additional history and to examine him.  He reported a gradual progression of weakness starting distally in his legs and evolving over several days to involve his arms.  On examination, his tone was flaccid in all extremities, his reflexes were unobtainable, and he had a diffuse pattern of weakness involving distal greater than proximal muscle groups and affecting his legs more so than his arms.  He could not lift his head off of the bed and would, at times, use his accessory muscles to help him breathe.  No sensory level or upper motor neuron signs could be detected.

I am sure I have lost the majority of readers at this point, but to another neurologist, my meaning is clear.  If each neurological exam is a careful interrogation of the nervous system, then the pattern of findings in this patient reveal a diffuse problem with peripheral nerve roots as the culprit.  Given his time course, the likely etiology is an autoimmune condition called Guillain-Barre Syndrome.

But why have I bothered to bore you with all of this minutia?  Because with a careful neurological history and physical, physicians have the power to localize neurological problems, create an accurate differential diagnosis, and formulate a targeted diagnostic and management plan on the basis of this prioritized differential.

This patient’s team had assumed his tetraparesis was caused by an infectious lesion in his cervical spine because it is common in this setting, but with a careful examination, we knew that this localization could not be correct.  As such, we cancelled his MRI and saved his family 1,000 Ghana cedi, not an insignificant cost.  Even better, we told our patient that although his recovery would be slow, that within 9-12 months, he would likely make a full recovery.  It was the first time that I saw him smile and next day he was actively working with the physical therapist to stand up from bed, which is the most important therapy that he could receive at this point.  It is a great reminder that sometimes the most powerful medicine we can offer is reassurance.

As much as I felt useless in caring for my first patient, I felt that we added great value to the care of our second patient.  By teaching residents fundamental skills in neurological examination and localization, we can help them to arrive at the correct diagnosis, thereby limiting unnecessary testing and honing in on the correct treatment.  Our examination costs nothing and in practiced hands is an invaluable tool.

Perhaps the most important thing that we have done this month is to challenge the idea that there is little we can do for neurological patients.  Given the current resource limitations, practicing neurology in Ghana currently is somewhat akin to what practicing neurology in the US was like 20 years ago.  The running joke that older physicians make is that neurologists “diagnose and adios” but we know that to be far from true.  We are practicing in an age where we can implant deep brain stimulators in Parkinson’s patients allowing them to walk again, where we can arrest multiple sclerosis early in its disease course and prevent long-term complications, where we can take patients with large vessel strokes, perform endovascular interventions and significantly limit the burden of their stroke.

My faculty mentors, Dr. Nirali Vora and Dr. Steven Sarfo, and former Stanford resident, Dr. Michael Ke, established a stroke unit earlier this year that currently provides specialized nursing care for 6 stroke patients.  During this visit, Dr. Vora has created admission and discharge forms with associated order sets to help ensure standardized care for these patients.  We are currently piloting these forms in the stroke unit, but hope to expand their use to the entire hospital.  The data collected from these forms will also help us to understand the population of patients who present to the emergency department acutely with the hope that in the future we can convince hospital administrators of the relevance of using thrombolytic therapies in this setting.