Keywords
GTBH - UCMS - neurotrauma - cranial - spinal
Introduction
UCMS under the University of Delhi was initially established in 1971 at the present
location of the Safdarjung Hospital. Later on, it was integrated with the Guru Teg
Bahadur Hospital, commonly known as GTBH in 1986 and was shifted to the present location
in a sprawling campus at Dilshad Garden to cater to the large population based in
north east Delhi and trans-Yamuna area ([Fig. 1]). The hospital made a humble beginning in 1987 with 350 beds and over the years,
it has established its place in the country as a premier institute and an epitome
of medical excellence.[1]
[2] Though initially it was established to provide affordable tertiary and quaternary
health-care meeting established standards of patient care to a large population mainly
from north east Delhi, at present, the majority of the patient inflow is from neighboring
states. As an ambitious project of the Delhi government, the GTBH provides quality
care with optimum standards to all sections of society, more so the economically backward
sections. Funds for running of the institution are provided by the government. Therefore,
unlike other autonomous institutions, it does not have access to liberal funds for
frequent procurement of expensive tools of infrastructure. However, despite these
limitations, the neurosurgery department has made significant progress in the recent
few years. In this article, I have tried to describe the brief history of neurotrauma
care, present status of manpower and infrastructure to manage neurotrauma patients,
difficulties yet to overcome, and the roadmap for future.
Fig. 1 (topmost): UCMS Building at Safdarjung Hospital (1973); (middle): Formation of UCMS
(1985–87); (bottom): UCMS (2020–21).
Brief History
The full-fledged neurosurgery department in GTBH was established in 1997 by Dr. Sanjeev
Kumar Dua who was an alumnus of G B Pant Hospital. With strong support from the administration
led by Prof. D. K. Srivastava (Ex-Medical Superintendent, GTBH) and guidance from
Prof. A.K. Singh (Ex-Head of the Department of Neurosurgery, G B Pant Hospital) Dr.
Sanjeev started to work from the ground level and assembled a team of dynamic Neurosurgeons.
Initially, Neurosurgery was allotted only two elective tables per week in the ENT
operation theater and the team members operated with their own personal instruments.
Subsequently, the Neurosurgery Department was allocated a space for 18 beds for indoor
admission. With tremendous support from Late Dr. Ashok Walia (Ex-Health Minister,
Govt. of Delhi) and Prof. D.K. Srivastava, required manpower including paramedical
staff and junior doctors were recruited and facilities were upgraded. Within a short
time, neurosurgery was allotted a dedicated operation theater in the sixth floor of
the hospital building for elective surgeries 3 days a week and a separate round the
clock single OT table on all days of the week in the emergency block for performing
emergency cases including trauma cases. The emergency OT was further equipped with
required micro-instruments, and initially 10 posts were sanctioned for post MS senior
residents who provided round the clock emergency services and catered to all neurotrauma
cases. Gradually, there was a steady increase in neurotrauma cases along with number
of surgeries. Over the years, some of the faculty members left for other endeavors
and in their place, new set of faculty members joined. Name of the faculty members
who have worked in the Department of Neurosurgery are listed in [Fig. 2].
Fig. 2 Past and present faculty members. Top row: (from left to right) Dr. Sanjeev Dua,
Dr. D K Vatsal, Dr. Iqroop Chopra. Second row: (from left to right) Dr. Ajay Mishra,
Dr. Rakesh Dua, Dr. Ajay Choudhary. Third row: (from left to right) Dr. Wajid Nazir,
Dr. Sanjeev Gupta, Dr. Gurubachan Singh Bottom row: (from left to right) Dr. Pragyan
Sarma, Dr. Dinesh Kumar Satti.
One of the major hurdles at this stage was the nonavailability of a separate Neurosurgery
ICU, which compromised patient care. Dr. Rakesh Dua took the initiative to start a
four-bedded Neuro ICU in the Neurosurgery ward, which was later extended with three
additional HDU beds. Due to the shortage of staff in the anesthesia department, ICU
was managed by manpower from neurosurgery after imparting required training. Another
major achievement of Dr. Rakesh Dua was the starting of DNB Neurosurgery course in
2006 with yearly intake of one candidate. With the starting of academic course, a
teaching post from CHS-III cader was also sanctioned to GTBH and the first teaching
faculty to join was Dr. Ajay Choudhury in October, 2007. The introduction of academic
residency improved patient care significantly. During the subsequent years, the department
made significant progress with a steady increase in OPD patients, indoor admissions,
wide spectrum of surgeries, and increase in the number of surgical procedures. However,
in the later part of 2012 following the resignation of several faculty members, the
department was left with only Dr. Gurubachan Singh as the lone faculty member. Although
the neurotrauma services continued, due to lack of adequate strength of faculty, DNB
Neurosurgery course was withdrawn. In subsequent years, though Dr. Wajid Nazir and
Dr. Dinesh Satti joined as nonteaching specialists in May 2014 and June 2015, respectively,
there was no significant upgradation of infrastructure in the department from 2013
to 2017.
Modernization of the Department with Present Infrastructure and Resources
Modernization of the Department with Present Infrastructure and Resources
In May 2017, Dr. Pragyan Sarma joined as the Assistant Professor of Neurosurgery from
the CHS-III cader. He was an alumnus of the National Institute of Mental Health and
Neurosciences (NIMHANS). With tremendous help and encouragement from the administration
and active support from Dr. Sunil Kumar, the then MD, GTBH, Dr. Pragyan along with
other two faculty members of the department were instrumental in procuring many modern
gadgets and upgradation of the department ([Table 1]).
