18.15 A Quantitative Analysis of Surgical and Trauma Care Capacity in Rural Haryana, India

Posted on January 18, 2016

M. B. Bhatia1, S. E. Cherukupalli2, K. J. Blair2, M. Boeck2,6,7, I. Helenowski2, S. Sharma8,9, B. Nwomeh4,10, M. B. Shapiro2, J. Thakur3, A. Bhalla3, M. Swaroop2 1Texas Tech University Health Science Center School Of Medicine,Lubbock, TX, USA 2Northwestern University Feinberg School Of Medicine,Division Of Trauma & Critical Care, Department Of Surgery,Chicago, IL, USA 3Postgraduate Institute Of Medicine Education And Research,Department Of Internal Medicine,Chandigarh, HARYANA, India 4Surgeons Overseas,New York, NY, USA 5Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 6Brigham And Women’s Hospital,Boston, MA, USA 7New York Presbyterian Hospital – Columbia,Department Of Surgery,New York, NY, USA 8Boston Children’s Hospital,Department Of Plastic Surgery,Boston, MA, USA 9Harvard School Of Medicine,Department Of Global Health And Social Medicine,Brookline, MA, USA 10Nationwide Children’s Hospital,Columbus, OH, USA

Introduction:
Injuries account for 10% of all deaths worldwide and disproportionately affect low- and middle-income countries (LMICs), including India. These disparities can be partially attributed to scarce surgical, emergency response and trauma services. Evaluation of health facility surgical and trauma capacities aids in the identification and subsequent correction of deficiencies at each level of care. This study aimed to estimate the surgical and trauma care capacities of government health facilities in Nanakpur, a rural community of 40,000 people in Haryana, India, using a modified version of the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool, which includes additional questions from the International Assessment of Capacity for Trauma (INTACT) and Tool for Situational Analysis to Assess Emergency and Essential Trauma Care (TSAAEESC) survey instruments.

Methods:
In June 2015 the modified PIPES tool was administered to the eight government health facilities with at least one operating room in Nanakpur. Evaluated facilities included two primary health centers, one secondary-level community health center, four tertiary hospitals and one tertiary subspecialty hospital. At each location, a physician, hospital administrator or scrub nurse completed the survey, which evaluated personnel, infrastructure, procedures, equipment and supplies. Quantitative analyses were performed for each subsection and overall indices were calculated for PIPES and INTACT. Median scores were compared via Wilcoxon rank sum tests.

Results:
The eight facilities had a median of 250 beds (IQR 6.0-784.0), three general surgeons (IQR 0-15.0) and 2.5 anesthesiologists (IQR 0.5-22.5). No operative interventions were performed at the primary health centers and only selective surgical procedures (primarily C-sections and orthopedic procedures) were offered at the community health center. Median index scores were significantly higher for tertiary versus primary and community health centers: PIPES (10.667 vs. 4.19, p=0.03) and INTACT (9.25 vs. 3.75, p=0.03). The inconsistencies between the highest and two lower-levels of care were greatest in regards to personnel (15.0 vs. 0, p=0.02) and procedures (37.0 vs. 5.0, p=0.02), with general surgeons and non-obstetric abdominal surgery only available at four tertiary hospitals.

Conclusion:
Through the use of a modified version of PIPES, information was gathered on the availability of elements necessary for the delivery of essential surgical and trauma care. The stark contrast between primary/community and tertiary health care facilities is most evident in personnel and procedures, reflecting the all-too-common shortage of available services at lower-level facilities. Ideally, these results will guide resource allocation to ultimately improve surgical and trauma capabilities at all facility levels, thereby providing this rural Indian population with equitable access to timely, quality care.

18.16 Cluster Munition Injuries and Research: Where Are We Now and What is an Academic Surgeon’s Role?

Posted on January 18, 2016

K. Chawla1, E. Habermann2, D. Jenkins3, A. L. Kushner4,5,6 1Mayo Medical School,Rochester, MN, USA 2Mayo Clinic,Robert D. And Patricia E. Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA 3Mayo Clinic,Division Of Trauma, Critical Care And General Surgery,Rochester, MN, USA 4Johns Hopkins Bloomberg School Of Public Health,Department Of International Health,Baltimore, MD, USA 5Columbia University College Of Physicians And Surgeons,Department Of Surgery,New York, NY, USA 6SurgeonsOverSeas,New York, NY, USA

Introduction: Cluster munitions (CM) are weapons of war that consist of multiple explodable subunits. Undetonated subunits frequently cause death and injury in civilians, mostly women and children. An international treaty banning the use of CM went into force in 2010; despite this, their use, though decreased, still continues. The goal of this study was to identify countries where civilians were most at risk of CM injuries and review the medical literature on CM as compared to research on landmine injuries.

