Surgical Training for Civilian Surgeons Interested in Humanitarian Surgery: A Scoping Review.

INTRODUCTION: Humanitarian surgery is essential to surgical care in limited resource settings. The difficulties associated with resource constraints necessitate special training for civilian surgeons to provide care in these situations. Specific training or curricula for humanitarian surgeons are not well described in the literature. This scoping review summarizes the existing literature and identifies areas for potential improvement. METHODS: A review of articles describing established courses for civilian surgeons interested in humanitarian surgery, as well as those describing training of civilian surgeons in conflict zones, was performed. A total of 4808 abstracts were screened by two independent reviewers, and 257 abstracts were selected for full-text review. Articles describing prehospital care and military experience were excluded from the full-text review. RESULTS: Of the eight relevant full texts, 10 established courses for civilian surgeons were identified. Cadaver-based teaching combined with didactics were the most common course themes. Courses provided technical education focused on the management of trauma and burns as well as emergencies in orthopedics, neurosurgery, obstetrics, and gynecology. Other courses were in specialty surgery, mainly orthopedics. Two fellowship programs were identified, and these provide a different model for training humanitarian surgeons. CONCLUSIONS: Humanitarian surgery is often practiced in austere environments, and civilian surgeons must be adequately trained to first do no harm. Current programs include cadaver-based courses focused on enhancing trauma surgery and surgical subspecialty skills, with adjunctive didactics covering resource allocation in austere environments. Fellowships programs may serve as an avenue to provide a more standardized education and a reliable pipeline of global surgeons.

Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway.

BACKGROUND: Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016-July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts. METHODOLOGY: A qualitative study design was used to examine the Mosul civilian trauma response. From August-December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified. RESULTS: The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system. CONCLUSIONS: The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.

Global Burden of Craniofacial Disorders: Where Should Volunteering Plastic Surgeons and Governments Focus Their Care?

PURPOSE: Approximately 11% of the global burden of disease is surgically treatable. When located within the head, face, and neck region, plastic surgeons are particularly trained to treat these conditions. The purpose of this study was to describe the etiology, disability, and barriers to receiving care for diseases of the head, face, mouth, and neck region across 4 low-and-middle-income countries. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument is a cluster randomized, cross-sectional, national survey administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. The survey identifies demographic characteristics, etiology, disease timing, proportion seeking/receiving care, barriers to care, and disability. RESULTS: Across the 4 countries, 1413 diseases of head, face, mouth, and neck region were identified. Masses (22.13%) and trauma (32.8%) were the most common etiology. Nepal reported the largest proportion of masses (40.22%) and Rwanda reported the largest amount of trauma (52.65%) (P < 0.001). Rwanda had the highest proportion of individuals seeking (89.6%) and receiving care (83.63%) while Sierra Leone reported the fewest (60% versus 47.77%, P < 0.001). In our multi-variate analysis literacy and chronic conditions were predictors for receiving care while diseases causing the greatest disability predicted not receiving care (ORa .58 and .48 versus 1.31 P < 0.001). CONCLUSIONS: The global volunteering plastic surgeon should be prepared to treat chronic craniofacial conditions. Furthermore, governments should address structural barriers, such as health illiteracy and lack of access to local plastic surgery care by supporting local training efforts.

North American pediatric surgery fellows' preparedness for humanitarian surgery.

INTRODUCTION: The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones. METHODS: We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests. RESULTS: ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05). CONCLUSION: While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets. LEVEL OF EVIDENCE: III.

A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare.

Importance: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective: To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants: An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures: The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results: Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance: Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

Directions for surgical capacity developments in Nepal: a population-based assessment.