Table 1
Major equipment at disposal at present
|
1. Operating microscope: Carl Zeiss OPMI
2. Drills-Bien air, Midas Rex, Stryker and Manman
3. Karl Storz Neuroendoscopy system (Spinal and cranial)
4. Cavitron Ultrasonic suction aspirator.
5. Neuromonitor-NIM eclipse 2
6. Neuronavigation: Stealth station-8
7. Intracranial Doppler
8. C-arm with DSA
9. Micro debrider set for endoscopic surgery
10. New operating table
11. DSA table
|
For surgery of cranial trauma cases, drills were regularly used for craniotomy following
procurement. This shortened the operative duration of cranial trauma cases. Because
the department had only one 24 hours OT table in the emergency OT complex, reduced
duration of surgery meant less waiting time for cases waiting for surgery, ultimately
leading to higher census and benefits to a lot of needy patients. The main volume
of neurotrauma patients of GTBH belong to lower economical strata. For their welfare,
tenders were floated for spinal and cranial implants. Rate contracts were formulated
at the institution level and high-quality spinal implants were acquired and provided
free of cost to needy patients. Also, endoscopic evacuation of intracranial hematomas
was started in the emergency OT. Another very notable achievement was the starting
of endovascular services free of cost for the needy patients. Dr. Pragyan, after obtaining
training from Japan and Canada, took the initiative to start the endovascular procedures
along with other two team members. Along with other vascular emergencies, embolization
of the recurrent chronic subdural hematomas was started as a pilot project benefiting
several patients ([Fig. 3]). DNB Neurosurgery course too was restarted in 2019 with intake of one candidate
per year.[3] GTBH has always been a hub of post MS senior residents trying for entrance examinations
of Mch course across with every year, several them of them getting selected to premier
institutes across India. However, the addition of DNB candidate, a vibrant academic
atmosphere in the department and upgradation in infrastructure led to improvement
in the overall patient care. During the 2020 Delhi riots, the neurosurgery department
successfully managed the huge load of patients and was lauded for its services by
many of the leading daily newspapers[4]. During the subsequent COVID pandemic engulfing the country in 2020 and 2021, the
GTB Hospital was converted to a full-fledged COVID hospital. The neurosurgery department
along with other departments provided exemplary services by managing many critical
patients. Also, the huge rush of mucormycosis patients following the pandemic was
successfully handled by the whole team of neurosurgery in collaboration with other
departments.
Fig. 3 Pre- and postoperative images of a case of middle meningeal artery embolization in
a case of chronic subdural hematoma.
Currently, the department runs with three full-time permanent faculties (one teaching
and two nonteaching). It has sanctioned strengths of 14 senior and an equal number
of junior residents. There is an intake of one DNB candidate per year. The department
has a bed strength of 77 with a separate dedicated 10 bedded Neurosurgery ICU and
separate wards for neurotrauma emergency, and preoperative and postoperative cases.
OPD runs 3 days a week and emergency services function round the clock ([Fig. 4]).
Fig. 4 (A) One of the postoperative cases of cervical corpectomy. (B) Set up in the emergency OT (C) One of the trauma cases with EDH following craniotomy. (D) One of the Delhi riot cases managed successfully.
The census of the number of neurotrauma procedures performed from 2014 to 2019 is
shown in [Table 2]. Census for 2020 and 2021 are not included as for a major duration during those
2 years, during the COVID pandemic GTBH was converted to a COVID center dedicated
exclusively to such patients.
Table 2
Census of operated cases of Neurotrauma from 2014–2019
|
Year
|
Number of cranial cases
|
Number of spinal cases
|
Total cases
|
|
2014
|
236
|
16
|
252
|
|
2015
|
254
|
14
|
268
|
|
2016
|
224
|
22
|
246
|
|
2017
|
322
|
32
|
354
|
|
2018
|
348
|
64
|
412
|
|
2019
|
414
|
84
|
498
|
Difficulties Encountered and Roadmap for Future
Difficulties Encountered and Roadmap for Future
In modern era, the main pillars of optimal neurotrauma care are a robust neuro-critical
care set up equipped with trained manpower, good infrastructure, and a hospital protocol
for polytrauma and neurotrauma patients. Minimizing the cost more so in third-world
countries, neurorehabilitation care and optimizing the available resources at hand
are equally important. At present, though there is a dedicated neuro-ICU in GTBH,
it is manned by the staff from the parent department due to lack of adequate strength
in the Anesthesia Department. Imparting proper training to residents and paramedical
staff is a stiff challenge more so when paramedical staffs are rotated frequently
and pool of post MS senior and junior residents keep changing. At times, it can compromise
patient care in critical cases at odd hours. Also, despite recent modernization of
the department, at times due to increased patient load, there is paucity of ventilators
and critical care beds. Though there is a provision to increase the ventilator beds,
cost is a major hindrance. One of the solutions discussed in our institute was the
procurement of indigenously built advanced portable ventilators in the All India Institute
of Medical Sciences by Dr. Deepak Agarwal. Though initial steps were taken toward
buying these, the COVID pandemic has hampered the progress. However, in the near future,
we plan to take it to a logical conclusion. Another major challenge is sensitizing
and training the staff in the casualty ward to follow and implement the existing hospital
protocol in polytrauma patients. Neurorehabilitation is another area where much work
still needs to be done in GTBH. In future, the department aims to address these challenges
and deliver the best care possible to neurotrauma patients. Steps are also being planned
to address the desperate need of 24 hours availability of neuroanesthetists, critical
care experts, and neuronurses. Neurosurgery department of GTBH is fully committed
to the advancement and promotion of neurotrauma services in the country.
