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  • Mission: BRAIN: Bridging Resources and Advancing International Neurosurgery

    Authors: Ankush Bajaj, BS
    Alfredo Quiñones-Hinojosa, MD
    Michael T. Lawton, MD
    James Yoon, MD

    Neurosurgical missions stir the humanitarian spirit in all of us, especially those fortunate enough to practice in hospitals flush with high technology, sleek devices, and robust resources. These missions offer opportunities to give back to patients in need and promote human welfare globally. However, there are undeniable gaps in the global neurosurgery community that extend far beyond the unmet patient need. These gaps include deficiencies in educational resources for residents and trainees, in the latest biomedical technologies and surgical instruments, and in hospital infrastructure for nursing, critical care, and anesthesiology. Due to these disparities, over 5 million individuals with treatable neurosurgical conditions go without surgery annually worldwide, according to a recent study by the Global Neurosurgery Initiative.1

    How can we bridge this disparity and advance global neurosurgery?

    In 2011, Dr. Alfredo Quiñones and I came together and founded Mission:BRAIN (Bridging Resources and Advancing International Neurosurgery) with this question in mind. He was a trainee of mine at the University of California – San Francisco who subsequently launched his career in neurosurgical oncology at Johns Hopkins Hospital and was attracting attention for his dramatic life story as a poor immigrant from Mexico succeeding in American neurosurgery. Not only did Alfredo have a genuine desire to improve the lot of his native people, but his notoriety would illuminate health care disparities in Mexico and help stimulate reform. With a team of volunteer nurses and surgical technicians, we ventured to Hospital Civil de Guadalajara in Guadalajara, Mexico. Since this inaugural mission, Mission:BRAIN has grown to work at six different sites in three countries – Mexico, Haiti, and the Philippines. We recruited leading neurosurgeons to join our organization, including George Jallo, Ted Schwartz, Mitch Berger, and Praveen Mummaneni, to name a few. We have performed over 100 surgeries to date. Our mission is to provide patients in need with access to advanced neurosurgical procedures, to educate providers on advancements in neurosurgical technique and care, and to empower local partners to create sustainable health systems.

    Providing complex neurosurgical care to underserved populations.

    One of the primary objectives of Mission:BRAIN is to provide the highest level of neurosurgical care to underserved populations at no cost to the patient. Those with complex neurosurgical issues who would otherwise forego treatment due to cost are chosen as surgical candidates. From a mother traveling over 20 hours by bus to get surgery while her neighbors watch her young son, to a farmer who works tirelessly in the rice field everyday despite his gait and balance issues to support his family, we are continuously inspired by the incredible strength and perseverance of patients and their families that we meet.

    Unlike other organizations that have focused on “bread and butter” neurosurgery like pediatric hydrocephalus or single-level spinal fusions, our organization focuses on complex vascular and neoplastic lesions. Notably, we performed the first bypass procedure for a giant internal carotid artery aneurysm in Guadalajara and the first clipping of a large basilar bifurcation aneurysm in Manilla. Many of the modern endovascular treatment options are not feasible in lowand middle-income countries due to prohibitive costs of stents and coils, which makes our open techniques so invaluable. Additionally, our team led by Dr. Mitch Berger performed the first awake speech and motor mapping for a brain tumor resection in the Philippines. We are grateful and humbled by the trust patients bestow on our team to be their healers in their vulnerable and trying times.

    Providing educational opportunities and inspiring the next generation of neurosurgeons

    Each of our mission trips emphasizes educational opportunities for neurosurgeons and other medical professionals. For neurosurgical residents, we conduct teaching rounds and case conferences to discuss technical aspects and impart clinical pearls. Additionally, we provide residents opportunities to scrub in and operate side-by-side with the Mission:BRAIN surgeons. The residents in the operating room are able to learn through direct observation and gain valuable hands-on experience by operating under close supervision. When circumstances allow, cases are broadcasted to a conference room to accommodate a larger audience of neurosurgeons and trainees, similarly to a live surgery demonstration course.

    For many trainees, witnessing these procedures being performed at their own institutions convinces them that these complex cases can be done in their environment without vast resources, inspiring them to further pursue technical excellence. As the proverb says, “if you see it happen, it must be possible.” Through connections built with our organization, several trainees from host institutions have completed observerships and research fellowships at Barrow Neurological Institute, UCSF, and Mayo Clinic.

