Stop the Bleed in the Era of Virtual Learning: A Novel Strategy for Remote Teaching and Evaluation.

INTRODUCTION: Traumatic hemorrhage is a leading cause of preventable mortality worldwide. The Stop the Bleed (STB) course was developed to equip layperson bystanders with basic bleeding control knowledge and skills. However, large in-person courses have been disrupted due to COVID-19. The aim of this study was to determine the feasibility of teaching and evaluating STB skills through remote video-based instruction. METHODS: After undergoing COVID-19 screening, groups of up to eight STB-naive adults were seated in a socially distanced manner and given individual practice kits. A remote STB-certified instructor provided the standard STB lecture and led a 10-min skills practice session via videoconferencing. Participants' skills were evaluated on a 10-point rubric by one in-person evaluator and three remote evaluators. Participants completed a postcourse survey assessing their perceptions of the course. RESULTS: Thirty-five participants completed the course, all scoring ≥8/10 after examination by the in-person evaluator. Remote instructors' average scores (9.8 ± 0.45) did not significantly differ from scores of the in-person evaluator (9.9 ± 0.37) (P = 0.252). Thirty-three participants (94%) completed the postcourse survey. All respondents reported being willing and prepared to intervene in scenarios of life-threatening hemorrhage, and 97% reported confidence in using all STB skills. CONCLUSIONS: STB skills can be effectively taught and evaluated through a live video-based course. All participants scored highly when evaluated both in-person and remotely, and nearly all reported confidence in skills and knowledge following the course. Remote instruction is a valuable strategy to disseminate STB training to students without access to in-person courses, especially during pandemic restrictions.

The Impact of Global Collaboration on the Academic Focus of the West African College of Surgeons: Are Worldwide Efforts Aligning with Local Priorities?

BACKGROUND: Global collaboration has the potential to induce a shift in research focus away from the priorities of those in low- and low-middle-income countries (LICs and LMICs). This study quantified international collaboration among surgery publications by Fellows of the West African College of Surgeons (WACS) and investigated if collaboration with upper-middle-income and high-income countries (UMICs and HICs) decreases the homophily of research focus. METHODS: Publications by WACS surgery Fellows from 1960 to 2019 were characterized as local WACS publications, collaborative publications without UMIC/HIC participation, or collaborative publications with UMIC/HIC participation. Research topics were determined for each publication, and topic percentages were compared between collaboration groups. RESULTS: We analyzed 5065 publications. Most (3690 publications, 73%) were local WACS publications, while 742 (15%) were collaborative publications with UMIC/HIC participation and 633 (12%) were collaborative publications without UMIC/HIC participation. UMIC/HIC collaborations contributed to 49% of the increase (378 out of 766 publications) from 2000 to 2019. Topic homophily was significantly lower between local WACS publications and collaborations with UMIC/HIC participation (differed in nine research topics) than it was between local WACS publications and collaborations without UMIC/HIC participation (differed in two research topics). CONCLUSIONS: Publications without international collaboration comprise most WACS research, but the rate of UMIC/HIC collaborations is rapidly increasing. We found that UMIC/HIC collaborations decreased the homophily of topic focus in WACS publications, indicating that global collaborations need to have greater emphasis on the priorities of those in LICs and LMICs.

Train the Trainer in Bleeding Control: A Two-Year Pilot Study in Low-Income and Middle-Income Countries.

INTRODUCTION: Traumatic hemorrhage represents a major cause of mortality in low-income and middle-income countries (LMICs). Thus, LMICs can benefit from improvements to prehospital hemorrhage management. One strategy is implementation of a bleeding control course using the "train the trainer" model (TTT) to increase course availability. The Stop the Bleed (STB) campaign provides laypeople with basic knowledge and skills of hemorrhage control. While the feasibility and success of the STB course have been demonstrated in the United States, course dissemination in LMICs has been slower and its feasibility using the TTT model has not been established. MATERIALS AND METHODS: From December 2017 to January 2019, instructors from the International Surgical Health Initiative conducted seven surgical humanitarian trips and taught 10 index 1-h STB training sessions across six LMICs. LMIC instructors were encouraged to continue providing STB courses following departure of the visiting instructors. Course data were collected from sign-in sheets and analyzed using Microsoft Excel. RESULTS: Ten index courses conducted by United States-trained STB experts trained 35 LMIC instructors over 2 y. Six of 35 offered 12 additional courses, certifying 323 new trainees, an 823% increase from the initial cohort. Overall, implementation of the TTT model yielded 22 STB courses in six LMICs, producing 358 new trainees. CONCLUSIONS: This pilot study shows the STB TTT model was feasible and effective in expanding bleeding control trainer capacity in four of six LMICs. Use of the TTT model in LMICs may represent a means to increase STB course availability and is one strategy to improve prehospital hemorrhage control in LMICs.

