Trauma Training for Nonorthopaedic Doctors in Low- and Middle-income Countries

Abstract

 

Increasingly, nonspecialist Ghanaian doctors in district hospitals are called upon to perform a variety of surgical procedures for which they have little or no training. They are also required to provide initial stabilization for the injured and, in some cases, provide definitive management where referral is not possible. Elsewhere continuing medical education courses in trauma have improved the delivery of trauma care. Development of such courses must meet the realities of a low-income country. The Department of Surgery, Kwame Nkrumah University of Science and Technology developed a week-long trauma continuing medical education course for doctors in rural districts. The course was introduced in 1997, and has been run annually since. The trauma course specifically addresses the critical issues of trauma care in Ghana. It has improved the knowledge base of doctors, as well as their self-reported process of trauma care. Through the process we have learned lessons that could help in the efforts to improve trauma training and trauma care in other low-income countries.

Introduction

Injuries are well documented as a leading cause of death and disability in developing countries and are increasing [^{5, 12, 22}]. Whereas a systematic approach to reducing the burden of injury in the developed countries has yielded good dividends, this cannot be said of developing countries [^{17, 18}]. On the other hand, there are great gains to be made in less-developed countries, where the rate of injury-related death is highest [^{5, 14}] and where most of the world's population lives. The range of injury control activities includes surveillance, prevention and treatment. Progress in any of these areas, particularly treatment, would yield substantial improvements.

Owing to the global rate of increase of vehicles and drivers, the proportion of deaths due to road traffic accidents is expected to rise, and for every person killed, many more are injured with temporary or permanent disability [^{5, 13}]. In Ghana, 81% of those seriously injured in road traffic accidents die before they get to the hospital [¹⁰]. Nearly one percent of all Ghanaians have an injury-related disability, 78% of which are due to extremity injuries [⁶]. There is a startling 8.8% yearly rate of increase in the number of casualties [²¹].

Several studies document high rates of medically preventable trauma deaths in developing countries, many from conditions that could be treated well in most hospitals [^{8, 10, 21}]. It is apparent that improvement in organization and planning for trauma care could lower these rates. Analysis of interventions implemented in high-income countries documents improvements in survival can be seen with better organization and planning for trauma care services. Well-organized trauma systems have decreased mortality among all treated trauma patients by 15-20% and decreased medically preventable deaths by 50% [^{15, 16}].

Low-cost improvements to upgrade trauma care are crucial [^{9, 19}]. A major aspect of such improvements is maximizing training. In developed countries, the Advanced Trauma Life Support (ATLS) course has been a mainstay of Continuing Medical Education (CME) and has been used to standardize and improve trauma care [^{3, 4}]. Regular institution of the ATLS courses has lowered the mortality rate of trauma victims [^{1, 2}]. However, the startup cost of the ATLS course is about 45,000 pounds (approximately $80,000 US), which is an insurmountable barrier to implementation in economically less developed countries.

Low technology, a resource-challenged environment, and limited capabilities for referral are the realities of less developed countries, which must be addressed by any educational approach. In many instances, general practitioners (GPs) are required to provide initial stabilization of the trauma patients and probably definitive treatment as well, including surgical procedures, without the input of specialists [^{7, 11, 19}]. In Ghana, GPs are routinely called upon to perform a variety of surgeries from Caesarean sections to the repair of typhoid ileal perforations. Therefore educational approaches to optimize trauma training must take into account such circumstances and realities.

The Department of Surgery, Kwame Nkrumah University of Science and Technology, developed a trauma CME course suited to the circumstances in the rural hospitals in Ghana [¹¹]. The department also sought to evaluate how well the course was achieving its goals of imparting the essential trauma treatment skills to course participants and the delivery of trauma care. We describe this training program, share the results of a questionnaire undertaken by our department, and suggest short term educational programs may improve the delivery of trauma care.

Ghana

Ghana is situated in West Africa, along the Greenwich Meridian, in a region formerly known as Gold Coast. Ghana has a per capita gross national product (GNP) of $340. The population is over 20 million, over 60% of whom live in rural areas. Major components of the labor force include agriculture (60%), industry (15%), and service (25%). The unemployment rate is approximately 20%, and 31% of the population lives below the poverty line. There is a current massive urban migration. The government is democratically elected. There is a universal health insurance system, which is partially funded by the government of Ghana.

The network of hospitals includes district hospitals, which have up to 200 beds, are usually manned by general practitioners (GPs), and serve rural areas up to 100,000 persons. There are 10 regions and each has a regional hospital with up to 500 beds, which may have one or two specialists, including a general surgeon, and serving up to 2 million people. There are two teaching hospitals with about a thousand beds each located in the two major cities of Accra and Kumasi. There are about 1600 doctors in the country (or one doctor for every 12,500 persons); approximately 70% of doctors work in the 2 major cities, leaving less than 30% to provide services for the rural areas.