    Surgeons alone cannot take care of neurosurgical patients: care for these complex patients requires a multidisciplinary team of nurses, intensivists, operating room personnel, and anesthesiologists. At Mission:BRAIN, we aim to create this system of care. One such example is our nursing care symposiums led by Lisa Hannigan, ACNP, and April Sabangan, RN. Additionally, we have collaborated with a neurocritical care specialist Dr. Romer Geocadin who led workshops with a team of anesthesiologists and intensivists at Philippine General Hospital to develop standardized post-operative protocols for neurosurgical patients. Our goal is to provide patients with high-level and holistic care, from surgery to recovery, and to encourage collaboration among all parties involved.

    Empowering the local partners to elevate the level of care in their own communities

    “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” As the adage goes, Mission:BRAIN strives to create impact that lasts far beyond our short stay. One week is hardly enough time or throughput to impact case backlog, but that week aims to empower local neurosurgeons to integrate new knowledge and techniques into their daily practice and improve care for their patients. One of the ways we accomplish this is by bringing donated medical supplies from device manufacturers and suppliers. Our industry partners have generously donated needed surgical instruments, aneurysm clips, and an intraoperative EEG machine to be used by local surgeons. In one of our earlier trips to Mexico, one of our Mission:BRAIN volunteer technicians repaired the operating microscope that had been out of commission for several months due to high repair costs, as well as a broken operating chair.

    Working at different sites with different cultures, we have learned that “one size does not fit all.” What worked in Guadalajara may not work in Mexico City or Monterrey. Differing needs must be identified and solutions must be tailored to the local environment. Successful solutions come only with open dialogue with the host institution. Before a week-long mission trip, our team spends many weeks in preparation to fully understand the needs of our hosts and to make contributions that respect their traditions. We view our role as catalysts who shine the spotlight onto issues, encourage the local community to get engaged, and facilitate sustainable solutions.

    Looking ahead to the future of global neurosurgery

    Important lessons have emerged from our international efforts. One major shortcoming of the U.S. health system is its monumental healthcare costs. In fact, our system is the most expensive in the world and price transparency is lost in layers of complex jargon and insurance plans. At the public hospital in Guadalajara, a board displays the prices of each surgical supply needed for an operation, which minimizes surgical waste and encourages cost containment. In fact, surgical instrument sets are often a third of the size of those back at our home institutions and there is little waste at the end of each case. Inspired by the transparency and efficiency in these low resource settings, our team conducted the first study quantifying operating room waste upon return to our home institution. We found approximately $968 of operating room waste per neurosurgical case and subsequently led educational and preference card review initiatives to reduce the amount of waste.2 Additionally, we have recently characterized patient out-of-pocket costs for various neurosurgical procedures in an effort to increase price transparency.3

    Advancing sophisticated neurosurgery globally is a major challenge. However, the heartfelt gratitude of patients, the curiosity and interest of trainees, and the enthusiasm and commitment of collaborators remind us of global neurosurgery’s importance. Our trips to Mexico began with Alfredo’s desire to give back to his native country, and our trips to Philippines began with April’s desire to give back to hers. Do you have a connection to some part of the world that tugs at your humanitarianism? The goal of global neurosurgery should be that treatable neurosurgical conditions get operated, and that patients all over the world have access to high-quality neurosurgical care, no matter where they live. We all entered this profession with the common goal of increasing the welfare of our patients. We urge you to collaborate with your international colleagues or with us, share your knowledge and expertise, and mentor the future leaders of neurosurgery. As we spread the message of hope and social responsibility, we hope that you will join us in reaching beyond our borders and raising standards of care for millions in need.

    1. Dewan WC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg. 2018 Apr 1:1-10. doi: 10.3171/2017.11. JNS171500
    2. Zygourakis CC, Yoon S, Valencia V, Boscardin C, Moriates C, Gonzales R et al. Operating room waste: disposable supply utilization in neurosurgical procedures. J Neurosurg. 2017;126(2):620-625. doi: 10.3171/2016.2. JNS152442
    3. Mooney MA, Yoon S, Cole T, Sheehy JP, Bohl MA, Barranco FD, et al. Cost transparency in neurosurgery: a single-institution analysis of patient out-of-pocket spending in 13,673 consecutive neurosurgery cases. Neurosurgery. 2019;84(6):1280- 1289. doi: 10.1093/neuros/nyy185

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