Stop the Bleed in Rural Sierra Leone: One Year of Interventions and Outcomes by Nursing Trainees.

BACKGROUND: Low- and middle-income countries (LMICs) bear the bulk of the global burden of traumatic injury, yet many lack adequate prehospital trauma care systems. The Stop the Bleed (STB) course, designed to equip bystanders with bleeding control skills, is infrequently offered in LMICs, and its impact in these settings is unknown. To examine the frequency and effectiveness of STB interventions in LMICs, we quantified nursing student trainees' encounters with bleeding victims after STB training in rural Sierra Leone. METHODS: Local providers and volunteers from a US-based surgical nongovernmental organization taught an STB course to nursing students in Kabala, Sierra Leone. One month and 1 year after the course, trainees completed follow-up surveys describing encounters with traumatic hemorrhage victims since the course. RESULTS: Of 121 total STB trainees, 82 completed the 1-month follow-up survey, with 75% reporting at least one encounter with a bleeding victim. This increased to 98% at 12 months (100 responses, average 2 ± 2 encounters). Injuries were most commonly sustained on victims' legs (32%) and most often precipitated by motorcycle crashes (31%). Respondents intervened in 99% of encounters, and 97% of patients receiving intervention survived. Although only 20% of respondents used a tourniquet, this technique produced the highest survival rate (100%). CONCLUSIONS: Nearly all respondents had encounters with victims of traumatic hemorrhage within 1 year of the STB course, and trainees effectively applied bleeding control techniques, leading to 97% survival among victims receiving intervention. These findings indicate the lifesaving impact of STB training in one rural LMIC setting.

Resuming Dental and Craniomaxillofacial Surgical Missions During the COVID-19 Pandemic: Guidelines and Recommendations.

STUDY DESIGN: Descriptive review article. OBJECTIVE: The purpose of this article is to provide guidelines and recommendations for how to safely resume dental and craniomaxillofacial STSMs. The following considerations will be discussed: the need for extensive collaboration between organizations and local leadership, the importance of COVID-19 testing, use and management of personal protective equipment, team selection and training, social distancing protocols, and criteria for patient and case selection. METHODS: A literature review was completed, identifying resources and current data regarding the safe resumption clinical activities during the COVID-19 pandemic. RESULTS: At this time, there are no protocols developed regarding the safe resumption of STSMs. Primary resources, including the CDC, WHO, and FDA should be closely monitored so that developed protocols from these recommendations reflect the latest information. CONCLUSION: This paper outlines general considerations and recommendations for dentists, oral health specialists, and craniomaxillofacial surgeons seeking to safely resume STSMs. These recommendations are designed to minimize the risk of exposure to COVID-19 by reinforcing social distancing protocols, reviewing criteria for patient and case selections, encouraging collaboration between organizations and local leadership, and team training. These guidelines should be tailored to fit the needs of each individual mission while keeping the safety as the main objective.

Does Global Surgery Interest Influence the Choice of Surgical Residency Program?

OBJECTIVE: Medical students actively seek global health opportunities. Surgical residents also show great enthusiasm for international missions, rotations and global surgery. Unfortunately, only 18% to 34% of all surgery residency programs offer such international opportunities. We surveyed fourth year medical students applying for surgery residency to determine if international surgery opportunities offered by a program would influence their match rank list. DESIGN: A 20 question survey was given to interviewees at our surgery residency program. Survey was optional and anonymous. We queried prior volunteerism, interest in global surgery and importance of international opportunities offered during residency. SETTING: Hackensack University Medical Center, Hackensack New Jersey PARTICIPANTS: All candidates interviewing for general surgery residency at Hackensack University Medical Center from October 2019 to January 2020. RESULTS: A total of 97 fourth year medical students interviewed, with a 66% response rate to the survey. Mean age was 27 years. 92% of students had volunteered during college and/or medical school. 41% of students had volunteered internationally. Majority of students were interested in a surgery residency program offering international opportunity. 78% of students planned to volunteer internationally after residency, and two-thirds planned to include global surgery in future career. Half of the students reported they would rank a residency program higher if it offered an international opportunity. Students who were immigrants were significantly more likely to rank a program higher in the match if an international opportunity was offered, compared to students born in the US (p < 0.05). CONCLUSIONS: There is great interest in global surgery and international volunteer opportunities amongst fourth year medical students who apply for surgery residency. The majority of applicants have prior volunteer experience either locally or abroad. Majority of students plan to volunteer internationally after residency and are interested in academic global surgery careers. Students will rank surgery residency programs that offer international opportunities higher in the match.

