Trauma training course: innovative teaching models and methods for training health workers in active conflict zones of Eastern Myanmar

A Systematic Review of Live Animal Use as a Simulation Modality ("Live Tissue Training") in the Emergency Management of Trauma

INTRODUCTION

Live anaesthetized animals are used as simulation models to teach techniques in the emergency management of trauma. We aimed to explore how "live tissue training" (LTT) is designed, delivered and evaluated in order to better understand and characterize aspects of educational merit.

METHODS

A systematic review was performed using PRISMA guidance. A combined approach, involving a 3-stage modified narrative synthesis process and reflexive thematic analysis was used to identify key concepts across the published literature.

FINDINGS

Qualitative synthesis of 48 selected articles suggests that LTT is mainly used to teach military and civilian physicians and military medical technicians. The procedures trained vary with the learner population, from simple pre-hospital trauma tasks to advanced operative surgical skills. Many courses use a combination of didactic and practical training, with an animal model used to train practical application of knowledge and procedural skills. Descriptions of the learning interventions are limited, and explicit use of educational theory or pedagogic frameworks were absent within the literature. Four themes were identified regarding aspects of LTT that are valued by learners: "recreating the experience," relating to fidelity and realism; "tick tock" "dynamics of hemorrhage", encompassing the impact of bleeding and urgent pressure to act; "emotional impact" of conducting the training, and "self-efficacy: I believe I can do it."

CONCLUSION

Thematic analysis of published literature suggests that there may be educational benefit in the use of live tissue models due to time criticality and bleeding, which creates a real-life event. LTT also invokes an emotional response, and learners experience an increase in self-efficacy from participation. We consider that these aspects and associated pedagogy should be addressed when researching and developing alternative simulation modalities, in order to intelligently replace, reduce and refine the use of animals in training practitioners in the emergency management of trauma.

Paediatric trauma education in low- and middle-income countries: A systematic literature review

Background

Trauma-specific training improves clinician comfort and reduces patient morbidity and mortality; however, curricular content, especially with regard to paediatric trauma, varies greatly by region and income status. We sought to understand how much paediatric education is included in trauma curricula taught in low- and middle-income countries (LMICs).

Methods

We conducted a systematic literature review in October 2020 and in July 2022 based on PRISMA guidelines, utilizing seven databases: MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Reviews, Cochrane Trials, and Global Index Medicus. Reports were limited to those from World Bank-designated LMICs. Key information reviewed included use of a trauma curriculum, patient-related outcomes, and provider/participant outcomes.

Results

The search yielded 2008 reports, with 987 included for initial screening. Thirty-nine of these were selected for review based on inclusion criteria. Sixteen unique trauma curricula used in LMICs were identified, with only two being specific to paediatric trauma. Seven of the adult-focused trauma programmes included sections on paediatric trauma. Curricular content varied significantly in educational topics and skills assessed. Among the 39 included curricula, 33 were evaluated based on provider-based outcomes and six on patient-based outcomes. All provider-based outcome reports showed increased knowledge acquisition and comfort. Four of the five patient-based outcome reports showed reduction in trauma-related morbidity and mortality.

Conclusion

Trauma curricula in LMICs positively impact provider knowledge and may decrease trauma-related morbidity and mortality; however, there is significant variability in existing trauma curricula regarding to paediatric-specific content. Trauma education in LMICs should expand paediatric-specific education, as this population appears to be underserved by most existing curricula.

Integrating community health volunteers into non-communicable disease management among Syrian refugees in Jordan: a causal loop analysis

OBJECTIVES

Globally, there is emerging evidence on the use of community health workers and volunteers in low-income and middle-income settings for the management of non-communicable diseases (NCDs), provision of out-of-clinic screening, linkage with health services, promotion of adherence, and counselling on lifestyle and dietary changes. Little guidance exists on the role of this workforce in supporting NCD care for refugees who lack access to continuous care in their host country. The goals of this work were to evaluate the current roles of community health volunteers (CHVs) in the management of diabetes and hypertension (HTN) among Syrian refugees and to suggest improvements to the current primary care model using community health strategies.

