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Global Trauma Surgeons Working in Low and Middle Income Countries - How Accessible Is ATLS?
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
position of Roux limb, or closure of mesenteric defects was associated with IH. During the study period, a change of practice to routine closure of mesenteric defects during laparoscopic gastrectomy was instituted. There was no difference in operative time (median 270 min, range 180-420 min with closure; median 270 min, range 200-390 min without closure) or perioperative morbidity (28.6% with closure, 25.0% without closure; P ¼ 0.85) with laparoscopic closure of mesenteric defects. Conclusions: The incidence of IH after gastrectomy with Roux-Y reconstruction for cancer is significant with both open and laparoscopic approaches, but these data suggest it is even higher with laparoscopic approach. Closure of mesenteric defects should be considered to minimize the incidence of this potentially devastating complication, especially after minimally invasive gastrectomy.
Open Laparoscopic All
DSTG
TG
All
1/99 (1.0%) 1/16 (6.2%) 2/115 (1.7%)
8/165 (4.8%) 3/18 (16.7%) 11/183 (6.0%)
9/264 (3.4%) 4/34 (11.8%) 13/298 (4.3%)
GLOBAL HEALTH 25.1. Global Trauma Surgeons Working in Low and Middle Income Countries - How Accessible Is ATLS? P. Ortiz1 T. Zakrison2; 1Hospital Eugenio Espejo, Quito, Pichincha; 2 University of Miami Miller School of Medicine - Ryder Trauma Center, Miami, Florida Introduction: Trauma volumes remain high in Low and Middle Income Countries (LMICs). Protocolized trauma care around the world has been facilitated by the American College of Surgeon’s Advanced Trauma Life Support (ATLS) course. It remains unclear how accessible this course is to trauma surgeons in these LMICs. We decided to explore if any barriers to enrollment exist for the ATLS course in one LMIC in South America using a novel research methodology applicable to global resource-poor settings around the world. Methods: Qualitative methodology was used to explore the ideas of trauma surgeons working at a public Level I Trauma Centre in a representative LMIC. A focus group consisting of six trauma surgeons was conducted. Interviews were then transcribed, coded and analyzed for emergent themes using grounded theory methodology to generate theory from data. Results: Interest in participating in and teaching ATLS for trauma surgeons remains very high. The main theme that emerged was the existence of significant barriers to ATLS participation. Further subthemes elucidated that these barriers were largely due to the prohibitive cost of the course, equivalent to 80% of one month’s salary for a local trauma surgeon. Residents were thus even more unlikely to have access to course enrollment. Further subthemes highlighted the disproportionate financial barrier faced by trauma surgeons working within the public sector, given their lower salaries overall. This is compared to private sector trauma surgeons who see a lower volume of trauma with less seriously injured patients. Solutions proposed included a free, generic, hospital-based trauma course modeled on courses like ATLS that would be accessible by all interested trauma providers. Conclusions: Significant financial barriers exist to taking ATLS for public-sector trauma surgeons in one representative LMIC. This reality may be similar for trauma surgeons in many other LMICs across the world. Generic and free trauma courses developed locally may be the global solution for these resource-limited regions. 25.2. Can Focused Trauma Education Initiatives Reduce Mortality OR Improve Resource Utilization in A Low-Resource Setting? R. T. Petroze,1,2 J. C. Byiringiro,2 G. Ntakiyiruta,2 R. Riviello,3 S. M. Briggs,4 T. Razek,5 D. Deckelbaum,5 R. G. Sawyer,1 P. Kyamanywa,2 J. F. Calland1;
1
Department of Surgery, Charlottesville, VA; 2Faculty of Medicine, Butare, _; 3Department of Surgery, Boston, MA; 4 Department of Surgery, Boston, MA; 5Centre For Global Surgery, Montreal, Quebec Introduction: Advanced Trauma Life Support (ATLS) teaches a systematic approach to the initial management of injured patients in over 60 countries. Limited data exists on the impact of ATLS or similar teambased courses on patient outcomes, particularly in low and middle-income countries (LMIC). We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. Methods: Two 3-day trauma education courses were conducted in the capital of Rwanda over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents and nurses. Prior to the course, a locally-developed trauma registry was implemented to systematically record patient demographics, pre-hospital care, initial physiology, early