OBJECTIVES: Lack of access to safe surgery is seen as a major issue that needs to be addressed. The aim of this study was to understand which combinations of factors relate to high occurrences of unmet needs and disability in Nepal, and consequently, how to focus future work to maximise impact in this country. METHODS: A large population-based survey was conducted in Nepal in 2014 to evaluate the unmet surgical needs that result in disability. Recorded factors included diseased anatomical areas, disease specifics, disease locations, injury types, reasons for having an unmet need and the types of disability. RESULTS: Included in the study were 2695 individuals. The anatomical areas facing the highest disabling unmet surgical need were Head (3.9% of population), Groin/Genitalia (2.2% of population) and Extremities (3.6% of population). Four focus areas could be defined. Increase affordability, availability and acceptability of surgical care to non-traumatic disabling conditions of (i) the eye, and (ii) extremities, and (iii) to traumatic disabling conditions of extremities and finally (iv) increase acceptability of having surgical care for non-traumatic conditions in the groin and genital area. For the latter, fear/no trust was the main reason for receiving no surgical care despite the resulting shame. CONCLUSIONS: This study defined four focus areas that showed the largest unmet needs that resulted in a perceived disability. For those areas, affordability, availability and acceptability of surgical need to be addressed through technical developments, capacity building and raising awareness.

OBJECTIFS: L'absence d'accès à une chirurgie sûre est considérée comme un problème majeur à résoudre. Le but de cette étude était de comprendre quelles combinaisons de facteurs étaient liées aux besoins non satisfaits et aux incapacités au Népal, et par conséquent, comment cibler les travaux futurs pour maximiser l'impact dans ce pays. MÉTHODES: Une vaste enquête de population a été menée au Népal en 2014 pour évaluer les besoins chirurgicaux non satisfaits qui entraînent une incapacité. Les facteurs enregistrés comprenaient les zones anatomiques, les spécificités, les localisations de la maladie, les types de blessures, les raisons pour lesquelles les besoins n'étaient pas satisfaits et les types d'incapacité. RÉSULTATS: 2695 personnes ont été incluses dans l'étude. Les zones anatomiques impliquées dans des besoins chirurgicaux les plus invalidants étaient les suivantes: tête (3,9% de la population), aine/organes génitaux (2,2% de la population) et extrémités (3,6% de la population). Quatre domaines cibles d'intervention pourraient être définis. Premièrement, augmenter l'accessibilité financière, la disponibilité et l'acceptabilité des soins chirurgicaux aux affections invalidantes non traumatiques de 1) l'œil, 2) des extrémités et 3) aux affections traumatisantes des extrémités, et enfin 4) augmenter l'acceptabilité des soins chirurgicaux pour les affections non traumatiques dans l'aine et les parties génitales. Pour ces derniers, la crainte/l'absence de confiance était la principale raison de ne pas recevoir de soins chirurgicaux malgré la honte qui en résultait. CONCLUSIONS: Cette étude a défini quatre domaines cibles d'intervention qui ont montré les besoins non satisfaits les plus importants ayant entraîné une incapacité perçue. Pour ces domaines, il convient de prendre en compte le caractère abordable, la disponibilité et l'acceptabilité des interventions chirurgicales par le biais de développements techniques, d'un renforcement des capacités et la sensibilisation.

The Golden Hour After Injury Among Civilians Caught in Conflict Zones.

INTRODUCTION: The term "golden hour" describes the first 60 minutes after patients sustain injury. In resource-available settings, rapid transport to trauma centers within this time period is standard-of-care. We compared transport times of injured civilians in modern conflict zones to assess the degree to which injured civilians are transported within the golden hour in these environments. METHODS: We evaluated PubMed, Ovid, and Web of Science databases for manuscripts describing transport time after trauma among civilian victims of trauma from January 1990 to November 2017. RESULTS: The initial database search identified 2704 abstracts. Twenty-nine studies met inclusion and exclusion criteria. Conflicts in Yugoslavia/Bosnia/Herzegovina, Syria, Afghanistan, Iraq, Israel, Cambodia, Somalia, Georgia, Lebanon, Nigeria, Democratic Republic of Congo, and Turkey were represented, describing 47 273 patients. Only 7 (24%) manuscripts described transport times under 1 hour. Transport typically required several hours to days. CONCLUSION: Anticipated transport times have important implications for field triage of injured persons in civilian conflict settings because existing overburdened civilian health care systems may become further overwhelmed if in-hospital health capacity is unable to keep pace with inflow of the severely wounded.

