My name is Randy Bell. I'm the Chief of Neurosurgery at the Walter Reed National Military Medical Center in Bethesda, Maryland. I'll be talking today about the management of traumatic brain injury in resource-scarce environments, and I'll do so from the military perspective. As you may know, the United States military has medical assets deployed around the world. Many of these environments are significantly scarce of resources that would be common to a practicing United States neurosurgeon. I'll start by providing some definitions that I think are helpful in framing this discussion. I will refer to in the beginning and continue to refer to throughout this discussion goals and approach, but the majority of the talk will focus on the clinical evaluation and management of patients with traumatic brain injury in resource-scarce environments. I think before we get into this too much, it's important to define some terms. Webster's Dictionary defines a resource as a source of supply or support, a source of information or expertise, a possibility of relief or recovery, an ability to meet and handle a situation. Opportunity is actually an economic term and it refers to the basic fact of life that there exists only a finite amount of human and non-human resources, which the best technical knowledge is capable of using to produce only limited maximum amounts of each economic good. So substituting technical for medical and economic for clinical, that definition becomes apropos in this setting. Really resource scarcity is any area where there's reduced material supply capabilities that limit the ability of the surgeon, neurosurgeon in this case, to provide the care that would normally be provided in their environment with unlimited or maximum resources. My background, I have deployed overseas to locations where resources were definitely limited deployed to Afghanistan. We did have a brick-and-mortar hospital structure. Our resource limitation, though, was dictated by whether or not we could get supply flights into and out of an airport where those flights were rocketed on a daily basis. Overall, I think that the definition of resource scarcity in traumatic brain injury management and really anywhere depends on your perspective. From my personal perspective, resource scarcity is any environment where resource limitations adjust the standard of care, from what I'm used to in the management of traumatic brain injury and other things, to one that does not meet the standard in my first world country or the United States. Looking at it from the perspective of a deployed military surgeon, general surgeon, or perhaps a small-town general surgeon in the United States, resource scarcity can mean no neurosurgeon present, limited operating rooms, perhaps limited supply. From the perspective of many physicians in the third world, countries like Afghanistan, resource scarcity can mean no available ventilator, no sterilized instruments, or perhaps not even the capability to sterilize instruments on a reproducible basis, no ICU care, maybe no electricity or running water. With this in mind, with those definitions in mind, and with the perspectives in mind, my general recommendation now and throughout this talk is, number one, keep it simple. Keep your approach simple. Number two, always know your resources and always know your capabilities. That can define what you can do. And lastly, and we'll discuss more of this later, but be comfortable with triage. There are circumstances where the resource limitations and not your surgical ability will dictate what you can and cannot do. Simply approaching this, I recommend several resources that can help sort of frame approach in this area. This text, which is an open-source text provided by the International Committee of the Red Cross, is a text entitled War Surgery. It's a two-volume set, and it does define trauma of every body system working in areas with limited resources and other situations of violence. It does frame the discussion well. As it pertains to the management of neurotrauma, this table is provided, and it, in general, I think provides good recommendations. Although the first line, neurotraumatology, is not neurosurgery, I'm not certain that is appropriate and or that most neurosurgeons would agree with that. I think it is appropriate to say that not all neurosurgery is neurotraumatology, but certainly all neurotraumatology falls within the purview of neurosurgeons. This text is written for the general surgeon who has limited experience in the neurosurgical world and is utilized by many countries around the world. The United States military also provides multiple resources for the management of trauma in resource-limited environments. These clinical practice guidelines are provided by the United States Army's Joint Trauma System in San Antonio, Texas. This particular clinical practice guideline addresses life-saving cranial procedures by non-neurosurgeons in deployed settings. So again, the resource limitation in this setting is no neurosurgeon available. There are many general surgeons in the United States military deployed around the world where adequate air evacuation or other type of transport to a neurosurgeon is not available. Injuries of a severe nature requiring surgery often present, and the question often asked is should I intervene as a general surgeon? This clinical practice guideline was reviewed and vetted by the AANS and CNS section on neurotrauma and addresses circumstances where general surgeons might have to perform procedures downrange, not in the United States, but downrange in deployed settings. As part of this guideline, we did provide recommendations concerning minimum training requirements in this setting to consider doing so. The guideline also provides recommendations for resources and materials. There are other knowledge-based resources available, open-source resources