interventions, and patient outcomes. Trauma registry data over the six months prior to the courses were compared to the six months afterwards with ED mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses using chi-square and Fisher’s exact test were conducted to discern statistical significance (p<0.05). Results: A total of 798 and 572 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. No significant baseline differences in physiology, mechanism of injury, injury type, or injury severity were detected. While overall mortality of injured patients in the ED decreased after education implementation from 8.8% to 6.3%, the difference was not statistically significant (p¼0.09). Patients with severe head injuries had the highest injury related mortality at baseline, which showed a statistically significant decrease from 58.5% (n¼55) to 37.1% (n¼23), (p¼0.009, OR 0.42, 95% CI 0.220.81). In the post-intervention period, head injury patients who were intubated were 80% less likely to die than those who were intubated in the pre-intervention period (p¼0.002, OR 0.18, 95% CI 0.06-0.53). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. Conclusions: The mortality of severely head-injured patients decreased after initiation of focused trauma education courses in the capital of Rwanda. The explanation for this observation may be complex and multi-factorial as no significant increase in resource utilization was noted during the study period, nor was any decrease in overall mortality noted for the population as a whole. As such, long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system. 25.3. Viewing International Collaborations From the Other Side: A Pilot Survey of African Surgeons by the SUS Committee On Global Academic Surgery. M. Frost,1 E. Yang,1 B. Nwomeh,2 S. L. Orloff,1 S. Krishnaswami1; 1 Department of Surgery, Oregon Health & Science University, Portland, OR; 2Department of Surgery, Nationwide Children’s Hospital, Columbus, OH Introduction: Interest in surgical collaborations with Low and Middle Income Countries (LMICs) is increasing. Previous studies have probed the views of US surgeons on these collaborations, but little is known about the corresponding attitudes of the LMIC partners. Methods: A paper survey was distributed to attendees of a session on resident training at the West African College of Surgeons meeting in Liberia in February 2012. Information was obtained on details of
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
position of Roux limb, or closure of mesenteric defects was associated with IH. During the study period, a change of practice to routine closure of mesenteric defects during laparoscopic gastrectomy was instituted. There was no difference in operative time (median 270 min, range 180-420 min with closure; median 270 min, range 200-390 min without closure) or perioperative morbidity (28.6% with closure, 25.0% without closure; P ¼ 0.85) with laparoscopic closure of mesenteric defects. Conclusions: The incidence of IH after gastrectomy with Roux-Y reconstruction for cancer is significant with both open and laparoscopic approaches, but these data suggest it is even higher with laparoscopic approach. Closure of mesenteric defects should be considered to minimize the incidence of this potentially devastating complication, especially after minimally invasive gastrectomy.
Open Laparoscopic All
DSTG
TG
All
1/99 (1.0%) 1/16 (6.2%) 2/115 (1.7%)
8/165 (4.8%) 3/18 (16.7%) 11/183 (6.0%)
9/264 (3.4%) 4/34 (11.8%) 13/298 (4.3%)
GLOBAL HEALTH 25.1. Global Trauma Surgeons Working in Low and Middle Income Countries - How Accessible Is ATLS? P. Ortiz1 T. Zakrison2; 1Hospital Eugenio Espejo, Quito, Pichincha; 2 University of Miami Miller School of Medicine - Ryder Trauma Center, Miami, Florida Introduction: Trauma volumes remain high in Low and Middle Income Countries (LMICs). Protocolized trauma care around the world has been facilitated by the American College of Surgeon’s Advanced Trauma Life Support (ATLS) course. It remains unclear how accessible this course is to trauma surgeons in these LMICs. We decided to explore if any barriers to enrollment exist for the ATLS course in one LMIC in South America using a novel research methodology applicable to global resource-poor settings around the world. Methods: Qualitative methodology was used to explore the ideas of trauma surgeons working at a public Level I Trauma Centre in a representative LMIC. A focus group consisting of six trauma surgeons was conducted. Interviews were then transcribed, coded and analyzed for emergent themes using grounded theory methodology to generate theory from data. Results: Interest in participating in and teaching ATLS for trauma surgeons