SETTING AND PARTICIPANTS

A participatory, multistakeholder causal loop analysis workshop with representatives from the Ministry of Health of Jordan, non-governmental organisations, United Nations agencies, CHVs and refugee patients was conducted in June 2019 in Amman, Jordan.

PRIMARY OUTCOME

This causal loop analysis workshop was used to collaboratively develop a causal loop diagram and CHV strategies designed to improve the health of Syrian refugees with diabetes and HTN living in Jordan.

RESULTS

During the causal loop analysis workshop, participants collaboratively identified and mapped how CHVs might improve care among diagnosed patients. Possibilities identified included the following: providing psychosocial support and foundational education on their conditions, strengthening self-management of complications (eg, foot checks), and monitoring patients for adherence to medications and collection of basic health monitoring data. Elderly refugees with restricted mobility and/or uncontrolled disease were identified as a key population where CHVs could provide home-based blood glucose and blood pressure measurement and targeted health education to provide more precise monitoring.

CONCLUSIONS

CHV programmes were cited as a key strategy to implement secondary prevention of morbidity and mortality among Syrian refugees, particularly those at high risk of decompensation.

A scoping review of high-fidelity bench models for teaching closed reduction of distal radial fractures

This article was migrated. The article was marked as recommended.

INTRODUCTION

Simulation training can be beneficial for developing clinical skills without risks to patients. This review considers the literature on simulation models used for teaching closed reduction (manipulation) procedures for distal radius (wrist) fractures, particularly high-fidelity models, and the evidence supporting the use of such models.

METHODS

A scoping review of Medline and Embase was performed.

RESULTS

Five articles described low-fidelity models, predominantly focussing on low costs and teaching basic principles. Three articles and two commentary pieces discussing high-fidelity models were identified.

DISCUSSION

Attitudes towards a high-fidelity simulator were assessed by Egan et al. (2013), who found the majority of participants to be in favour of the model's use as a teaching tool, although participant selection may have been subject to bias. Mayne et al. (2016) subsequently used a high-fidelity model including radio-opaque markers and more objective measurements tools to assess orthopaedic trainees' closed reduction technique and adequacy of the achieved fracture position and casting. Seniority correlated with higher scores on objective structured assessment of technical skills (OSATS) and global rating scores (GRS) but not radiological measures of fracture position or cast quality, and over 90% of all participants achieved an adequate reduction. Seeley et al. (2017) used radiological measurements and time to task completion with another high-fidelity reduction model. The two most experienced participant groups could not be differentiated on any radiological measures of fracture reduction or on the time taken for reduction, although these groups were significantly better than the most junior participants.

CONCLUSION

The discussed models appear helpful to teach inexperienced participants the basic principles and steps in a procedures but a plateau effect appears to limit the potential benefit to more experienced learners. The constraints of educators' time and financial costs may influence the usage of such models in this type of training.

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

BACKGROUND

Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.

OBJECTIVE

The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.

METHODS

We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.

RESULTS

Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).

CONCLUSIONS

This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.

Status of Emergency Signal Functions in Myanmar Hospitals: A Cross-Sectional Survey

Introduction

Low- and middle-income countries (LMICs) have a large percentage of global mortality and morbidity rates from non-communicable diseases, including trauma. The establishment and development of emergency care systems is crucial for addressing this problem. Defining gaps in the resources and capacity to provide emergency healthcare in LMICs is essential for proper design and operation of ECS (emergency care services) reinforcement programs. Myanmar has particular challenges with road access for providing timely emergency medical care, and a shortage of trained health workers. To examine the ECS capacity in Myanmar, we used the Emergency Care Assessment Tool (ECAT), which features newly developed tools for assessing sentinel conditions and signal functions (key interventions to address morbidity and mortality) in emergency care facilities.

Methods

ECAT is composed of six emergent sentinel conditions and corresponding signal functions. We surveyed a total of nine hospitals in five states in Myanmar. A constructed survey sheet was delivered by e-mail, and follow-up interviews were conducted via messenger to clarify ambiguous answers.

Results

We categorized the nine participating institutions according to predefined criteria: four basic-level hospitals; four intermediate-level; and one advanced-level hospital. All basic hospitals were weak in trauma care, and two of 12 signal functions were unavailable. Half of the intermediate hospitals showed weakness in trauma care, as well as critical care such as shock management. Only half had a separate triage area for patients. In contrast, all signal functions and resources listed in ECAT were available in the advanced-level hospital.

