Basic Surgical Care Research Articles

Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania.

BackgroundProviding basic surgical and emergency care in rural settings is essential, particularly in Tanzania, where the mortality burden addressable by emergency and surgical interventions has been estimated at 40%. However, the shortages of teaching faculty and insufficient learning resources have hampered the traditionally intensive surgical training apprenticeships. The Muhimbili University of Health and Allied Sciences consequently has experienced suboptimal preparation for graduates practising surgery in the field and a drop in medical graduates willing to become surgeons. To address the decline in circumstances, the first step was to enhance technical skills in general surgery and emergency procedures for senior medical students by designing and implementing a surgical skills practicum using locally developed simulation models.MethodsA two-day training course in nine different emergency procedures and surgical skills based on the Canadian Network for International Surgery curriculum was developed. Simulation models for the surgical skills were created with locally available materials. The curriculum was pilot-tested with a cohort of 60 senior medical students who had completed their surgery rotation at Muhimbili University. Two measures were used to evaluate surgical skill performance: Objective Structured Clinical Examinations and surveys of self-perceived performance administered pre- and post-training.ResultsThirty-six students participated in the study. Prior to the training, no student was able to correctly perform a surgical hand tie, only one student was able to correctly perform adult intubation and three students were able to correctly scrub, gown and glove. Performance improved after training, demonstrated by Objective Structured Clinical Examination scores that rose from 6/30 to 15/30. Students perceived great benefit from practical skills training. The cost of the training using low-tech simulation was four United States dollars per student.ConclusionSimulation is valued to gain experience in practising surgical skills prior to working with patients. In the context of resource-limited settings, an additional benefit is that of learning skills not otherwise obtainable. Further testing of this approach will determine its applicability to other resource-limited settings seeking to develop skill-based surgical and emergency procedure apprenticeships. Additionally, skill sustainability and readiness for actual surgical and emergency experiences need to be assessed.

Surgical task shifting in Sub-Saharan Africa.

The poor availability of surgical services in developing countries is a long neglected problem that has recently gained attention [1],[2]. Violence, injury, and obstetric emergencies are among leading causes of mortality and morbidity that can be mitigated through surgical intervention. Surgically treatable problems are estimated to account for up to 11% of the world's disability-adjusted life years [1]. In addition to this massive disease burden there are problems that are seriously debilitating (cataract) or stigmatizing (fistula). Surgical interventions are often viewed as expensive and complex, but many common problems amenable to surgery in resource-limited settings are cost-effective and do not require specialized staff and equipment. The World Health Organization (WHO) has prioritized a list of cost-effective surgical interventions for developing countries including emergency care of trauma, obstetrical complications, and acute abdomens as well as elective care of hernias, clubfoot, cataracts, hydroceles, and otitis media [3]. One of the main barriers to surgical care—defined as the safe provision of pre-operative, operative, and post-operative surgical and anesthesia services—in resource-limited settings is the shortage of trained health workers. Africa accounts for 24% of the global disease burden but only 3% of the global health workforce [4]. The reasons for this are well documented and include inadequate salaries and poor working conditions leading to staff attrition, unwillingness of international donors to support financing for human resources [5], an insufficiency of medical schools [6], and the brain drain of health staff to resource-rich countries [4],[7],[8]. The human resource crisis is most acute at the level of specialists, including surgeons and anesthesiologists [9],[10]. In East Africa, there are 0.25 fully trained surgeons per 100,000 persons compared to 5.69 per 100,000 in the United States [11],[12]. The actual minimum number of surgeons required is unknown. Given the unlikelihood of even a modest increase in the number of surgeons and anesthesiologists working in Africa in the near future, a number of approaches are being piloted to overcome the skills shortage. These include surgical camps and specialist outreach programs (often supported by international experts) and the mobilization of non-physician clinicians (NPCs) to perform surgical and anesthetic tasks [13]. This latter approach, which involves the shifting of tasks from surgeons and anesthesiologists to non-specialists, has the greatest potential to provide coverage of basic surgical care, especially in rural areas. Task shifting involves the delegation of certain medical responsibilities to less specialized health care workers. In sub-Saharan Africa, task shifting has recently been promoted and formalized to help address the HIV/AIDS epidemic [14]. This paper discusses some of the experiences of surgical task shifting to date, and outlines lessons from task shifting in the delivery of HIV/AIDS care.

Surgical training in east Africa

Injury, like HIV infection, is a growing epidemic in east Africa, and large numbers of injured people are at risk of death or lifelong disability because of a lack of basic surgical care. WHO has recently said that without improved surgical services, up to 10% of the population will die from injury and 5% of pregnancies will result in maternal death.1 Surgical services in the region are inadequate, and recruitment to surgical training programmes is dropping as medical school graduates see better salaries and lifestyles elsewhere.