that can help augment care in resource-limited environments. This is the CBIC algorithm. This was generated following the Seattle International Severe Traumatic Brain Injury Consensus Conference. Which was a group of subject matter experts in the field of traumatic brain injury who met and created algorithms that, based on expert consensus, were appropriate in this area. This resource is an excellent resource for downrange military environments, for resource-limited, perhaps rural environments within the United States and around the world, and really any environment where traumatic brain injury care is provided. So at this point, we'll move on to the pearls that I've learned over the last 19 years of being in the military, specifically dealing with three areas with respect to patient care. Consensus and evaluation is the first section. I start off this section by reminding everyone listening that the most important diagnostic tool is the physician performing the neurologic examination. There are multiple circumstances where perhaps diagnostic adjuncts that we take for granted in the United States, like a working CAT scanner, may not be available. The neurologic exam, in my opinion, is the most important initial step. It should be performed by an expert in the field of neurosurgery or neurology or neurocritical care as it pertains to patients where there is a question of salvageability. This exam definitely helps and is the first step in determining whether or not a patient is salvageable and then the course of action based on that physical examination is critical. Of course, it's absolutely necessary to remember that there is residual medication from intubation or resuscitation often present and must be distinguished. That must be taken into account and used to distinguish a low GCS that is artificial versus real. And also, it does go without saying, many have experienced non-neurosurgical or neurology-based GCS scores. They're often inaccurate and that just comes from repetition and not necessarily seeing what we in our field are used to seeing. So obviously, as I stated before, the diagnostic adjunct of choice is a CAT scanner. What if the CT scan is not available? When CT is not available, don't forget the utility of x-ray. These are some dramatic examples of what an x-ray can show, but there are x-rays on multiple planar imaging that can be obtained to determine the side of, for example, a penetrating injury and or the location of the skull fracture. And that can help to localize and potentially aid in the diagnostic evaluation. I am a big fan of quantitative pupillometry. This is a bedside device that can be used to do a pupillary examination. It can be utilized by any technician, nurse, or physician. The pupillary exam is often inaccurate and just estimated with bedside testing. This device will actually take a picture of the pupil, as you can see here, and it will calculate the constriction velocity and determine what's called a normative pupillary index. This normative pupillary index can, as it lowers, precede issues with intracranial pressure and or dysfunction. And it can help with lateralizing or localizing injury. This is a patient we took care of several years ago, a case of paradoxical brain herniation through a decompressive craniotomy defect. You can see the scan when the patient arrived on the far left. There doesn't appear to be any space-occupying lesion on the right side, and the brain is appropriately herniating out the large cranial defect. Several days later, the patient's physical examination reduced, and while it appears that the brain is herniating out more on the CT scan, it was not apparent on physical examination. Quantitative pupillometry was obtained. You can see on this graph, and it did precede the CT scan by several minutes. The right-sided line is the lower line, and you can see that the dips in the normative pupillary index preceded the CAT scan and did help predict. This patient did require return to the operating room and removal of the space-occupying lesion that was there. There are other adjunct devices that can be used. The technology in this setting is not, I think, where it needs to be at this point. There are handheld EEG devices that can utilize EEG to provide assessments on degree of concussion and brain injury with machine algorithmic conversions. There's also handheld near-infrared spectroscopy devices that can detect intracranial hemorrhage. At this point, while approved for certain indications, they really should not be used to replace CT scan. However, if you are in an environment where CT scan is not available, it is possible that these devices can help aid. So following the diagnostic portion, proceeding directly to whether or not surgical intervention is necessary, I think the most important question to ask and answer whether you're in a resource-scarce or resource-plentiful environment is, is the injury salvageable? And from the military perspective, I can tell you there are questions that we have to ask that include, should I intervene? Do I have the resources to intervene? Or do I need to make the patient expectant? Expectant is essentially a status in triage that basically moves that patient to the side where you treat other patients that have injuries where the resources can be applied and you can make a difference. Overall, what factors, neurologic factors, go into salvageability? This is the SPIN score, which was recently validated. And you can see that there are expected components of the SPIN score that then correspond directly with salvageability. Points are given to better conditions, so you can see a perfect motor score of 9 points. Pupillary reactivity equal 9 points, and the higher the score, the more likely there is to be salvageable. This is in the setting of penetrating brain injury. There are other possible ways of doing this in closed head injury