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult Laparoscopic Cholecystectomy in Surgical Missions.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes. MATERIALS AND METHODS: A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension. RESULTS: 68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC. CONCLUSION: Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

Surgical subspecialists in West Africa: Workforce size, training opportunities, and contributing factors.

BACKGROUND: The global burden of disease treatable by surgical subspecialists remains an outstanding area of need, and yet little is known about the subspecialist workforce worldwide, especially in sub-Saharan Africa. This study aims to quantify the subspecialty surgical workforce and number of subspecialty training programs in West Africa and to identify socioeconomic factors predicting the number of subspecialists in West African countries. METHODS: West African subspecialists and accredited fellowship training programs in 17 West African countries were quantified using membership data from the West African College of Surgeons and compared with publicly available workforce data from the United States, the United Kingdom, and East, Central, and Southern Africa. Spearman's coefficients were calculated to identify socioeconomic predictors of subspecialist surgical workforce. RESULTS: Of 2,181 surgeons, 712 (32.6%) were surgical subspecialists. Three (18%) of 17 West African countries had greater than 11 subspecialists. There were 174 subspecialty training programs in the region, though 13 countries (76%) had no programs. The number of subspecialists correlated most strongly with the number of subspecialty training programs (rS = 0.68, P = .003) but also correlated significantly with gross population and number of medical schools (rS = 0.50-0.52, P ≤ .05). CONCLUSION: Subspecialist surgeons represent one third of surgeons in West Africa, though most countries have fewer than 12 providers. The number of subspecialists is significantly correlated with the number of subspecialty training programs, and yet many West African countries lack accredited programs. These results suggest that investing in training programs is the most valuable potential strategy to address the shortage of surgical subspecialists in West Africa.

A Pilot Study of Surgical Trainee Participation in Humanitarian Surgeries.

BACKGROUND: The impact of general surgery resident participation on operative case time and postoperative complications has been broadly studied in the United States. Although surgical trainee involvement in international humanitarian surgical care is escalating, there is limited information as to how this participation affects care rendered. This study examines the impact of trainee involvement on case length and immediate postoperative complications with regard to operations in low- and middle-income settings. METHODS: A retrospective chart review was conducted of humanitarian surgeries completed during annual short-term surgical missions performed by the International Surgical Health Initiative to Ghana and Peru. Between 2017 and 2019, procedures included inguinal hernia repairs and total abdominal hysterectomies (TAHs). Operative records were reviewed for case type, duration, and immediate postoperative complications. Cases were categorized as involving two attending co-surgeons (AA) or one attending and resident assistant (RA). RESULTS: There were 135 operative cases between 2017 and 2019; the majority (82%) involved a resident assistant. There were no statistically significant differences in case times between the attending assistant (AA) and resident assistant (RA) cohorts in both case types. All 23 postoperative complications were classified as Clavien-Dindo Grade I. In addition, resident assistance did not lead to a statistically significant increase in complication rate; 26% in the AA cohort versus 74% in the RA cohort (P = 0.3). CONCLUSIONS: This pilot study examining 135 operative cases over 2 y of humanitarian surgeries demonstrates that there were no differences in operative duration or complication rates between the AA and RA cohorts. We propose that surgical trainee involvement in low- and middle-income settings do not adversely impact operative case times or postoperative complications.

Closing the Gender Gap in Global Surgery: Trends at the Academic Surgical Congress.

