Antonio Bernardo, MD
June 2000
Dr Bernardo's Report to FIENS after the mission in Peru
In 1999- 2000 I spent 14 months in Peru as a volunteer for the Foundation for International Education in Neurological Surgery.
My objective was to work withPeruvian neurosurgeons who were interested in implementing skull base surgery programs within their institutions. I brought donated materials to help implement these programs and had the unique opportunity of working within each hospital’s Neurosurgery department. Most of the set up materials I needed I brought with me such as, 7 cadaveric heads as well as various donated surgical tools. For future reference, I would recommend doing as I did and checking any cadaveric specimens and other donated materials on the flight as extra luggage. This seems to be the easiest and least expensive solution, albeit a bit uncomfortable for airline check-in personnel. The Continental Airlines staff was very helpful and gracious enough to waive excess baggage fees since they were donated medical supplies. It would also be helpful in the future to be aware of airline weight and content restrictions to get through customs quickly in the U.S. The hassle of getting the heads there was definitely worth it, they were invaluable to us.
Unfortunately, the bureaucracy in Peru and many other South American countries can represent, at times, a tough obstacle. For example, in my case the entire shipment and process was very well thought out by Dr. Anselmo Pineda, President of the Peruvian American Neurosurgical Foundation, who having done this before had taken care of the bureaucratic aspect of the donations providing me with proper paperwork from the Peruvian embassy. In spite of our efforts, the donations I brought with me were stuck in customs for more than a month, valuable time spent stuck in a web of burocratic hassles. I would suggest arranging things well in advance with local Peruvian authorities to make sure that future donations will be cleared as soon they arrive in the country.
I was honestly warned before arriving in Peru on the poor standard of health care I would have found in the country, but in spite of the pessimistic previsions, my first impression of how they manage health care was not bad at all.
I started my first three-month period at the Department of Neurosurgery of the Hospital Gulliermo Almenara directed by the very well known Dr. Uldarico Rocca.Hospital Almenara is part of the Es Salud system, which means they can count on considerable economic support. EsSalud is a Peruvian national health plan covering salaried workers and their families, or about 25% of the nation's 26 million people. The other national health plans include the Ministry of Health, which covers about 60% of the population serving mainly those unable to afford medical coverage, and the military system, which covers another 5%. The remaining Peruvians are covered through private hospitals and private insurance companies.
It was my overall impression that the Department of Neurosurgery at Hospital Almenara is well organized and for the most part very efficient. They have a clinical meeting every Monday morning attended by the department personnel as well as by the famous Dr. Esteban Rocca, with thorough case discussion and management. The OR is very well organized, following American standards. They have a Zeiss microscope which was very old and tough to maneuver. It is my understanding they have recently acquired a more efficient Leika and a Midas Rex drill. They desperately need good drill bits for skull base surgery. Their entire spectrum of microsurgical instrumentation is very limited, having only 3 or 4 drill bits and a halo retractor. There is a neurosurgical intensive care unit consisting of 8 beds with a neurointensivist on shift 24 hours, 2 ventilators and qualified personnel. They do not routinely monitor the ICP. In my opinion, the quality of the peri-operative management of neurosurgical patients was somewhat poor and could be improved upon in the future with periodic on-site refresher courses by qualified volunteer personnel.
In spite of the initial difficulties, I managed to set up a functional skull base dissection lab at Hospital Almenara where we were able to perform most of the entire spectrum of skull base surgery approaches. The main thing we were lacking was a proper surgical drill. Dr. Rocca bought a drill at the local Ace Hardware store with which we managed sufficiently, surprisingly enough. Obviously, a proper surgical drill would have made a world of difference in the continuation of our procedural training.
I organized with the help of Dr. Rocca, skull base dissection clinics with the participation of the entire neurosurgical personnel. Each session consisted of approximately 3 surgeons, including myself, ranging from the youngest resident to the chief of neurosurgery. I found all of the neurosurgeons I worked with to be enthusiastic and extremely motivated in learning more about skull base approaches as well as furthering their training in this area in the future.
I should point out they have a sizable amount of patients with intracranial lesions, that due to their location and unusually large size would benefit most from typical skull base surgery approaches. Most surgeons in Peru are still not trained in performing alternative surgical routes. This project of training surgeons in a dissection lab turned out to be very helpful, especially considering that Hospital Almenara has adequate equipment to perform such complex skull base procedures.
I had the opportunity of performing skull base surgical procedures on patients with the local neurosurgeons at Hospital Almenara (such as translabyrinthine, transcochlear, orbito-zigomatic, anterior petrosectomy). In doing so, we were able to prepare before the procedure in the lab and directly apply our anatomical training session in the operating room. Thus confirming the importance of a skull base dissection lab in preparing and training for these types of procedures. It is my understanding that at Almenara they will integrate the lab into part of their clinical neurosurgical training and practice.
Needless to say, what our project really needed for its continuation was a good surgical drill, additional surgical instrumentation, as well as some educational materials i.e., books and c.d. ROM’s. With this in mind, I have asked for support from Dr. Kelly and FIENS.