Course Development

The department sought to develop a core set of essential trauma-related surgical skills that all GPs working in rural hospitals in Ghana should have and a highly effective teaching method, designed to maximize retention in a short time period. A week-long program in four broad areas was developed: (1) initial emergency management; (2) safe management of injuries by GPs in a rural African hospital setting; (3) diagnosis of injuries that ordinarily need referral, and safe transfer of victims; and (4) what to do when such referral is difficult or impossible.

This course covers the breadth of trauma care, and employs both lectures and practical skills stations: (1) initial assessment and management of life-threatening injuries (airway, breathing, circulation, diagnosis of internal bleeding); (2) head injuries; (3) chest injuries; (4) abdominal and urologic injuries; (5) burns; (6) hand injuries; (7) facial injuries; and (8) extremity injuries. The practical component includes procedures such as airway management/intubation (using mannequins), application of plaster of Paris casts, and an entire day of animal surgery. In cases where referral is not possible, injuries to the chest and abdominal area will ideally be diagnosed and handled at the district hospitals. All doctors, regardless of level, leave the animal lab proficient in venous cut down, chest tube insertion, diagnostic peritoneal lavage and débridement of open fractures.

From an orthopaedic perspective, the course is intended to teach doctors to recognize limb-threatening injuries like open fractures and their complications and referring these patients after resuscitation, initial wound management, and immobilization. Examples of orthopaedic skills include the closed management of fractures in adults and children, débridement of open fractures, recognition and treatment of limb-threatening conditions (vascular injury, compartment syndrome), and amputations.

Pre- and Posttest

Assessment of understanding of the course content was accomplished by a test with 30 multiple choice questions (Appendix 1). The questions are grouped into categories, and include the initial evaluation and management, torso injuries, plastic surgical injuries, orthopaedics and radiology. There was indeed improvement in the score for all major sections of the course, suggesting an increase in the trauma-related knowledge of the doctors after the course [¹¹]. This was so across the spectrum of topics. Areas needing improvement could be stressed in future courses (Appendix 1). The evaluation revealed extremely low pretest scores for some of the frequently missed topics.

Postcourse Interviews

A postcourse questionnaire was administered approximately one year after the course was taken to assess how well the materials had assisted the physicians in improving their delivery of trauma care; many of the doctors indicated they performed more trauma-related procedures. Most of the doctors had performed basic airway management, chest tube insertion, irrigation and débridement of open fractures [¹¹]. However, no doctor had performed any advanced airway procedure. The low utilization of advanced airway procedures may indicate the difficulty of teaching these adequately in a short period of time. It may also indicate lack of adequate airway equipment and limited facilities and infrastructure with which to deal with critically injured patients in rural hospitals [^{8, 9, 20}]. Certainly, upgrading care for the critically injured may require more than just training doctors alone. The less emergent procedures, such as irrigation and débridement of open fractures, were also performed. Probably, the utility of the course lies in both its ability to improve trauma-related morbidity as well as decrease mortality.

Discussion

In economically developed countries, the Advanced Trauma Life Support Course (ATLS) course has been developed to standardize and improve trauma care. The startup cost creates a barrier to initiating such courses in a low-income country like Ghana. As such, there was a need to develop alternate educational approaches relevant to the realities of low-income countries. Such courses must address the resource constrained environment (low technology), in which there are limited capabilities for referral.

The trauma CME course developed by the Department of Surgery, Kwame Nkrumah University of Science and Technology specifically addresses the critical issues of trauma care in Ghana. The course has improved the knowledge base of doctors as well as their self-reported process of trauma care. Approximately 200 doctors have taken this course, and we have applied for accreditation through both the medical and dental councils. The trauma course has been accredited (CME) for residents in General Surgery. More than 120 nurses have taken the course, and we are looking at developing a similar program specifically for nurses. In addition, a recertification process has started. There are obviously lessons which could help in efforts to improve trauma training and trauma care in other low-income countries.

We recommend stakeholders (governments, international community, others) support programs which provide continuing medical education in trauma care, such as ATLS (or variations) and/or locally developed courses such as that developed at Kwame Nkrumah University of Science and Technology. The most important thing is for institutions and governments to promote whatever courses are available, to develop locally appropriate courses if none exist, and/or to import courses like ATLS if funding is available. There should be wider dissemination of existing courses, with support by governments (political and financial), so that all front line trauma care providers (e.g. doctors working in the casualty ward, surgeons taking trauma call) at the busier institutions receive such training regularly (e.g. every 4 years or so). This should apply to the teaching hospitals, regional hospitals, and district hospitals which receive a high volume of trauma cases (e.g. along busy roads, etc). Similar considerations apply to nurses working with trauma patients. There should be equal emphasis on the development and promotion of continuing nursing education in trauma care.

Acknowledgment

We thank Drs. Charles Mock, Gabriel Boakye and all the lecturers in the Department of Surgery, for their various contributions in the development and implementation of the course over the years.