INTRODUCTION: Female researchers are underrepresented in academic surgery. While they are increasingly producing original research, they lag male researchers in productivity. This disparity is not well understood within the nascent field of global surgery. The following study examines gender parity in global surgery research presented at the Academic Surgical Congress and within subsequent publications. METHODS: Abstracts presented at the Academic Surgical Congress (ASC) between 2015 and 2019 in "Global Surgery" sessions were reviewed to obtain title, the first author (FA) and senior author (SA). The authors were classified by gender. The Scopus database was queried by two reviewers for abstracts with corresponding publications, citations, and journal impact factors. Statistical analysis was conducted using chi-square analysis and t-tests where appropriate. RESULTS: Of a total of 6635 abstracts, 218 global surgery abstracts over a 5-year period were identified. Of these abstracts, 96 (44%) had female FAs, while 56 (26%) had female SAs. When comparing gender, female (44%) FAs and male (56%) FAs were equally represented. While SAs were significantly less likely to be female (26% versus 74%, P < 0.0001), female senior authorship increased significantly within the study period. Output with respect to publications, citations, and journal impact factors were equal by gender. CONCLUSIONS: This study presents 5 y of gender trends in global surgery scholarly work presented at the ASC. Despite an overall predominance of male senior authors, the paradigm is shifting with a recent trend to gender parity. Male and female authors have equal output and are equally impactful. Findings of gender equity in academic global surgery are encouraging, and further study of other disciplines are warranted.

Expanding post-operative follow-up in rural Sierra Leone: A community-based protocol.

INTRODUCTION: Humanitarian surgeries are performed in low- and middle-income countries (LMICs) to help address untreated surgical disease. Post-operative follow-up is challenging but crucial to monitor recovery, detect complications, and assess outcomes. Establishing a comprehensive protocol in partnership with local healthcare personnel may improve patient adherence. METHODS: A retrospective review of missions from 2011 to 2019 to Sierra Leone by the International Surgical Health Initiative (ISHI). In 2017, a protocol was established with the following key elements: patient education, community leader recruitment, and logistical support. Patient demographics and follow-up rates were compared between groups. RESULTS: In total, 396 patients underwent operations from 2011 to 2019. Most patients were male (84%), mean age 40 ± 14 years, and primarily underwent hernia repair (68%). Initially, follow-up rates of 205 patients were <5%; after protocol implementation, follow-up rates among 128 patients who received operations increased to 96-97%. CONCLUSIONS: A community-based follow-up protocol in Sierra Leone yielded high patient adherence. The protocol emphasizes context-appropriate patient education and community engagement. Protocols are feasible and generalizable to patients cared for by international and hosting surgical teams.

Developing a Sustainable Program for Volunteer Surgical Care in Low-Income and Middle-Income Countries.

Volunteer medical missions to low-income and middle-income countries have been a popular but unregulated method of providing care to underserved regions of the world as they work to improve surgical capacity. This article addresses various organizational tenets, such as forming a mission statement, selecting a site location, determining funding sources, establishing a team, patient safety, organization, and postoperative care and follow-up.

Long-Term Follow-Up of Humanitarian Surgeries: Outcomes and Patient Satisfaction in Rural Ghana.

BACKGROUND: Nongovernmental organizations conduct short-term surgical outreach to lessen the substantial global burden of surgical disease. Long-term outcomes of short-term surgical missions (STSMs) are underreported, raising concern for clinical sequelae and patient satisfaction with essential general surgeries. This study aims to describe long-term follow-up results of one general surgical nongovernmental organization's provision of care in rural Ghana with focus on patient-related outcomes and satisfaction. METHODS: From 2013 to 2018, Tetteh Quarshie Memorial Hospital in Mampong, Ghana, was the host site of annual 1-wk International Surgical Health Initiative (ISHI) STSMs. Beginning in 2016, an ISHI provider-hosted follow-up clinics augmented by mobile telephone support. Surgical patients from 2013 to 2016 were contacted by the local nursing staff and evaluated for long-term outcomes and self-reported satisfaction. RESULTS: Sixty-nine of 256 patients (27%) responded; 39 patients (57%) were interviewed and examined by an ISHI physician, whereas 30 patients (43%) received mobile telephone follow-up. Mean age was 47 (±18) y, with 44% female patients, and mean duration of follow-up was 1.5 (±1) y. Eleven patients (16%) had surgical and anesthesia complications. All patients reported improvement in symptoms and activity level. Eighty-six patients reported complete satisfaction (5/5). Factors associated with reduced patient satisfaction (<5/5) included increased age and complications. CONCLUSIONS: To our knowledge, this is one of the first studies focusing on patient-reported outcomes for the evaluation of long-term follow-up of general surgery STSMs. With mobile technology, long-term follow-up is achievable toward obtaining meaningful outcomes. Complications in this series are within an acceptable range, whereas symptom improvement and overall satisfaction are high.

Gender Equity in Humanitarian Surgical Outreach: A Decade of Volunteer Surgeons.