remains very high. The main theme that emerged was the existence of significant barriers to ATLS participation. Further subthemes elucidated that these barriers were largely due to the prohibitive cost of the course, equivalent to 80% of one month’s salary for a local trauma surgeon. Residents were thus even more unlikely to have access to course enrollment. Further subthemes highlighted the disproportionate financial barrier faced by trauma surgeons working within the public sector, given their lower salaries overall. This is compared to private sector trauma surgeons who see a lower volume of trauma with less seriously injured patients. Solutions proposed included a free, generic, hospital-based trauma course modeled on courses like ATLS that would be accessible by all interested trauma providers. Conclusions: Significant financial barriers exist to taking ATLS for public-sector trauma surgeons in one representative LMIC. This reality may be similar for trauma surgeons in many other LMICs across the world. Generic and free trauma courses developed locally may be the global solution for these resource-limited regions. 25.2. Can Focused Trauma Education Initiatives Reduce Mortality OR Improve Resource Utilization in A Low-Resource Setting? R. T. Petroze,1,2 J. C. Byiringiro,2 G. Ntakiyiruta,2 R. Riviello,3 S. M. Briggs,4 T. Razek,5 D. Deckelbaum,5 R. G. Sawyer,1 P. Kyamanywa,2 J. F. Calland1;
1
Department of Surgery, Charlottesville, VA; 2Faculty of Medicine, Butare, _; 3Department of Surgery, Boston, MA; 4 Department of Surgery, Boston, MA; 5Centre For Global Surgery, Montreal, Quebec Introduction: Advanced Trauma Life Support (ATLS) teaches a systematic approach to the initial management of injured patients in over 60 countries. Limited data exists on the impact of ATLS or similar teambased courses on patient outcomes, particularly in low and middle-income countries (LMIC). We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. Methods: Two 3-day trauma education courses were conducted in the capital of Rwanda over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents and nurses. Prior to the course, a locally-developed trauma registry was implemented to systematically record patient demographics, pre-hospital care, initial physiology, early interventions, and patient outcomes. Trauma registry data over the six months prior to the courses were compared to the six months afterwards with ED mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses using chi-square and Fisher’s exact test were conducted to discern statistical significance (p<0.05). Results: A total of 798 and 572 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. No significant baseline differences in physiology, mechanism of injury, injury type, or injury severity were detected. While overall mortality of injured patients in the ED decreased after education implementation from 8.8% to 6.3%, the difference was not statistically significant (p¼0.09). Patients with severe head injuries had the highest injury related mortality at baseline, which showed a statistically significant decrease from 58.5% (n¼55) to 37.1% (n¼23), (p¼0.009, OR 0.42, 95% CI 0.220.81). In the post-intervention period, head injury patients who were intubated were 80% less likely to die than those who were intubated in the pre-intervention period (p¼0.002, OR 0.18, 95% CI 0.06-0.53). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. Conclusions: The mortality of severely head-injured patients decreased after initiation of focused trauma education courses in the capital of Rwanda. The explanation for this observation may be complex and multi-factorial as no significant increase in resource utilization was noted during the study period, nor was any decrease in overall mortality noted for the population as a whole. As such, long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system. 25.3. Viewing International Collaborations From the Other Side: A Pilot Survey of African Surgeons by the SUS Committee On Global Academic Surgery. M. Frost,1 E. Yang,1 B. Nwomeh,2 S. L. Orloff,1 S. Krishnaswami1; 1 Department of Surgery, Oregon Health & Science University, Portland, OR; 2Department of Surgery, Nationwide Children’s Hospital, Columbus, OH Introduction: Interest in surgical collaborations with Low and Middle Income Countries (LMICs) is increasing. Previous studies have probed the views of US surgeons on these collaborations, but little is known about the corresponding attitudes of the LMIC partners. Methods: A paper survey was distributed to attendees of a session on resident training at the West African College of Surgeons meeting in Liberia in February 2012. Information was obtained on details of