Methods: Data on CM injuries were obtained from the Cluster Munition Monitor database. Health care per capita data were obtained from the World Bank. Development and gender indices were obtained from the United Nations Human Development Reports. Two reviews of PubMed were conducted in August 2015, one using the search terms ‘cluster munitions’ and the other ‘landmines.’

Results:Although global casualty estimates are as high as 55,000 for CM, from the 1960s through 2013, only a total of 19,419 CM casualties were documented. Approximately, 94% were civilian victims. In 2013, casualties from CM remnants were reported in ten countries: Cambodia, Croatia, Iraq, Lao PDR, Lebanon, South Sudan, Sudan, Syria and Vietnam, and Western Sahara. A majority of the victims have been documented in four countries (Table 1). The literature review revealed only 10 papers on CM with the first written in 2003. Only 5 were research papers, the others were commentaries. For landmines, there were a total of 106 papers of which 38 were research papers dating back to the 1980s.

Conclusion:Despite an international treaty banning the use of CM, injuries to civilians commonly occur. The countries with the highest numbers of casualties have few health resources to care for their population and thus would benefit from improved surgical capacity. Unlike landmines, little research on CM injuries is described in the literature. Academic surgeons can contribute by: 1) joining with colleagues in affected countries to undertake research, and 2) raise awareness on the need to improve surgical and rehabilitation capabilities for injured victims located mostly in low-resource countries.

18.17 Surgical Needs in Rural India: A Population-Based Survey in Nanakpur, Haryana

Posted on January 18, 2016

S. E. Cherukupalli1, M. Bhatia2, S. Gupta3,4, N. Nagarajan5, M. Boeck1,6,7, S. Sharma8,9, B. C. Nwomeh4,10, J. Thakur11, M. B. Shapiro1, A. Bhalla11, M. Swaroop1 1Northwestern University Feinberg School Of Medicine,Department Of Surgery, Division Of Trauma And Critical Care,Chicago, IL, USA 2Texas Tech University Health Sciences Center School Of Medicine,Lubbock, TX, USA 3University Of California, San Francisco, East Bay,Oakland, CA, USA 4Surgeons Overseas,New York, NY, USA 5Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 6Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 7New York Presbyterian Hospital-Columbia,Department Of Surgery,New York, NY, USA 8Boston Children’s Hospital,Department Of Plastic Surgery,Boston, MA, USA 9Harvard Medical School,Department Of Global Health And Social Medicine,Boston, MA, USA 10Nationwide Children’s Hospital,Columbus, OH, USA 11Postgraduate Institute Of Medical Education And Research,Chandigarh, HARYANA, India

Introduction:
Recent global estimates show an astounding five billion people lack access to safe, quality and timely surgical care. The rates of major surgeries in low- and middle-income countries (LMICs) are much lower than those of more developed nations. Surveys at the community level provide a more accurate measure of unmet surgical need compared to facility-based surveys. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical need (SOSAS) population-based survey tool.

Methods:
The study was undertaken between June and July 2015 in Nanakpur, Haryana. The region was divided into three sectors, with eight clusters each for sampling. Two clusters per sector were randomly selected for a total of 50 households (93 respondents) interviewed. The head of household provided demographic data, and surgical histories in six distinct anatomical regions were obtained from two household members. Questions were modified from the SOSAS survey to better capture distinct characteristics of Nanakpur’s population. We defined current surgical need as a self-reported surgical problem present at the time of the interview and unmet surgical need as a surgical problem in which the respondent did not access care. Categorical and continuous variables were analyzed using Pearson’s chi-squared and Kruskal Wallis tests, respectively.

