By Nelson J. Maldonado, MD, Manuel Jibaja, MD, Claudio Scherle, MD, and Jose I. Suarez, MD (left to right)
Ecuador is a South American country straddling the equator and crisscrossed by the Andean Mountain Range. It has a population of 14.5 million, and is bordered by Colombia to the North and Peru to the South. Ecuador’s largest two cities are Quito (its capital), located at 9,500 feet above sea level, and Guayaquil, located at sea level. Ecuador’s population is a melting pot of people of European, Amerindian, African, and Middle Eastern descent. Due to the ethnic diversity of its people and the various altitudes at which they dwell, health care professionals are faced with unique medical conditions. Health care coverage is provided by three different systems: private pre-paid services, pension-based Social Security, and government-paid programs to cover the poorest inhabitants.
Quilotoa Volcano lagoon, Ecuador
Advanced Hospital Care
The Hospital de Especialidades Eugenio Espejo (HEEE) is the main public hospital in Quito with a capacity of 420 fully staffed and licensed beds. HEEE is the main national referral hospital for all specialties, and as such, a national pioneer in the management of acute neurologic pathologies. In 2015, it became the first hospital in the country to develop a stroke/step down unit (SU), and so far it remains the only hospital to do so. HEEE has developed via international collaborations a unique clinical neurosciences department with fellowship-trained neurologists, neurointensivists, neurosurgeons, neuro interventionists, and physical medicine and rehabilitation specialists.
The SU is located on the eighth floor within the neurology general unit. It has nine beds with continuous systemic monitoring capabilities, which are centralized to a main nursing station. We provide semi-intensive vigilance for patients with ischemic stroke, ICH, subarachnoid hemorrhage, myasthenia gravis (MG), status epileptics (SE), and guillain barre syndrome (GBS), among others, as long as no mechanical ventilation is required following established international protocols.
Our team is led by one neurointensivist and one vascular neurologist and composed of internal medicine residents (as there are no neurology residency programs in the country at the present time), nurses, and physical therapists. The nurse-to-patient ratio is 1:5. We have the capability to perform bedside evaluations such as carotid and transcranial doppler ultrasound. However, we are hampered by the lack of adequate and well-maintained equipment, which limits the development of neurosonology. We are constantly faced with challenges to perform timely ancillary tests, such as echocardiograms, MRIs, and CT scans, mainly due to equipment failure and a dearth of specialists to perform the tests. In addition, HEEE is not equipped with continuous EEG technology. Moreover, the medications available to control elevated blood pressure, one of the main targets of management in an SU, differ when compared to the U.S. or Europe. For example, the only parenteral antihypertensive available is sodium nitroprusside, and the only antiepileptic drugs are phenytoin and valproate. We are capable, however, of administering IVIG for acute inflammatory or autoimmune processes. Despite all these challenges, we are happy to report that since November 2016, 131 stroke patients haven been evaluated in the SU, 89 of them with acute ischemic stroke and 12 received IV r-TPA, and 29 with ICH.
The HEEE has had a mixed-type ICU since 1988. It began with a capacity of six beds and has progressively increased to 23. The ICU functions as an open unit (there are no closed units in the country) and is a national referral center. On average, the annual number of admissions is 900 patients, the median length of stay is seven days, and the in-hospital mortality rate is 18.3 percent. About 32 percent of admissions are patients with some type of acute neurological pathology who require mechanical ventilation. By order of frequency, the main neurological pathologies seen in the ICU include brain tumors (about 150 patients yearly), followed by severe traumatic brain injury (TBI)—70 patients, and neurovascular issues (ICH and ischemic stroke)—60 patients, among others. As the national neurovascular referral center, we receive patients with aneurysmal subarachnoid hemorrhage, arteriovenous malformations, and fistulas from across the country. Patients are admitted under the care of the intensivist team with consultation to neurology and neurosurgery services. An intensivist and a group of ICU residents lead the rounding team. The nurse-to-patient ratio is 1:3. There are no physician assistants or advanced practice nurses in Ecuador. The ICU management protocols are based on the application of currently available and accepted international guidelines, bearing in mind our limitations. These include the lack of proper equipment such as restricted capabilities for multimodality neuromonitoring and endovascular therapies, and no continuous EEG technology. In addition, there are limitations in the availability of parenteral medications, temperature management devices, and plasma exchange machines.
Education and Training
Education and training programs in general critical care have been available for the last 15 years. However, there is currently no formal neurocritical care training program in the country. Our ICU has become actively involved in local and international research projects, such as the BEST TRIP trial.
We have instituted international collaborations with the goal of improving patient care, promoting education and training of health care professionals, and establishing research projects. Edgar Samaniego, MD, and Santiago Ortega, MD, from Iowa State University (ISU) join the local neurointerventional team every three months and treat complex vascular cases. We are currently setting up a formal agreement between the Universidad San Francisco de Quito (USFQ)/HEEE and ISU to develop a neurointerventional training program. In addition, we have been working on a curriculum for a neurocritical care fellowship program and guidelines for the development of a neurocritical care unit under the leadership of Jose I. Suarez, MD, from The Johns Hopkins University, and Nelson Maldonado, MD, from USFQ.
The International Neurologic and Neurocritical Care Annual Conference takes place in Quito, and after three successful gatherings, we are very proud and happy to report that for the 2017 meeting we have partnered with NCS to turn it into the official venue for the South American Regional Chapter of NCS. The conference is scheduled during the third week of November, and specialists from all over South America and the United States will attend and share their clinical experiences and potential research collaborations. Simultaneous translation is available to enhance the exchange of ideas among attendees. We also have organized a parallel Neurocritical Care Research Summit at the Galapagos archipelago to evaluate needs and recommendations for research in this field in Ecuador and throughout the region.
Finally, we are maturing research projects such as the High Altitude Neurophysiology and Applied Knowledge (HANAK) program, which is a combined effort between U.S. academic centers, USFQ, and YACHAY led by Jose I. Suarez and Nelson J. Maldonado with the overall goal of understanding neurophysiologic differences between high altitude and sea level dwellers.