as well. What resource factors go into salvageability? What are the OR and ICU capabilities? Is the hospital system and or clinic and or deployed forward surgical team perhaps that you may be involved with, do they have the capabilities in the OR to take care of these patients? As a surgeon, does the surgeon have the capability to take care of the patient with the tools that are available? Are there other patients that might have injuries that are more readily salvageable with the resources available? And this is the concept that we discussed earlier of triage. In general, you have to make a decision based on the resources that you have to dedicate to the patient based on how many patients you have and how many resources you have. In this setting, mass casualties are possible, and that specifically can create a temporary resource limitation where any casualty number that you have, I mean, the mass casualties, any casualty number that exceeds the available resources and therefore creates a temporary resource limitation or scarcity. The types of triage immediate, meaning an injury that must be dealt with now, delayed, something that can be delayed but still requires urgent intervention, minor injuries again, and then that expected management where the resource limitations and or capabilities are far exceeded by the injury and the patient is set aside until such time as perhaps additional resources become available. From a triage perspective, in other words, you dedicate your limited resources to those with the highest probability of survival first, and you have to be comfortable with expectant designation. The important aspect of triage is that it's not a single event. Triage is a concept that must be constantly revisited, re-triage as you go perhaps as more patients come in and or more resources become available. I show this slide because downrange in military medical settings, one of the significant resource limitations is something simple. It is very difficult to do a craniotomy without an electric drill. This is obviously a small device and something that I've advocated be a part of just the standard outfitting of every forward support surgical team and smaller hospital. The alternative is here, and this is a Giggly Saw and Hudson Brace. While many who are listening to this have utilized these devices, they are certainly not easy to utilize. They do require additional time, and expecting a non-neurosurgeon anywhere in the world to utilize this device and do so effectively is not appropriate. This is a significant resource limitation outside of larger United States military treatment facilities overseas, and it can be an issue. Once your diagnosis, initial evaluation, and whatever management has completed, if you are in a resource-scarce environment, it is appropriate to consider transporting the patient to an environment with additional resources or higher level of care. For the neurosurgeon and really any physician in the setting of traumatic brain injury, considerations should include how far the patient has to travel. If it's a short distance, rotary wing aircraft like helicopters are appropriate. They'll fly at low altitude, and that does reduce the issues associated with cabin pressurization since there really isn't any. For longer distances of travel, for example, in the United States military, it is routine for patients with significant traumatic brain injury to travel multiple hours over long distances at high altitudes. Fixed-wing aircraft may be necessary. If that's the case, cabin pressurization becomes important. Consideration of whatever intracranial air volume is present following a surgical intervention is important, as cabin pressurization may increase the size of the air contained inside of the head. Is intracranial pressure management necessary? Does the patient have a ventriculostomy or cranial decompression present? This can help protect the patient over long distances of travel where a neurosurgeon may not be readily available to support the patient. And again, if you're utilizing a fixed-wing aircraft to transport a patient with a significant traumatic brain injury, while this may seem simple, it's important to load the patient head first, head facing forward into the aircraft. That is how aircraft take off and land. The nose is going to be up, and so if the patient is head towards the rear of the aircraft, the head for a period of time will be lower than the heart, and this can artificially increase intracranial pressure. And then depending on the degree and magnitude of the injury, whether or not critical care air transport is necessary during that transport. The pictures at the bottom show the inside of a C-17 aircraft. This is a standard military aircraft for transport. At this point, the pallets contain seating for physicians transporting overseas along with some other equipment that you can see in the back. These can be converted to floor-to-ceiling intensive care unit beds for patient transport. In conclusion, as stated in the beginning, there are resource-scarce environments around the world, including in the United States. Resource scarcity and limitation depends on the perspective of the person asking, am I in a resource-scarce environment? I think it's important to know what your resources are at all time. Know your capabilities, not only your personal capabilities, but those of the people that you work with in the hospital and or attend if that is your environment. It's important to be comfortable with triage, even if it means expectant management or setting a patient aside because you don't have the resource capabilities to treat the patient. And then lastly, it's important to consider transport options to better-resourced environments as soon as is safe and possible. Thank you.

Dr. Randy Bell

Neurosurgery

Traumatic Brain Injury

Resource-Scarce Environments

Triage

Diagnostic Tools