BACKGROUND: Workforce trends in surgery demonstrate persistent gender inequity. Humanitarian surgical outreach opportunities exist for surgeons; however, it is unclear as to whether gender disparities exist in this arena. This pilot study examines gender equity among volunteer surgeons using a decade of compiled data from a surgical nongovernmental organization (NGO) that hosts multinational surgical outreach. We aim to evaluate gender proportions among surgical volunteers, compare the gender profiles of NGO surgeons with local and nationwide cohorts, and examine the productive output of surgical volunteers by gender. MATERIALS AND METHODS: A retrospective review was conducted of the records of the International Surgical Health Initiative, an NGO that hosts short-term surgical missions, to generate a demographic roster of volunteers between 2009 and 2018. Comparisons were made of gender profiles within volunteer cohorts against local institutional data and nationwide surgical workforce data. Productivity outputs of surgical volunteers were compared. Chi-square tests and Wilcoxon two-sample statistical t-tests were used. RESULTS: A total of 23 short-term surgical trips were inclusive of 227 volunteers, and 61% (139) were female. Physicians were less likely to be female than other volunteers. In addition, nonsurgical volunteers were more likely to be female compared with surgical volunteers (67% versus 44%, P < 0.01). No gender differences were observed by average number of trips or propensity for repeat trips among surgical volunteers. No differences were found in proportions of female surgical attendings and residents in the NGO cohort compared with the local and national cohorts. CONCLUSIONS: Females contribute substantially to surgical outreach, representing more than half the volunteers in this organization. Gender profiles of female surgeons in this NGO are in parity with those of surgical attendings and residents in the national census. Male and female volunteer surgeons are equally productive. There is an equitable gender representation among volunteer surgeons in this NGO. Further studies of other surgical organizations participating in surgical outreach are required toward a more complete understanding of female participation in international humanitarian efforts.

Neurosurgery in the Brazilian Amazon: Is It Possible?

BACKGROUND: The need for neurosurgical care across the globe remains a public health issue. The creation of sustainable neurological surgery departments and training programs will be indispensable in alleviating the burden of neurological disease in low to middle income countries (LMICs). METHODS: We reviewed the history of the neurological surgery department and residency program of Santarém in the state of Pará, Brazil, from 1999 to the present. We have described the epidemiology unique to the region and provided evidence of a sustainable practice in a LMIC. The challenges, limitations, and resources were explored. RESULTS: We have provided a historical vignette of the evolution of neurological surgery in the Brazilian Amazon, including the creation of a sustainable neurological surgery practice and accredited residency program. In addition, we assessed the neurological surgery burden and epidemiology unique to the region, with an emphasis on the community and indigenous health in this remote area. We also explored the future directions of this example, which could affect the international neurological surgery community. CONCLUSION: A sustainable neurosurgery practice and training program is possible in a LMIC. Training neurosurgeons in developing regions of LMICs is a sustainable method to decrease the morbidity and mortality of neurological diseases and prevent the misdistribution of physicians in a country. We encourage adaptation of sustainable neurological surgery practices in similar regions across the world to increase access to necessary neurosurgical care.

Integrating Bleeding Control Training Into Surgical Missions in Low- and Middle-Income Countries.

BACKGROUND: Basic bleeding control (BCon) techniques can save lives globally but the knowledge is not widespread in low-income countries where trauma is a common cause of death. Short-term surgical missions (STSMs) are an effective route to share this public health initiative around the world. MATERIALS AND METHODS: Over 2017-2018, the International Surgical Health Initiative organized STSMs to locations in Sierra Leone, Bangladesh, Peru, and Ghana. The hour-long official American College of Surgeons Basic Bleeding Control course was offered to host participants several times over the course of the mission. Data including number and size of classes, type of trainee, instructors trained, and success rate in demonstrating acquisition of core BCon principles and techniques were collected. RESULTS: Over the course of four, week-long STSMs, 748 people were successfully trained in BCon over 27 sessions, with an average of 28 trainees and up to four instructors per class. One-hundred percent of trainees demonstrated acquisition of required skills proficiency. Trainees included health care workers and those in public security roles. CONCLUSIONS: Concurrent with a short-term surgical mission, a substantial number of health care providers and would-be bystanders can be trained in BCon in countries most impacted by trauma. Local instructors can be trained to teach BCon independently to sustain the initiative. STSMs are a feasible modality to teach bleeding control techniques to an international audience that does not have rapid access to effective prehospital care.

Correction to: Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.

Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum.

BACKGROUND: Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk. METHODS: Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression. RESULTS: Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes. CONCLUSIONS: Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.