A systematic review of oil tanker truck disasters: Identifying prevention targets.

INTRODUCTION: Oil tanker truck disasters have been reported worldwide; however, the circumstances, causes, and health effects of these disasters have not been described. To address this gap, we performed a systematic review using PRISMA criteria to better understand this public health problem and identify prevention targets. METHODS: The academic and lay literatures were systematically searched for terms related to oil tanker truck disasters. Reports about civilian oil tanker truck disasters that occurred from 1997-2017 were included. Details about the disasters were summarized, including circumstances, identifiable causes, and health effects. RESULTS: The search yielded 4713 Nexis Uni articles, 199 Google results, and one PubMed article; 951 records met inclusion criteria, describing 224 oil tanker truck explosions or fires. At least 2909 people died as a result of these disasters, and 3038 additional people were hospitalized. Almost all deaths (94%) occurred in low- and low-middle-income countries (LMIC). This may largely be due to scooping - the practice of collecting spilled oil from disabled tanker trucks for use or resale. Using the Haddon matrix, potential targets for future disaster prevention were identified. CONCLUSIONS: These data highlight the circumstances, causes, and health burden related to oil tanker truck disasters. Most began as collisions or rollovers, but nearly half of the fatalities involved scooping. The findings suggest opportunities to promote road safety, improve scene safety and security protocols used by drivers and first responders, and promote public understanding of the dangers of scooping to prevent mass casualty disasters from disabled tanker trucks, particularly in LMIC.

Where There Is No Trauma System: A Successful Patient Evacuation in the Republic of Kiribati.

Research is lacking around how best to approach trauma care in resource poor settings, particularly in remote areas such as the islands of the South Pacific. Without examples of successful treatment of high-risk cases in these settings, countries are unable to move forward with developing policies and standardized procedures for emergency care.The Republic of Kiribati is a Pacific Island nation composed of 33 islands spanning over 2,000 miles in the central Pacific Ocean. With the only hospital located on Kiritimati Island and inadequate boat transportation, the government recently committed to providing an aircraft for patients to receive appropriate medical care. In 2016, a 20-year-old female, primigravida, on a neighboring island, failed to progress in labor for 24 hours and needed an emergency cesarean section. A radio call was made to Kiritimati, and a team consisting of a general surgeon, nurse, and a laboratory technician was dispatched. The patient was brought to the local clinic and flown to Kiritimati where a team was prepared to perform the cesarean section.The successful patient evacuation emphasizes the importance of a dedicated health care team, government commitment, and the constant quality communication when approaching feasibility of trauma and emergency care. (Disaster Med Public Health Preparedness. 2019;13:774-776).

Health Care Providers in War and Armed Conflict: Operational and Educational Challenges in International Humanitarian Law and the Geneva Conventions, Part I. Historical Perspective.

Since 1945, the reason for humanitarian crises and the way in which the world responds to them has dramatically changed every 10 to 15 years or less. Planning, response, and recovery for these tragic events have often been ad hoc, inconsistent, and insufficient, largely because of the complexity of global humanitarian demands and their corresponding response system capabilities. This historical perspective chronicles the transformation of war and armed conflicts from the Cold War to today, emphasizing the impact these events have had on humanitarian professionals and their struggle to adapt to increasing humanitarian, operational, and political challenges. An unprecedented independent United Nations-World Health Organization decision in the Battle for Mosul in Iraq to deploy to combat zones emergency medical teams unprepared in the skills of decades-tested war and armed conflict preparation and response afforded to health care providers and dictated by International Humanitarian Law and Geneva Convention protections has abruptly challenged future decision-making and deployments. (Disaster Med Public Health Preparedness. 2019;13:109-115).