Conclusion

Basic-level facilities in Myanmar were shown to be suboptimal in trauma management, with critical care also inadequate in intermediate facilities. To reinforce signal functions in Myanmar health facilities, stakeholders should consider expanding critical functions in selected lower-level health facilities. A larger scale survey would provide more comprehensive data to improve emergency care in Myanmar.

Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries

Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services.

Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates.

Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study.

Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.

Health Care Simulation in Developing Countries and Low-Resource Situations

INTRODUCTION

Health care simulation, as a complement to traditional learning, has spread widely and seems to benefit both students and patients. The teaching methods involved in health care simulation require substantial human, logistical, and financial investments that might preclude their spread in developing countries. The aim of this study was to analyze the health care simulation experiences in developing countries.

METHODS

A comprehensive literature search was performed from January 2000 to December 2016. Articles reporting studies on educational health care simulation in developing countries were included.

RESULTS

In total, 1161 publications were retrieved, of which 156 were considered eligible based on title and abstract screening. Thirty articles satisfied our predefined selection criteria. Most of the studies were case series; 76.7% (23/30) were prospective and comparative, and five were randomized trials. The development of dedicated task trainers and telesimulation were the primary techniques assessed. The retrieved studies showed encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly tested on the training tool itself. Two of the tools have been proven to be construct valid with clinical impact.

CONCLUSION

Health care simulation in developing countries seems feasible with encouraging results. Higher-quality studies are required to assess the educational value and promote the development of health care simulation programs.

Comparison of trauma care systems in Asian countries: A systematic literature review

OBJECTIVE

The study aims to compare the trauma care systems in Asian countries.

METHODS

Asian countries were categorised into three groups; 'lower middle-income country', 'upper middle-income country' and 'high-income country'. The Medline/PubMed database was searched for articles published from January 2005 to December 2014 using relevant key words. Articles were excluded if they examined a specific injury mechanism, referred to a specific age group, and/or did not have full text available. We extracted information and variables on pre-hospital and hospital care factors, and regionalised system factors and compared them across countries.

RESULTS

A total of 46 articles were identified from 13 countries, including Pakistan, India, Vietnam and Indonesia from lower middle-income countries; the Islamic Republic of Iran, Thailand, China, Malaysia from upper middle-income countries; and Saudi Arabia, the Republic of Korea, Japan, Hong Kong and Singapore from high-income countries. Trauma patients were transported via various methods. In six of the 13 countries, less than 20% of trauma patients were transported by ambulance. Pre-hospital trauma teams primarily comprised emergency medical technicians and paramedics, except in Thailand and China, where they included mainly physicians. In Iran, Pakistan and Vietnam, the proportion of patients who died before reaching hospital exceeded 50%. In only three of the 13 countries was it reported that trauma surgeons were available. In only five of the 13 countries was there a nationwide trauma registry.

CONCLUSION

Trauma care systems were poorly developed and unorganised in most of the selected 13 Asian countries, with the exception of a few highly developed countries.

Lessons from the frontline: using experiences from conflict zones to improve trauma care and outcomes

Over the years healthcare services during conflict have informed healthcare practice especially in trauma care. Conflict zones have constraints not very different from low-resource settings specifically in dealing with urban violence. Yet, there is limited in-depth study on conflict medicine. This is being slowly recognised in health literature. Two recent papers in International Health have indicated that trauma care packages in conflict settings could be adapted in low-resource settings. There is a need to overview and audit healthcare services in conflict zones further to identify more areas of overlap and possible lessons it holds for improving trauma outcomes in other settings.

Pediatric Resuscitation Education in Low-Middle-Income Countries: Effective Strategies for Successful Program Development

Despite established international guidelines, there is considerable variability in the quality of resuscitative care received by critically ill children in low-middle-income countries. While this problem is certainly multifactorial, education of health care workers is an important determinant of care quality. This article will discuss approaches to health care worker education in pediatric resuscitation in low-middle-income countries, with emphasis on aspects of educational programs that may contribute to positive educational and clinical outcomes.