Lessons from head injuries for Ghana
By Dr. Nii Bonney Andrews

It was indeed a freak accident. While Felipe Massa was travelling at 170 mph in an F1 Ferrari, a metal spring fell off the racing car in front of him.

The metal piece bounced off the race track and struck his helmet above his left eye.

On account of the high speeds, the helmet got broken and the metal piece struck Massa on his forehead, fracturing his skull and causing bleeding and swelling in his brain. This immediately rendered him unconscious, causing him to lose control of his racing car; it skidded off the track and struck a nearby wall.

Almost immediately, there is a fully equipped and staffed ambulance to get him out of the racing car PROPERLY- without causing further damage to his head, neck or lower spine.

Then he is sent to a waiting helicopter that takes him to a fully equipped hospital. There, a team of well trained and equipped specialist neurosurgeons diagnose his injuries and proceed to perform delicate brain surgery on him in order to protect his brain, remove the blood clots and repair his skull.

Afterwards, he is kept in a modern intensive care unit in a drug induced coma for about 48 hours. Nine days after his life threatening accident, Massa is fully awake and alert and is being interviewed on CNN. He states that he is planning to travel across the Atlantic from Hungary to his native Brazil the next day and planning his return to motor racing!!!

That is international best practice - such is what can be achieved with proper planning and prioritizing, even in as difficult and frustrating an activity as the care of the head injured patient.

Head injuries have the highest mortality or death rate for all injuries and the commonest cause is road traffic accidents. The death rate in the first world is 25%; can you imagine what it is in our country - the fourth world? (yes, you read it right, fourth!).

Needless to say, we do not even have the statistics and have not even began to put in place the mechanisms for collecting them.

The long term complications of head injuries include paralysis, epilepsy and problems with speech, vision, smell, reading, writing, coordination and memory.

These disabling problems devastate working people, for head injuries are commonest in the 20-40 age group. It is even more painful to see head injuries in children; the commonest cause being their involvement as pedestrians in road traffic accidents.

Prompt and skilful transportation of a head injured patient to hospital as was seen in the case of Massa is also very important. A REAL ambulance (“proper one”) with life support systems, professionally trained staff with knowledgeable hands-on supervision is indispensable. Do we have that here? Have we thought about it? Is it on our list of priorities? Do we know how to get it done? Have those in charge done it before….or they have just read about it and done a few “courses” with some notes? The West African Rescue Association, a private voluntary ambulance service, has first world facilities and personnel right here in Ghana and they have already saved many lives. Can we not replicate their model?

Next, prompt diagnosis with a Head CT scan is indispensable in head injuries- this is international best practice. I cannot help but recall sending a young lady with a head injury for a Head CT scan within an hour after being called to see her. Just as we finished her scan, a patient was brought in from the emergency room of a public hospital. He had been lying unconscious in the emergency room for over 16 hours with a head injury after a fall from a motor bike!!!!- He died in protest a few hours later.

For over 25 years neurosurgeons have known that in the commonest kind of severe brain injuries, the death rate increases 2-3 times if definitive treatment is not given within the first 3 hours of the injury. So are we serious when we are NOT organized in such a way that our head injured patients can get proper treatment based on a Head CT scan within 2 hours of their injury? If we did not know that then….well, now I have told you and you can go and check for yourself and act accordingly.

Definitive treatment must also be prompt. International best practice says within 2-3hours. It should be done by specialists with the highest degree of competence in head injuries and adequate post surgical facilities must be available- preferably in a Neuro Intensive Care Unit under the direction of a neurosurgeon.

Intensive Care Units (ICU) are not part of our landscape….and no howls of protest can change this- just go round and check. Massa’s stay in a well equipped and staffed ICU (“a proper one”) was key to his survival and recovery with little or no complications. The fact is that there are at least two generations of physicians in this country who know next to nothing about Intensive care, and by this I mean more than temperature, blood pressure, pulse and urine output! No howls of protest here either; currently, the total number of intensive care beds for the 24 million of us is at most twelve.

However, with thorough planning, prioritizing and placement of knowledgeable people in the right places, all this can change. For it is on record that thirteen years ago, a young lady with head injuries far worse than those sustained by Massa received first world treatment in this country. Like Massa she was also placed in a drug induced coma and her brain pressure carefully monitored continuously to keep it normal. She survived as a result of the treatment and is now an independent, competent and hardworking professional. Such successes are few and far between since we have NOT institutionalized international best practices; our lives still rest on the luck of the draw or the edicts of personalities and their cronies; a typically fourth world dispensation.

F1 provided Felipe Massa with international best practice treatment for his head injury. Are we ready to submit, learn and do the same in Ghana?

In Ghana- yes, international best practice is accessible  with respect to benefits for Article 71 holders (six cars or thirteen? four houses or two? Pensions for parliamentarians anyone?) but not to prevent malaria (so we think insecticide nets and drug combinations will save us), nor to take care of head injured patients adequately nor to train our aspiring specialists properly.

The true third world countries such as Egypt, Morocco, South Africa have these latter things in place and more. When shall we have the same high international standards as we like to think that we are at par with them? No amount of posturing or grand titles can help us; our woeful weaknesses and deficits are all there for anyone to see; they kill and maim us every day, and we need to fix them through sobriety, hard work and by removing all the square pegs from the round holes.

Finally, any one who thinks or says that I am being populist (as is now the usual charge in Ghana for talking commonsense) can come and tell me so, face to face in Aviation House- it will be a “teachable moment”- and he should not come by car.

Dr. Nii Bonney Andrews

The author is a neurosurgeon and Chief of Neurosurgery and Vice-President of neuroGHANA.