During our dissections, we recorded an abundance of photographic material and presented 3 papers at the national meeting in October, where I was also invited to give a talk. Since then, I have given lectures on skull base surgery topics at the weekly conference of The Peruvian Neurosurgical Society.
My first impression of what we accomplished at Hospital Almenara was very gratifying, but unfortunately, I had to face a somewhat different reality when I had the opportunity to travel outside of Lima with some of my colleagues. We were invited to visit hospitals in other cities throughout Peru at which time I observed situations I would consider very grave. In Lima, there are approximately 10 public neurosurgical centers, (not including the private institutions) with some 150 neurosurgeons. Whereas outside Lima the entire region and main provinces rely on 1 or 2 neurosurgeons for populations of upwards of one million. Amazingly enough, these surgeons work in the most primitive of medical environments with no CT scan and often without the most basic of necessary surgical instrumentation. Most of the time, there is no means for making a diagnosis and the majority of those patients who cannot afford to reach the neurosurgical centers of Lima have no other option than to go untreated. Future humanitarian efforts should undoubtedly be focused on the peripheral areas of Peru.
In October I finished my work at Hospital Almenara and started my next three month period at the Instituto de Ciencias neurological “ Oscar Trelles” of Lima. This neurological institute is part of the Ministerio de Salud system, the “poor side’” of the Peruvian heath care system. This institute is located in a historical but impoverished area of Lima. It is also widely known that it is one of the most dangerous of areas of Lima. I found this to be a somehow fascinating dynamic right in the heart of the city. Beyond the chaos of a hygienically disastrous, dangerous neighborhood, hidden behind the hospital walls was a little jewel.
The staff at the hospital consists mostly of volunteer caregivers. They all work together like a big family. During my stay there were donations from FIENS as well as from other sources. Dr. Origitano sent us a Zeiss microscope with recording equipment and FIENS sent (with the help of Dr. Kelly and Dr Pineda) 3 of the latest Midas Rex drills and a brand new set for spine fixation. We had quite a lot of problems to clearing the everything from customs, but all of the surgeons were extremely grateful for the donation. I set up a skull base lab in the microsurgical research area with 2 fully equipped working stations with 2 microscopes, and organized courses for dissection. The courses were attended daily by the hospital’s surgeons as well as by surgeons from other hospitals of the Ministerio de Salud system. We performed the entire spectrum of skull base procedures using the cadaver heads I took from United States. During my three month stay, I routinely performed skull base surgery on patients as well as general neurosurgery. This was a great experience for me. In my opinion, they do well with what they have available to them, although I think they could benefit greatly with further assistance from FIENS. The hospital lacks the basics to provide even a decent standard of surgical care. They need an ultrasonic aspirator, good bipolar forceps (The ones I used in the OR hardly ever worked properly), a decent head holder for the operating table, some more equipment for the ICU and possibly on-site training for the neurointensivists ( this would be extremely helpful). The surgeons are all excellent. They really do an amazing job especially when you take in consideration the conditions in which they work.
In this same time period I spent a week in Arequipa, a beautiful city in the Andes in the southern region of Peru. They have a very busy neurosurgical center with a large staff but for some strange reason (they say for lack of training) they do not perform vascular surgery. Therefore, all vascular cases have to be sent to Lima, hundreds of miles away. They would greatly benefit from an experienced vascular neurosurgeon willing to spend some time training them. I traveled there and brought with me a brand new Leika microscope kindly loaned to us by the local Leika representative. With the help of a Zimmer drill previously donated by FIENS, we trained on cadaver heads I brought with me from Lima and afterwards I performed skull base surgery ( translabyrinthine approach) on patients.
My last 2 months in Lima were spent at the Hospital Rebagliati, a beautiful and very functional hospital with an extremely busy neurosurgical department headed by Dr. Alvarez, an excellent young neurosurgeon. They accepted me with incredible enthusiasm and helped me in setting up a very functional dissection laboratory where we performed daily courses on skull base surgery. The level of participation of each surgeon was incredible. I participated in their surgical schedule as well, mostly on skull base surgery cases.
Each hospital I worked in throughout the country, I installed a microsurgical dissection laboratory, I organized dissection courses, gave presentations at various national and international meetings during my stay, secured donations from FIENS at various institutions and managed the process of their proper allocation.
The overall experience I had in Peru was nothing short of amazing. I find myself reflecting on what contribution I made and those who helped me get there, the considerable donations that were made and the hospitality of each person I worked with in Peru as well as here in the U.S. I was quite taken by the spirit of the Peruvians. It is what I think of often and what continues to inspire me most. They continue to teach me generosity, even those who don’t have much. They do the best with what they have available. I feel that continuing humanitarian effort would surely contribute to improve the standard of their health care. This experience has been very important for me, I had the opportunity of sharing my experience in skull base surgery with my Peruvian collegues and in the same time I undoubtedly learned a lot from them. I will be at FIENS disposal for any other initiative they feel I could be helpful for.
Sincerely
Antonio Bernardo, M.D.