Developing a Comprehensive Surgical Simulation Program for Medical Students in the Rwandan Context

Abstract

INTRODUCTION: Simulation is a recognized tool for effective technical and nontechnical surgical skills training in a low-risk environment. Although benefits are obvious for both high- and low-income contexts, most simulation curricula have been targeted to high-resource settings. We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda. METHODS: Content areas were identified through a modified Delphi process implemented across sub-Saharan Africa, with emphasis on the needs of surgical teams practicing in district hospitals. Sixty-eight surgical practitioners and educators across Eastern, Central, Southern, and West Africa participated. An interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students generated scenario- and procedure-based content for the junior surgical clerkship simulation curriculum. RESULTS: Participants had 75% agreement on 32 procedures and scenarios which could potentially be taught using simulation. Agreement was highest for aseptic technique, surgical gloving and gowning, consent, basic suturing techniques, and use of local anesthesia. The simulation training schedule (Table) was designed to begin with a 12-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options. Table. - Surgical Simulation Sessions for the Simulation Intensive Week and Weekly Sessions Week Simulation Curriculum Content Simulation Intensive Week Day 1 Informed Consent, WHO Safety Checklist, Patient Positioning, Patient Draping Day 2 Local Anesthesia, Introduction to Surgical Instruments, Introduction to Knot Tying, Introduction to Suturing Day 3 Interactive ATLS, Basic Airway Management, Chest Tube Insertion, Focused Assessment Sonography for Trauma Ultrasound, Log-roll Day 4 Drainage of Superficial Abcess, Wound Debridement and Drainage, Excision and Biopsy of a Cutaneous Lesion Day 5 Endotracheal Intubation and Trauma Simulation Scenarios Weekly Session 1-8 Venous Access (Peripheral and Central), Insertion of Nasogastric Tubes, Intestinal Obstruction Scenarios, Rectal Examination and Proctoscopy, Breast Examination and Biopsy, Urethral and Suprapubic Catheterization, Splinting and Plaster of Paris Application, Head Trauma Scenarios, Burn Patient Assessment and Management CONCLUSION: Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students’ knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.