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Michael Traynor, MD
Surgical Training Programs Across Rural Africa Better Prepare Surgeons for Humanitarian Disasters than US-Based Training
Purpose: There is great need for more surgeons to provide quality care for patients impacted by humanitarian disasters and for the millions of people in rural Africa who lack access. However, prior literature suggests surgeons trained in resource-rich environments, such as those from the United States in Accreditation Council for Graduate Medical Education (ACGME) programs, are ill-equipped to navigate challenges in humanitarian crises.2,3 Faith-based hospitals have been training general surgeons locally in rural and sub-Saharan Africa for 25 years1. We aimed to investigate whether surgeons training in sub-Saharan Africa were more specifically equipped than those in resource rich countries to care for populations impacted by humanitarian disasters.
Methods: Operative procedures were categorized and validated from a cohort of twenty Pan-African Association of Christian Surgeons (PAACS) graduates from five training programs in four countries. Public reports of ACGME experience were utilized. Comparisons were made to the reported experience of Médecins Sans Frontières (MSF) in humanitarian disasters2.
Results: Humanitarian disasters require broad surgical experience, notably essential general surgery, orthopedics, urology, and obstetrics and gynecology. For such procedures, PAACS trainees performed more major cases than ACGME graduates in the categories of gynecology & obstetrics (p=0.0001), orthopedics (p=0.0003), operative trauma (p=0.0003), and urology (p=0.0001). While ACGME graduates performed more cases than PAACS graduates for abdomen (p=0.002), breast (p=0.04), thoracic (p=0.0001), laparoscopy (p=0.0001), and vascular categories (p=0.0002), these were not as relevant to the experience of essential surgery required in humanitarian disasters.
Conclusion: Compared to ACGME residents, PAACS trainees perform and acquire competence in more operations that are relevant to the experience of MSF in humanitarian disasters. Training surgeons in low-resource settings who are well-equipped to address humanitarian disasters should be a priority.
Purpose: Procedural simulation in healthcare is frequently used in high income countries and has demonstrated effectiveness in the acquisition of procedural skills. With the known benefits of using simulation in health professions education and the link to improved patient outcomes, low- and middle-income countries (LMICs) have also adopted healthcare simulation training. Researchers have increasingly investigated the efficacy of simulation at improving procedural skills in LMICs. To guide such efforts and prioritize research questions, the scope of the current simulation research in LMICs must be better understood. Therefore, we aim to summarize the current state of procedural skills healthcare simulation in LMICs, including the cost, cost-effectiveness, and overall sustainability of these simulation programs.
Methods: A systematic review was performed of original research articles that assessed procedural simulation for healthcare professionals and students in LMICs. Databases queried included MEDLINE®, Embase, Cochrane, Scopus, and African Index Medicus. Additionally, grey literature was included from thematically related systematic reviews. Two researchers independently screened titles and abstracts to determine eligibility. After articles were selected for full text review, articles were divided between authors who, in teams of two, independently reviewed and coded information from their subset of articles. Paired authors reached consensus through discussion when discrepancies existed. Information extracted from each article included country, study design, simulation type, discussion of simulation cost or cost effectiveness, discussion of sustainability, and outcomes studied. Research outcomes in each study were characterized by whether the outcome measured learner performance in simulated settings or in real clinical settings and whether the outcomes measured were related to knowledge, time, the process of performing a skill, and/or the end-product of skill performance.
Results: From a pool of 4,106 articles published up to November 2019, 423 were considered for full-text review after title and abstract screening. After full text review, 190 articles were included in this review. Of those, 39 articles (21%) were randomized controlled trials and 151 were observational cohort studies (79%), of which the vast majority were a pre-, post-test experimental design. Obstetrics and neonatal medicine were the area of simulation most studied (74 articles, 39%), followed by general surgery (31 articles, 16%) and Basic Life Support (BLS) (25 articles, 13%). The majority of studies (149 articles, 78%) compared simulation to no intervention or pre-existing educational activities. The majority of outcomes measured were knowledge-based. The overwhelming conclusion was that simulation is a superior educational methodology when compared to no intervention in LMIC settings. Several studies mentioned cost (72 articles, 38%), cost-effectiveness (4 articles, 2%), or sustainability (64 articles, 34%) in the article text. However, few articles included monetary cost (20 articles, 11%) and no studies analyzed sustainability efforts or cost-effectiveness as research outcomes.
Conclusions: Simulation as a means of education and training works in LMICs. Not surprisingly, simulation shows significant benefits in most domains of healthcare training. The authors would argue that given the positive effects of simulation on learning, future studies in LMICs should focus on comparing different simulation techniques or questions directed at sustainability and cost-effectiveness of simulation in LMICs.
