"A short trauma course for physicians in a resource-limited setting: Is low-cost simulation effective?".

INTRODUCTION: Morbidity and mortality from intentional and unintentional injury accounts for a high burden of disease in low- and middle-income countries. In addition to prevention measures, interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality. A trauma curriculum tailored to low-resource settings was implemented in Managua, Nicaragua utilising traditional didactic methods and novel low-cost simulation methods. Knowledge gain in attending and senior residents was subsequently assessed by using pre- and post-written tests, and by scoring pre- and post-simulation scenarios. MATERIALS AND METHODS: A 5-day trauma course was designed for Nicaraguan attending and senior resident physicians who practice at six hospitals in Managua, Nicaragua. On days 1 and 5, participants underwent pre- and post-training evaluations consisting of a 26-question written exam and 2 simulation cases. The written exam questions and simulations were randomly assigned so that no questions or cases were repeated. The Wilcoxon signed-rank test was used to compare pre- and post-training differences in the written exam, and the percentage of critical actions completed in simulations. Time to critical actions was also analyzed using descriptive statistics. RESULTS: A total of 33 participants attended the course, including 18 (55%) attending and 15 (45%) resident physicians, with a 97% completion rate. After the course, overall written examination scores improved 26.3% with positive mean increase of 15.4% (p<0.001). Overall, simulation scores based on the number of critical actions completed improved by 91.4% with a positive mean increase of 33.67 (p<0.001). The time to critical action for completion of the primary survey and cervical spine immobilisation was reduced by 55.9% and 46.6% respectively. CONCLUSIONS: A considerable improvement in participants' knowledge of trauma concepts was demonstrated by statistically significant differences in both pre- and post-course written assessments and simulation exercises. The participants showed greatest improvement in trauma simulation scenarios, in which they learned, and subsequently demonstrated, a standardised approach to assessing and managing trauma patients. Low-cost simulation can be a valuable and effective education tool in low- and middle-income countries.

Medicina integral en Nicaragua 1987-1993 / Medicina integral in Nicaragua 1987-1993

En 1986 comenzó la creación de la Medicina Integral. El 38,6 por ciento de los médicos formados en esa época eran médicos generales y en servicio social, atendiendo la consulta de morbilidad y los diferentes programas en el nivel primario de atención. Se planteó la necesidad de formar un especialista multiperfil, para elevar la calidad de atención en el nivel primario, disminuyendo el costo por su carácter polivalente y por su acción integral; fortaleciendo además la práctica docente asistencial e investigativa. En 1987 empieza la formación del médico integral con una duración de tres años en el único hospital general de Managua, Hospital Carlos Marx. Entre 1987 y 1990 la docencia fue asumida por médicos integrales de la República Democrática Alemana; a partir de 1990 es realizada por docentes nicaragüenses y evaluada según normas de la Universidad Nacional Autónoma de Nicaragua y el Ministerio de Salud