Neuromonitoring with the Spinal Brigade in Honduras

By May 18, 2018Articles

Lauren Olejarz, CNIM
Surgical Neurophysiologist III
May 18, 2018

The World Pediatric Project (WPP) coordinates and mobilizes surgical, diagnostic, and medical specialty teams to provide treatment for young people in countries where advanced pediatric care is unavailable to children in need. I was lucky to be invited on a mission trip to Honduras as part of this program. It was an incredible experience, one that I will l never forget.

Our Spinal Brigade consisted of myself for intraoperative neuromonitoring (IONM), two pediatric orthopedic surgeons, a surgical assistant, two post-anesthesia care unit (PACU) nurses, a critical care fellow, an anesthesiologist, an anesthesia assistant, a device representative, and our WPP guide who served as translator and general assistant for just about anything. Honduras only has one pediatric orthopedic surgeon trained in scoliosis correction. He was to assist us at the clinic, along with two surgical residents from a local medical program. A few additional Honduran nurses also helped in the OR and recovery.

We were utilizing a clinic that isn’t in use except for medical mission work, so we had to take almost everything we needed—instruments, implants, anesthesia equipment, drugs, bottles, face masks, and tape.  After arriving in San Pedro Sula on Saturday, we unloaded our bags and organized our PACU and two operating rooms.

Our plan was to operate on two children concurrently each day over the course of four days, with one of our surgeons in each room.  We decided to perform straightforward cases on Monday to get the flow figured out, and then slightly more difficult cases on Tuesday and Wednesday to give those patients the most time to heal and spend with our recovery nurses. Two more straightforward cases were scheduled for Thursday, and Friday was reserved for packing up and accommodating a local neurosurgeon who asked for assistance with a cancer patient whose spine was compromised. We needed to have all of our pediatric patients prepared to go home by Friday night since the facility would not be staffed after we left, and that was a large part of the decision process when choosing the children who would receive care during the week.

On Sunday, 54 children presented at the clinic, and we needed to choose 12 candidates. Of those 12, the surgeons would decide which eight children would get corrective spinal surgery. The selection process was one of the most heart-wrenching things I have ever experienced.  We saw children who would have been good candidates, but they were put on a list for the next trip, as there were more severe patients who needed to go first. We also saw patients who were not healthy enough for the procedure and recovery to happen within our short timeframe.  The hardest stories to hear came from the patients who were fantastic candidates to have their lives changed, but the procedures would have been too dangerous to perform in Honduras.

A wheelchair-bound young man with an extensive curve among other health issues came in with his mother and told us why he wanted and needed the procedure. Every time he spoke he had to lift himself out of his chair in order to expand his lungs so that he could get out a full sentence.  We were very interested in his case; the procedure, however, would call for some intense osteotomies and column resection with the risk of a lot of blood loss, dural tears, etc.  Given his specific medical history, the mortality risk of this procedure was huge, even if performed in the United States. During the course of the evaluation, the patient asked, “What percent?  What is my percent risk of death in the United States, and what do I need to do to have the procedure done there?”  He wanted to know his chances, willing to accept a strong risk of death because he just wanted a normal life.  It indicates how far these patients are willing to go.  His situation was the most dire to me, but ALL of the children expressed a similar desire for normalcy.

Many of the children who came to the clinic traveled hours to get there. They don’t have the option to do these cases at their public hospital.  It’s the Spinal Brigade or nothing for the vast majority of them. Narrowing the candidates from 54 to eight was difficult, but we had to logically assess and choose the best patients given the limits of what we could offer.  Eventually, we chose the candidates, placed them in order for surgery, and before I knew it, it was Monday morning.

Our protocol called for the first procedure to start at 7:30-8:00, and the second patient came into the room shortly after.  Since I was the only neurophysiologist, I was running both rooms, semi-simultaneously. It proved to be a stressful time, but totally worth it, no question about that. I would get the first patient set up and run baselines, and by the time I did that, they would be finishing induction on the second, so Patient 1 would have exposure start and I would run over to get Patient 2 set up and run baselines.  For the duration of both surgeries, I would run a set or two of data (SSEPs and TcMEPs) and then go back to the other room.  The correction portion of each surgery was staggered just a bit because of slightly staggered start times, so I was able to be in each room during those times.  It was not easy, but since I have worked many times with both surgeons, we have a relationship built on trust, and they were patient given our limited resources.  All in all, it went very smoothly.

As the week went on, it was incredible to see the smiling faces of our kids in the PACU.  With minimal pain medications, they were up and moving so quickly! They even had contests to see who was first to walk, who walked the farthest, and who had gained the most height after being straightened up!

Every time one of our team members passed by, the parents came out to hug and thank us. The children called out to show us how they could sit up, or stand, etc.  In my position in IONM, I very rarely get to see the PACU progression of my patients, so this was an absolutely amazing part of the experience!

Friday’s neurosurgery patient was a man in his early 20s.  He was suffering from a type of cancer that destroyed the L5 vertebra in its entirety.  He was wheelchair bound and very weak. His wife took care of almost everything for him.  There is no cure for him—the tumor cannot be removed—so our goal was to help decrease his severe pain.  The neurosurgeon wanted to use electromyography to help with fusing, to relieve some pain at the L5 root. We got an update on his progress Saturday morning when his wife (who spoke English and translated for him) told us, with tears in her eyes, that for the first time in TWO YEARS he was able to get solid sleep with minimal pain. He had been on high amounts of pain medication before the surgery and now was more comfortable with less medicine. Visibly seeing the relief on his face reminded me why I do what I do every day.  While we couldn’t stop the progression of his cancer, we could help make his quality of life a little bit better, and for that, they were so grateful.

In addition to the tumor fusion, we did eight scoliosis surgeries and changed the futures of these children. I often think of our comfortable, settled positions. As part of our busy lives and daily routines, we tend to see surgery after surgery, one no different from the last. We rarely see how much of an impact we actually have on each individual patient’s life and the lives of their friends and family.  Seeing the impact in the eyes of a child is absolutely the best way to see the results of our work, and it’s vital that we stop and think from time to time about the larger purpose of what we do. These kids were so happy, so excited, so grateful, and just so appreciative.  They made friendship bracelets for some of the nurses. They found us on Facebook and continue to update us on how much happier and healthier they are now.  If you ever have the opportunity to experience something like this, do not hesitate.  You will not regret a single moment.

Lauren Olejarz

About Lauren Olejarz

Lauren Olejarz, CNIM, Surgical Neurophysiologist III, works in the St. Louis region, Central Illinois, and Wisconsin. She joined SpecialtyCare in 2015 and spends most of her time providing neuromonitoring services for orthopedic spine cases. She is also proficient in monitoring neuro spine, brain, ENT, and vascular surgeries. In her free time, Lauren enjoys playing indoor and sand volleyball, riding her motorcycle, and hiking with her dogs.