Outcomes of Pancreatic Cyst: Analysis of 90,958 Patients from Nationwide Inpatient Sample Database
Kenji Okumura, MD, FICS, Resident, Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
Acute pancreatitis (AP) may be associated with serious complications. While the management of AP has improved in past decades, complications of pancreatic pseudocyst in major databases have not been studied. The purpose of this study was to investigate the nationwide outcome of hospitalization for pancreatic pseudocyst.
A retrospective review was conducted using data from the 2005 - 2014 National Inpatient Sample. Adults (age, ≥ 18 years) with a diagnosis of cyst/pseudocyst, as defined by ICD-9-CM codes, were included in analysis and adults with a diagnosis of pancreatic benign tumor or malignancy were excluded. Patients were divided into two groups: Early Phase (EP), 2005 - 2009, and Later Phase (LP), 2010 - 2014. Differences in outcomes including mortality, length of stay (LOS), and total cost of hospital care were assessed using multivariable regression models.
90,958 patients were admitted in the study period [39,249 (43%) EP, and 52,078 (57%) LP]. The mean age was younger in EP than that in LP (57.0 vs. 58.0, p<0.001). The mortality was significantly higher in EP than that in LP (2.3% vs. 1.3%, p<0.001). Compared to EP, LP showed that the total cost of care was significantly higher, however, LOS was significantly shorter ($58k vs. $67k, respectively, p<0.001; 9.8 vs. 8.3 days, respectively, p<0.001). After adjustment of demographics, LP showed better survival than EP (Odds Ratio 0.75; 95% Confidence Interval 0.67-0.83, p<0.001).
Our study showed the trend of the treatment of pancreatic pseudocyst. The outcome of pseudocyst had improved compared to before.
Early and Late Postoperative Complications of Mandible Reconstruction: Osseous Versus Soft Tissue Flaps
Jake Goldstein, Medical Student, Medical Student, Loyola University Chicago Stritch School of Medicine, Forest Park, IL
Flap reconstruction has expanded a physician's ability to treat patients with complex mandible defects. This study compared complication rates between the current gold standard, osseous free flaps (OFF), and the alternative, soft tissue flaps with a reconstruction bar (STF).
Retrospective chart review of patients who underwent mandible reconstruction with OFF or STF at Loyola University Medical Center from 2007 to 2017. Early complications (EC) occurred within thirty days of surgery and late complications (LC) thereafter.
Twenty-eight patients were reconstructed with STF and 100 with OFF. Thirty-three patients had an EC (25.8%) and 31 had a LC (32.6%). In the group of patients that received an OFF, 25 experienced an EC (25.0%) and 27 experienced a LC (36.0%). In the group of patients that received a STF, 8 experienced an EC (28.6%) and 4 experienced a LC (14.3%). Eleven patients had multiple early complications (8.6%) and 19 had multiple late complications (32.6%). In the patients who received an OFF, 9 patients experienced multiple early complications (9.00%) and 17 experienced multiple late complications (18.7%). In the patients who received a STF, 2 patients experienced multiple early complications (7.1%) and 2 patients experienced multiple late complications (7.7%). Of the 100 patients reconstructed with an OFF, 14 were readmitted (14.0%), 6 of which were flap-related (42.9%) and 8 for other medical indications (57.1%). Of the 28 patients reconstructed with a STF, 4 were readmitted (14.3%), 1 of which was flap-related (25.0%) and 3 of which were not related to their flap (75.0%).
STF did not show higher rates of complications.
Risk Factors for Failure of Non-Operative Management in Patients with Intracranial Hemorrhage and Blunt Splenic Injury
Nicole Boswell, BS, Medical Student, University of South Carolina School of Medicine, Greenville, SC
There is limited literature evaluating failure of NOM in blunt splenic injuries and its effects on outcomes in TBI patients. Poor oxygen delivery and hypotension are well known risk factors for poor outcomes in TBI patients, both of which can occur in the setting of hemorrhage from failure of NOM in blunt splenic trauma. This is an institutional review of risk factors associated with failure of NOM of blunt splenic injury in patients with concomitant TBI.
This is a retrospective chart review of patients in the trauma registry at Greenville Memorial Hospital from March 2013 to July 2019. We reviewed 562 charts of patients with the diagnosis of blunt splenic trauma, of which 107 had a diagnosis of intracranial hemorrhage. We used Chi square analysis and student’s T-test to extrapolate risk factors for failure of NOM.
555 patients of the 562 met inclusion criteria into the study. Eighty-nine of those were admitted for NOM, 45 of which failed NOM. Fifteen of those 45 that failed NOM had a concomitant intracranial hemorrhage (ICH). Elevated heart rate (p=0.007), elevated ISS (p=<0.001), decreased GCS (p=<0.001), and presence of mechanical ventilation (p=0.002) were risk factors for failure of NOM with associated intracranial hemorrhage. Of those with ICH that failed NOM, 86.7% (n=13) were male. Mortality rates were increased in those with ICH who underwent NOM compared to those without ICH (p= 0.005). CT blush, hemoperitoneum, and other abdominal injuries were less frequently seen in the NOM group since most of those patients entered the operative management group.