Health Care Providers in War and Armed Conflict: Operational and Educational Challenges in International Humanitarian Law and the Geneva Conventions, Part II. Educational and Training Initiatives.

ABSTRACTNo discipline has been impacted more by war and armed conflict than health care has. Health systems and health care providers are often the first victims, suffering increasingly heinous acts that cripple the essential health delivery and public health infrastructure necessary for the protection of civilian and military victims of the state at war. This commentary argues that current instructional opportunities to prepare health care providers fall short in both content and preparation, especially in those operational skill sets necessary to manage multiple challenges, threats, and violations under international humanitarian law and to perform triage management in a resource-poor medical setting. Utilizing a historical framework, the commentary addresses the transformation of the education and training of humanitarian health professionals from the Cold War to today followed by recommendations for the future. (Disaster Med Public Health Preparedness. 2019;13:383-396).

Rethinking burns for low & middle-income countries: Differing patterns of burn epidemiology, care seeking behavior, and outcomes across four countries.

PURPOSE: Low-and middle-income (LMIC) countries account for 90% of all reported burns, nevertheless there is a paucity of providers to treat burns. Current studies on burns in LMICs have not evaluated the gap between care seeking and receiving. This study explores this gap across socioeconomically similar populations in a multi-country population based assessment to inform burn care strategies. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument is a cross sectional national, cluster random sampling survey administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. The survey identifies burn etiology, demographics, timing, disability, and barriers to receiving care. RESULTS: Among 13,763 individuals surveyed, 896 burns were identified. Rwanda had the highest proportion of individuals seeking and receiving care (91.6% vs 88.5%) while Sierra Leone reported the fewest (79.3% vs 70.3%). Rwanda reported the largest disability while Nepal reported the highest proportion with no disability (47.5% vs 76.2%). Lack of money, healthcare providers, and rural living reduce the odds of receiving care by 68% and 85% respectively. CONCLUSIONS: Despite similar country socioeconomic characteristics there was significant variability in burn demographics, timing, and disability. Nevertheless, being geographically and economically disadvantaged predict lack of access to burn care.

Road traffic injuries: Cross-sectional cluster randomized countrywide population data from 4 low-income countries.

INTRODUCTION: Road traffic injuries (RTI) are a leading cause of morbidity and mortality around the world. The burden is highest in low and middle-income countries (LMICs) and is increasing. We aimed to describe the epidemiology of RTIs in 4 low-income countries using nationally representative survey data. METHODS: The Surgeons Overseas Assessment of Surgical Needs (SOSAS) survey tool was administered in four countries: Sierra Leone, Rwanda, Nepal and Uganda. We performed nationally representative cross-sectional, cluster randomized surveys in each country. Information regarding demographics, injury characteristics, anatomic location of injury, healthcare seeking behavior, and disability from injury was collected. Data were reported with descriptive statistics and evaluated for differences between the four countries using statistical tests where appropriate. RESULTS: A total of 13,765 respondents from 7115 households in the four countries were surveyed. RTIs occurred in 2.2% (2.0-2.5%) of the population and accounted for 12.9% (11.5-14.2%) of all injuries incurred. The mean age was 34 years (standard deviation ±1years); 74% were male. Motorcycle crashes accounted for 44.7% of all RTIs. The body regions most affected included head/face/neck (36.5%) followed by extremity fractures (32.2%). Healthcare was sought by 78% road injured; 14.8% underwent a major procedure (requiring anesthesia). Major disability resulting in limitations of work or daily activity occurred in 38.5% (33.0-43.9%). CONCLUSION: RTIs account for a significant proportion of disability from injury. Younger men are most affected, raising concerns for potential detrimental consequences to local economies. Prevention initiatives are urgently needed to stem this growing burden of disease; additionally, improved access to timely emergency, trauma and surgical care may help alleviate the burden due to RTI in LMICs.