The Implementation of Simulation-Based Learning for Training Undergraduate Medical Students in Essential Surgical Care Across Sub-Saharan Africa: a Scoping Review

Much surgery in sub-Saharan Africa is provided by non-specialists who lack postgraduate surgical training. These can benefit from simulation-based learning (SBL) for essential surgery. Whilst SBL in high-income contexts, and for training surgical specialists, has been explored, SBL for surgical training during undergraduate medical education needs to be better defined. From 26 studies, we identify gaps in application of simulation to African undergraduate surgical education, including lack of published SBL for most (65%) World Bank-defined essential operations. Most SBL is recent (2017-2021), unsustained, occurs in Eastern Africa (78%), and can be enriched by improving content, participant spread, and collaborations.

Developing a Surgical Simulation Curriculum for the Rwandan Context

OBJECTIVE

We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda.

DESIGN

This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students.

SETTING

University of Global Health Equity, a new medical school located in Butaro, Rwanda.

PARTICIPANTS

Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship.

RESULTS

The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options.

CONCLUSIONS

Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students' knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.

Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda

BACKGROUND

An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience.

METHODS

An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners' experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys.

RESULTS

Response rate was 93.3% (n = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast.

CONCLUSIONS

The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

The History and Evolution of the West African College of Surgeons/Jos University Teaching Hospital Trauma Management Course

BACKGROUND

Inadequate trauma care training opportunities exist in Low- and Middle-Income Countries. Jos University Teaching Hospital and the West African College of Surgeons (WACS) have synergized, over the past 15 years, to introduce a yearly, certified, multidisciplinary Trauma Management Course. We explore the history and evolution of this course.

METHODS

A desk review of course secretariat documents, registration records, schedules, pre- and post-course test records, post-course surveys, and account books complemented by organizer interviews was carried out to elaborate the evolution of the Trauma Management Course.

RESULTS

The course was started as a local Continuing Medical Education program in 2005 in response to recurring cycles of violence and numerous mass casualty situations. Collaborations with WACS followed, with inclusion of the course in the College's yearly calendar from 2010. Multidisciplinary faculty teach participants the concepts of trauma care through didactic lectures, group sessions, and hands-on simulation within a one-week period. From inception, there has been a 100% growth in lecture content (from 15 to 30 lectures) and in multidisciplinary attendance (from 23 to 133 attendees). Trainees showed statistically significant knowledge gain yearly, with a mean difference ranging from 10.1 to 16.1% over the past 5 years. Future collaborations seek to expand the course and position it as a catalyst for regional emergency medical services and trauma registries.

CONCLUSIONS

Multidisciplinary trauma management training is important for expanding holistic trauma capacity within the West African sub-region. The course serves as an example for Low- and Middle-Income contexts. Similar contextualized programs should be considered to strengthen trauma workforce development.

A Modified Open Primary Laparoscopic Surgery Port Placement through Umbilical Tube

Background:

A safe, reliable technique for primary trocar introduction is important for laparoscopic surgery. In resource-constrained settings where there is paucity of needed equipment and cost is prohibitive, a method utilizing fewer instruments will be useful.

Aim:

This study aims to describe a method of primary trocar introduction that utilizes any available port.

Methods:

A supra- or infra-umbilical incision is made into an everted tubular umbilicus. The linear alba is incised and the resultant opening bluntly developed, after which any available port is inserted using the trocar as a guide. The trocar is withdrawn while the sleeve is pushed in.

Results:

One hundred and three successful insertions were affected in 107 patients with age range of 1–75 years, with no significant gas leaks.

Conclusion:

This modified open approach is a simple and reliable way of primary port insertion. Access is gained easily in different age groups and umbilicus types.

PNEUMATIC REDUCTION OF INTUSSUSCEPTION IN CHILDREN: EXPERIENCE AND ANALYSIS OF OUTCOME AT JUTH, JOS, A TERTIARY HEALTH CENTRE IN NORTH CENTRAL NIGERIA

CONTEXT

Intussusception is a common childhood abdominal surgical emergency worldwide resulting in considerable morbidity and mortality if not promptly treated. Ultrasound-guided pneumatic reduction has been proven to be the most reliable and successful non-operative management option with the least complication rate.

AIMS

To evaluate our local experience with the ultrasound-confirmed pneumatic reduction of childhood intussusception and to determine factors that predict successful outcome.

SETTINGS AND DESIGN

A retrospective study of children less than 2 years old who presented to our facility with uncomplicated idiopathic intussusceptions between June, 2012 and June, 2017.

MATERIALS AND METHODS

The clinical diagnosis was confirmed by abdominal ultrasonography. Pneumatic reduction with a locally assembled equipment was performed on selected and resuscitated patients; abdominal ultrasound scan was then performed to confirm successful reduction. The procedure was considered to have failed if unsuccessful after the third attempt. Laparotomy was performed on patients with failed procedure.

STATISTICAL ANALYSIS USED

Statistical Package for Social Sciences version 24 was used for data analysis. Categorical variables were compared using Fisher exact test (with odds ratios and 95% confidence intervals where appropriate) and numeric variables compared using the student t-test. Statistical significance was set at p< 0.05.

RESULTS

Twenty five out of 36 children with intussusception were selected for the procedure with M:F ratio 1.8:1 and a mean age of 7.08 (SD 4.18) months. Only 9 (36%) presented early (ie within 24 hours). While non-bilious vomiting was the commonest symptom, blood-stained finger on rectal examination was the commonest sign in the patients. The overall success rate was 60% (15 patients). Early presentation accounted for only 5 (33%) of successful procedures. The presence of an abdominal mass was associated with increased likelihood of success (OR 9.75,[95% CI [1.38-68.78], p≥0.022), while the presence of a rectal mass was associated with a reduced likelihood of success (OR 0.16 95%CI [0.026-0.917], p≥0.042 ). Age, sex, and duration of symptoms before presentation did not influence outcome. Early presentation was however significantly associated with success at first attempt, compared to late presentation, in those with successful outcomes. Recurrence was observed in one (6.7%) of the successful cases. The mean duration of hospital stay in those that had successful outcome, 3.4(SD1.0) days was significantly shorter than that for those who had laparotomy for failed reduction, 8.0(SD3.1) days (p<0.001). There was no bowel perforation and no mortality recorded.

CONCLUSIONS

The successful pneumatic reduction rate was 60%. The major predictors of success in this study were the presence of abdominal mass and the absence of intussusception apex in the rectum. Early presentation was significantly associated with success at first attempt, compared to late presentation, in those with successful outcomes. There was no bowel perforation or mortality. Ultrasound-confirmed pneumatic reduction of intussusception is a simple, easy, safe and effective non-operative management of uncomplicated intussusception in well selected children in our environment.