Overall, elevated heart rate, elevated ISS, decreased GCS, and presence of mechanical ventilation were seen more frequently in patients with ICH that underwent NOM for blunt splenic trauma. Patients who underwent NOM with ICH had higher mortality rates than those without ICH.
Purpose: Seventy per cent of the global population do not have access to safe and affordable surgical and anaesthesia care, and 90% of them are found in the low and middle-income countries. The World Health Organization deemed perioperative mortality rate as a gross indicator for access to safe and affordable surgical and anaesthesia care. India is the second-largest country by population and the World Bank considers India to be a low-middle income country. This predisposes the Indian population to not have access to safe and affordable surgical care. We aimed to descriptively assess the perioperative mortality rate of a low resource non-governmental organization hospital in India.
Methodology: We performed a retrospective clinical audit from January 2016 to February 2020. We collected the operation volume from the operation theatre registry, all recorded deaths in relation to surgery during the timeframe of data collection and investigated each death. We also investigated patients who were discharged against medical advice to have a holistic view of the perioperative mortality of the hospital. The data was then analysed descriptively with Microsoft excel.
Results: The operation theatre registry recorded 1860 patients who underwent major operations with sedation. The perioperative mortality was 3 (0.16%). Mortality was found in general surgery (n=2) and obstetrics and gynaecology (n=1) department. The case-mix done under obstetrics and gynaecology was at 1046 (56.2%), general surgery at 614 (33.0%) and orthopaedics at 200 (10.8%). There were 388 (20.8%) emergency cases recorded. This was persistent with every year that was recorded with emergency cases ranging from 18-22%. We found that our average surgical volume per year was 448 (excluding the year 2020), this was consistent with previous years after extrapolating the surgical volume.
Conclusion: Vivekananda Memorial Hospital is a non-governmental organization (NGO) hospital that serves 300 thousand population from 4 districts in the state of Karnataka with 100 beds. Among these 300 thousand population, there are multiple hospitals serving this population. Within this hospital, there were 4 obstetrician, 1 orthopaedic surgeon and 1 general surgeon. The attending paediatrician, task shifts to becoming the attending anaesthesiologist for all cases in the hospital. There is 1 ICU bed for both adults and children, and 1 post-operative recovery bed. There is 1 operation theatre for general surgery and orthopaedics cases and 1 operation theatre for obstetrics and gynaecological cases. This hospital can provide open laparotomy and caesarean section delivery. Using the bellwether procedures as a benchmark, this hospital can provide most of the essential procedures needed. With limited human resource and hospital resources, the hospital is still able to perform better than the global standard of operative safety with a perioperative mortality rate of 0.16%. However, by interviewing the surgeons, there were a few patient data that was not captured although a rigorous process was performed to attempt to capture all patient data. Case selection to undergo safe surgery in low resource hospitals are imperative. Wisdom paired with clinical experience must guide referrals to larger hospitals with the appropriate capacity to provide safe surgical care. This audit shows that access to safe and affordable surgical care is achievable in a low resource NGO setting.
According to the Lancet Commission on Global Surgery, it describes access to safe and affordable surgical and anaesthesia care includes financial safety. Perioperative mortality does not capture this. It captures a general understanding of the access to a health facility, and the safety and capacity of surgical and anaesthesia care. We took the liberty to further assess the fiscal charges of the health services provided. Almost all services provided in this hospital charged cheaper services in comparison to the other hospitals. Tribal groups receive 50% off on top of the usual charges and if they cannot pay the 50% reduced hospital charges, healthcare can be made pro bono on a case by case basis. This further strengthens our study that access to surgical and anaesthesia care is achievable even in a low-resource setting.
Introduction : The WHO Surgical Safety Checklist aims to decrease errors ,adverse events, and thus increase teamwork and communication in surgery. The checklist ensures the safety of patients during surgery. The aim is to complete an audit on the level of compliance to the WHO surgical safety checklist in surgical operating theatres at MGM Hospital.
Method : The data was collected retrospectively , where in the first part of the study only 20 general surgery case files were studied to cross-check its compliance with the WHO Surgical safety checklist. The place of audit was at the MGM Operation theatres and was conducted for a period of 1 month during November 2020. Interventions were carried out by a series of meetings and discussions with the medical and the nursing staff. Results were re-audited after 2 weeks in all surgical departments to cross-check and compare the compliance in other allied surgical departments as well.
Results : In the first part of the study , 60% of the compliance was reported in all three stages of the checklist for General surgeries. After the re-audit , the compliance observed in General surgery, Orthopedic , ENT , CVTS ,Urology , Neurosurgery were 90% , 90% , 90% , 90% ,95% and 90% respectively.
Discussion : Compliance is seen to be greater in major surgeries than in minor surgeries. The compliance with all items in the checklist and active participation by all medical and nursing staff is mandatory for successful implementation of the Surgical safety checklist.