Global Surgery Pro-Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

Global surgery, especially academic global surgery, is of tremendous interest to many surgeons. Classically, it entails personnel from high-income countries going to low- and middle-income countries and engaging in educational activities as well as procedures. Academic medical personnel have included students, residents, and attendings. The pervasive notion is that this is a win-win situation for the volunteers and the hosts, that is, a pathway to bilateral academic success. However, a critical examination demonstrates that it can easily become the bold new face of colonialism of a low- and middle-income country by a high-income country.

Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study.

BACKGROUND: The purpose of this observational study is to characterize the use of social media content pertaining to global surgery. METHODS: A search for public posts on social media related to global surgery was performed over a 3-month window, from January 1st, 2019, to March 31st, 2019. Two public domains were included in the search: Instagram and Twitter. Posts were selected by filtering for one hashtag: #GlobalSurgery. A binary scoring system was used for media format, perspective of the poster, timing of the post, tone, and post content. Data were analyzed using Chi-squared tests with significance set to p < 0.05. RESULTS: Overall, 2633 posts with the hashtag #GlobalSurgery were publicly shared on these two social media platforms over the 3-month period. Of these, 2272 (86.3%) referenced content related to global surgery and were original posts. Physicians and other health professionals authored a majority (60.5%, 1083/1788) of posts on Twitter, whereas organizations comprised a majority of the posts on Instagram (59.9%, 290/484). Posts either had a positive (50.2%, 1140/2272) or neutral (49.6%, 1126/2272) tone, with only 0.3% or 6/2272 of posts being explicitly negative. The content of the posts varied, but most frequently (43.4%, 986/2272) focused on promoting communication and engagement within the community, followed by educational content (21.3%, 486/2272), advertisements (18.8%, 427/2272), and published research (13.2%, 299/2272). The majority of global surgery posts originated from the USA, UK, or Canada (67.6%, 1537/2272), followed by international organizations (11.5%, 261/2272). Chi-squared analysis comparing Instagram with Twitter performed examining media content, tone, perspective, and content, finding statistically significant differences (p < 0.001) the two platforms for each of the categories. CONCLUSION: The online social media community with respect to global surgery engagement is predominantly composed of surgeons and health care professionals, focused primarily on promoting dialogue within the online community. Social media platforms may provide a scalable tool that can augment engagement between global surgeons, with remaining opportunity to foster global collaboration, community engagement, education and awareness.

Introducing a Morbidity and Mortality Conference in Rwanda.

OBJECTIVES: To assess the structure, format, and educational features of a morbidity and mortality (M&M) conference in Rwanda. To determine factors associated with adverse events and to define opportunities for improvement. DESIGN: Retrospective, descriptive study of all cases presented at a surgical M&M conference over a 1-year period. Cases were reviewed for factors associated with adverse events and opportunities for improvement. Factors were characterized as delays in presentation, delays in diagnosis, delays in the operating room, errors in judgment, technical errors, advanced disease, and missing resources or malnutrition. Opportunities for improvement were categorized at the physician or hospital level. SETTING: University Teaching Hospital of Kigali, a tertiary referral hospital in Rwanda. PARTICIPANTS: Cases presented at the surgical M&M conference over a 1-year period. RESULTS: Over a 1-year period, there were a total of 2231 operations with 131 in-hospital mortalities. There were 62 patients discussed at M&M conference. Of those discussed, there were 34 (55%) in-hospital deaths and 32 (52%) unplanned reoperations. Common diagnostic categories included 30 (48%) gastrointestinal, 15 (24%) trauma, and 10 (16%) neoplasm. Delays were commonly cited factors affecting outcomes. There were 22 (35%) delays in presentation, 23 (37%) delays in diagnosis or management, and 20 (32%) delays to the operating room. Errors in judgment occurred in 15 (24%) cases and technical errors occurred in 18 (29%) cases. Twenty-three (37%) patients had a critical resource missing and 17 (27%) patients had advanced disease. Malnutrition was associated with 11 (18%) adverse events. Participants identified opportunities for improvement in 48 (77%) cases. CONCLUSION: M&M conference can be used in a low-resource setting as an educational tool to address core competencies of practice-based learning and improvement and systems-based practice. It can define factors associated with surgical adverse events and opportunities for improvement at the physician and hospital levels.

Associations with Perioperative Mortality Rate at a Major Referral Hospital in Rwanda.

BACKGROUND: Little is known about perioperative mortality in sub-Saharan Africa. The perioperative mortality rate (POMR) and associated factors at a major referral hospital in Rwanda were measured. METHODS: The operative activity at University Teaching Hospital of Kigali was evaluated through an operative database. As a part of this larger study, patient characteristics and outcomes were measured to determine areas for improvement in patient care. Data were collected on patient demographics, surgeon, diagnosis, and operation over a 12-month period. The primary outcome was POMR. Secondary outcomes were timing and hospital location of death. RESULTS: The POMR was 6 %. POMR in patients under 5 years of age was 10 %, 3 % in patients 5-14 years and 6 % in patients age >14 years. For emergency and elective operations, POMR was 9 and 2 %, respectively. POMR was associated with emergency status, congenital anomalies, repeat operations, referral outside Kigali, and female gender. Orthopedic procedures and age 5-14 years were associated with decreased odds of mortality. Forty-nine percent of deaths occurred in the post-operative recovery room and 35 % of deaths occurred within the first post-operative day. CONCLUSIONS: The POMR at a large referral hospital in Rwanda is <10 % demonstrating that surgery can save lives even in resource-limited settings. Emergency operations are associated with higher mortality, which could potentially be improved with faster identification and transfer from district hospitals. Nearly half of deaths occurred in the post-operative recovery room. Multidisciplinary audits of operative mortalities could help guide improvements in surgical care.

Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital.

OBJECTIVE: To define the operations performed by surgical residents at a tertiary referral hospital in Rwanda to help guide development of the residency program. DESIGN: Cross-sectional study of all patients operated by surgical residents from October 2012 to September 2013. SETTING: University Teaching Hospital of Kigali (Centre Hospitalier Universitaire de Kigali [CHUK]), a public, tertiary referral hospital in Kigali, Rwanda. PARTICIPANTS: All patient data were entered into the operative database by surgical residents at CHUK. A total of 2833 cases were entered into the surgical database. Of them, 53 cases were excluded from further analysis because no surgical resident was listed as the primary or assistant surgeon, leaving 2780 cases for analysis. RESULTS: There were 2780 operations involving surgical residents. Of them, 51% of procedures were classified under general surgery, 38% orthopedics, 7% neurosurgery, and 4% urology. Emergency operations accounted for 64% of the procedures, with 56% of those being general surgery and 35% orthopedic. Further, 50% of all operations were trauma, with 71% of those orthopedic and 21% general surgery. Surgical faculty were involved in 45% of operations as either the primary or the assistant surgeons, while the remainder of operations did not involve surgical faculty. Residents were primary surgeons in 68% of procedures and assistant surgeons in 84% of procedures. CONCLUSIONS: The operative experience of surgery residents at CHUK primarily involves emergency and trauma procedures. Although this likely reflects the demographics of surgical care within Rwanda, more focus should be placed on elective procedures to ensure that surgical residents are broadly trained.