Benefits of international trauma rotation in South Africa: comparison with a trauma center in Tokyo : Emergency and Critical Care Medicine

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Benefits of international trauma rotation in South Africa: comparison with a trauma center in Tokyo

Nagao, Tsuyoshia; Nakahara, Shinjia,b,∗; Fujita, Takashia; Sakamoto, Tetsuyaa; Steyn, Elminc

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Emergency and Critical Care Medicine 2(4):p 179-180, December 2022. | DOI: 10.1097/EC9.0000000000000048
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Despite the importance of adequate training, young surgeons in developed countries nowadays face certain limitations in gaining surgical experiences because of decreasing trauma numbers and the rapid development of nonoperative interventions.[1,2] Consequently, off-the-job trauma training courses are valuable to compensate for the insufficient real-world experience in the clinical setting. International clinical rotations have recently become an attractive option for surgical training: surgeons from developed countries visit developing countries where high trauma caseloads allow for surgical training that is unavailable in their home countries.[3]

One of the authors undertook an international trauma rotation in South Africa, where numerous surgeons from developed countries have undergone trauma rotations.[4,5] This paper reports the experience of training in South Africa compared with that in Japan and discusses the benefits, difficulties, and future of international trauma rotations.

The author, after working in the Emergency Department of Teikyo University Hospital in Tokyo for 15 months from April 1, 2016, to June 30, 2017, underwent an international trauma rotation at Tygerberg Hospital in Cape Town, South Africa for 6 months from July 1, 2017, to December 31, 2017. Tygerberg Hospital is designated as a level 1 trauma center and accepts 1000 to 2000 trauma cases per month. In contrast, Teikyo University Hospital, as an emergency critical care center treating severely ill and injured patients (equivalent to level 1 trauma center), treats only 300 to 400 severe trauma patients per year, despite being one of the highest volume centers in Japan.

Reflecting the different patient volumes, the number of operations experienced by the author in the 2 hospitals differed considerably (Table 1). The number of emergency trauma operations experienced at Tygerberg Hospital was 102 in 6 months (204 per year) versus 27 in 15 months (22 per year), respectively. The author experienced a large number of penetrating injuries, particularly gunshot injuries, which are extremely rare in Japan. Accordingly, the number of operations experienced in Tygerberg Hospital in 6 months was equivalent to approximately 5 years of operations in Teikyo University Hospital.

Table 1 - Comparison of the Number of Trauma Operations Experienced in Tygerberg Hospital in 6 Months and Teikyo University Hospital in 15 Months
Tygerberg Hospital Teikyo University Hospital
Experienced Number in 6 mo Estimation for 1 y* Experienced Number in 15 mo Estimation for 1 y*
Trauma operations (total) 151 302 49 39
 Emergency operations 102 204 27 22
 Penetrating injuries 86 172 10 8
 Blunt injuries 16 32 17 14
*Estimation is the product of the monthly average and 12 (months).

International rotation in South Africa can offer great opportunities for on-the-job training in trauma surgery for trainees from countries with a low trauma incidence. A high-volume academic trauma center may provide visiting surgeons with intensive surgical training and offer exposure to a broad spectrum of trauma cases in shorter time periods, which is impossible in their home countries. Moreover, they can receive training in the treatment of a wide variety of trauma mechanisms, particularly gunshot injuries, which may be extremely rare in countries with strict gun regulations.

The training benefits are not limited to the immersive exposure to clinical practice but also encompass a well-organized educational program based on principles and theories of trauma care, offered by experienced academic surgeons. Several teaching hospitals including Tygerberg Hospital are affiliated to Stellenbosch University. Academic staff supervise trainees in their clinical activities and academic presentations and offer educational teaching rounds and lectures. Therefore, this is an unparalleled exposure to “traumatology” as an established discipline for surgeons from Japan where traumatology is an immature discipline.

In addition, host hospitals can also benefit from international rotations. International trainees possess some experience in general surgery and are able to contribute as a part of the workforce in host hospitals, which face high patient numbers and perpetual staff shortages. Tygerberg Hospital always has 1 to 4 international trainees in the trauma surgery division, and they sometimes assist junior surgical residents with operations, which is usually a role of the senior surgical residents.

However, international rotation programs have several issues that need to be addressed to maximize their effectiveness and benefits for both home and host hospitals/countries. First, the majority of the international rotations are organized by private negotiations. Candidates must contact host hospitals personally and complete procedures for a temporary medical license on their own, which takes a long time. The author spent more than 2 years completing licensing procedures. Second, trainees are usually self-financed because external financial support for international trauma rotations is rarely available, and neither the host nor home hospitals can pay their salaries.[5] Lack of financial support makes international rotations less appealing for young surgeons. Third, several host hospitals in developing countries have limited resources and therefore lack sufficient facilities or skills for minimally invasive surgeries or interventional radiology procedures for trauma.[5]

We suggest the development of a more systematized and formalized framework for a staff exchange between developing and developed countries, which can address the aforementioned issues and provide mutual benefits to both home and host hospitals.[4,5] The process of negotiation and licensing could be shortened with a more formal system. In addition, financial support can encourage young surgeons to apply for international rotation programs. Senior staff exchange could facilitate the transfer of advanced technologies from developed to developing countries.

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

Nagao T and Fujita T conceived the concept of this paper. Nagao T and Nakahara S drafted the manuscript and the other co-authors contributed to critically revising it.



Ethical approval of studies and informed consent

Not applicable.




This study was presented at the 4th World Trauma Congress held in San Diego, September 26–29, 2018.


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5. Mantica G, Fransvea P, Virdis F, et al. Surgical training in South Africa: an overview and attempt to assess the training system from the perspective of foreign trainees. World J Surg. 2019;43(9):2137–2142. doi:10.1007/s00268-019-05034-7

Low- and middle-income countries; On-the-job training; Trauma surgery

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