Training to serve unmet surgical needs worldwide.

In 1999, our world’s population passed the six billion mark. An estimated one-third to one-half of our world’s population—2 to 3 billion people—still lack basic surgical care! In this paper we attempt to address the question, “How best can surgical needs be met in a sustainable manner within resources available for training in less-developed populations?” Our goal is to raise awareness of the enormous unmet needs for surgical care in less-developed regions and to suggest ways in which Fellows of the American College of Surgeons may assist in helping meet the needs. In many developing countries, surgical training programs are patterned after North American or European programs. This tends to encourage subspecialization and might not produce surgeons adequately trained to manage the broad spectrum of surgical needs for which people attend their local district hospitals. A complete roster of surgical specialists cannot be made available in most district hospitals throughout the world. So surgeons serving in these hospitals require training and experience that encompass a broader range of surgery than is provided by the usual programs for training general surgeons. We will describe the needs, define the spectrum of surgery in most district hospitals, and outline some affordable and innovative options for surgical care. Our emphasis is on training and sustainability.

Supplement overview

Supplements to mainstream scientific journals come in several varieties. Proceedings of scientific meetings of special interest, reviews of specific topic areas, and compendia of information about new drugs or techniques are common forms for the content of supplements. Most of these appeal to a very limited audience. It is, therefore, a particular pleasure to review the articles in this supplement to the American Journal of Surgery prepared by Dr. Wieman and his colleagues. This group of clinicians and investigators has successfully gone beyond the usual constricted view of supplements to supply a comprehensive update on the pathogenesis, pathophysiology, and care of a significant clinical problem—nonhealing diabetic ulcers of the lower extremity. In my view, they have succeeded in providing a concise and readable look at the basic science, clinical origin, and medical and surgical care of this entity. The educational value of this presentation is, as a consequence, substantial. In addition, there is a comprehensive review of the development and testing of one growth factor that appears to be of value in the care of diabetic foot ulcers, becaplermin (recombinant human platelet-derived growth factor-BB, or rhPDGF-BB), which promotes the development of granulation tissue and has led to improved healing in clinical trials. This agent has the approval of the US Food and Drug Administration for clinical use and is marketed under the brand name Regranex (becaplermin) Gel (McNeil Pharmaceuticals, Raritan, NJ).

Swiss health care delivery system: impact of financial restrictions on surgical education.

In 1990 Swiss health care expenditures totaled 26.3 billion Swiss francs, corresponding to 7.8% of the gross national product. Over the last 5 years expenditures have increased by 43.1%. Given the economic and political realities, future endeavors must be directed at stemming escalating costs. As 51.5% of health care resources are spent on hospital care, a substantial portion of financial restrictions and reorganization have been directed at this sector. These restrictions on hospital care have a direct impact on surgical practice and education. The resulting concentration of manpower and resources demand a new definition of the role of the general surgeon within the revised hospital system. In the face of a dilution of experience and knowledge due to an increasing number of specialized surgeons, the role of the general surgeon who provides basic surgical care must be redefined. These new trends must also be integrated into future training programs. The introduction of a structured surgical curriculum can limit the number of surgical trainees and maintain a high standard of quality.

Handbook of Surgery

This is the sixth edition of a familiar, pocket-sized book that has been a handy reference for many medical students and house officers since its first edition appeared two decades ago. However, despite its familiar appearance, a number of changes have been made, including a new publisher and editor, more legible type, and major revisions of many chapters. This is the most comprehensive text in the peripheral brain genre, and it boasts an impressive list of distinguished contributors whose names are not often seen in handbooks. The introductory chapters, on shock and trauma by Dr Trunkey, preoperative and postoperative care by Dr Schrock and others, anesthesia by Dr Guadagni, and surgical infections by Drs Jawetz and Flora, give a solid grounding in basic surgical care. There are fourteen specialty chapters, on endocrine, head and neck, breast, pulmonary, cardiac, alimentary tract, gynecology, urology, vascular, hand, plastic, orthopedic, pediatric, and neurologic surgery.

Current Surgical Diagnosis Treatment,

This valuable text aptly performs the mission its authors propose—to present in a concise manner essential surgical principles and basic surgical care knowledge for the needs of both medical students and practicing surgeons. The book, a compend of about 62 authors, provides a volume of essential "pearls," practical approaches to numerous common surgical problems and references to recent review articles. As is common to all current surgical texts, the authors have covered the surgical subspecialties in a cursory and superficial manner. Perhaps limiting this text to general surgery subjects alone and decreasing the present size of 1,108 pages, thereby reducing the wear and tear on the paper binding, will enable the next edition of this excellent student and house officer manual to become a standard in its field.