Results:
One hundred percent of households selected for the survey participated, with a total of 93 individuals and a median age of 35 years (IQR 26-50). Eighty-six percent were female, 59.1% literate and 23.7% employed. Twenty-eight individuals (30.1%; 95% CI: 21.0-40.5) indicated they had a current surgical need (body region: face 2, chest/breast 1, back 1, abdomen 3, groin/genitalia 4, extremities 17). Those with a current surgical need had a higher median age (46.5 vs. 33 years, p=0.034) and lacked funds to travel to a tertiary center (64.3% vs. 32.4%, p=0.041). Once transport was available, the median travel time to a tertiary center was 60 minutes (IQR 45–90). Six individuals had an unmet surgical need (6.5%; 95% CI: 2.45-13.5).

Conclusion:
The SOSAS tool has been used to estimate surgical needs at the population level in multiple regions across the globe. This pilot study, the first in India, highlights a significant burden of surgical disease in the remote area of Nanakpur. These data are useful preliminary evidence to highlight the urgent need to strengthen surgical systems in rural parts of India. Further studies should be conducted to better estimate the burden of surgical diseases throughout India, to accurately inform policymakers of the need to improve access to care.

18.11 Epidemiology Of Peritonitis At A Referral Hospital in Rwanda

Posted on January 18, 2016

L. Ndayizeye1,3, C. Ngarambe1,3, B. Smart5, R. Riviello1,2, J. Majyambere4, J. Rickard1,2 1University Teaching Hospital Of Kigali,Kigali, , Rwanda 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Rwanda,College Of Medicine And Health Sciences,Kigali, , Rwanda 4Kibungo Referral Hospital,Kibungo, , Rwanda 5Rush University Medical Center,Chicago, IL, USA

Introduction:
Peritonitis is a common surgical emergency, but there are few studies detailing causes and outcomes of peritonitis in low- and middle-income countries. This study sought to describe the epidemiology and outcomes of patients undergoing operation for peritonitis at a major referral hospital in Rwanda.

Methods:
This report describes data on all patients presenting to a Rwandan referral hospital with clinical features of peritonitis over a six-month period. Data were collected on demographics, clinical presentation, laboratory and radiographic studies, operative findings, and complications. The primary goal was to describe the epidemiology and etiology of peritonitis at a referral hospital in Rwanda.

Results:
There were 281 patients presenting with peritonitis over a six-month period of which 217 (77%) were adult and 64 (23%) were pediatric. Most patients were male (68%). Localized peritonitis accounted for 32% of cases while 68% were generalized. 72 (26%) of patients presented to the hospital with symptoms lasting for more than a week. The most common cause of peritonitis was intestinal obstruction (39%), followed by appendicitis (17%) and trauma (14%). Females were more likely to be diagnosed with appendicitis (29% versus 10%, p<0.001) or tumor (7.8% versus 2.6%, p=0.046) whereas males were more likely to be diagnosed with a traumatic injury (18% versus 4%, p=0.002) or peptic ulcer perforation (210% versus 3%, p=0.042). 46 (16%) patients were admitted to the intensive care unit postoperatively and 27 (10%) patients required vasopressors. The mean length of hospital stay was 9.8 days (standard deviation 9.1). Major complications were seen in 25% of patients, with 36 (13%) patients requiring a return to the operating room. The post-operative mortality rate was 17%.

Conclusion:
Peritonitis is a common surgical emergency in Rwanda and patients presenting with peritonitis have a relatively high morbidity and mortality. In contrast to reports from high-income countries, peritonitis was most commonly associated with intestinal obstruction, appendicitis and trauma. Many patients presented in a delayed fashion, with symptoms for over a week. Focusing interventions on early recognition and management in these patients could potentially improve outcomes.

18.12 Perspectives on the optimal surgery resident international trauma rotation

Posted on January 18, 2016

R. A. Tessler1, S. Gupta1,2, B. T. Stewart3, E. G. Wong2,4, T. McIntyre5, R. S. Godfrey1, R. R. Price6, A. D. Fox7, A. L. Kushner2,8,9, K. N. Remick10 1University Of California – San Francisco , East Bay,Surgery,Oakland, CA, USA 2Surgeons OverSeas,New York, NY, USA 3University Of Washington,Surgery,Seattle, WA, USA 4McGill University,Surgery,Montreal, QC, Canada 5State University Of New York, Downstate,Surgery,Brooklyn, NY, USA 6University Of Utah,Surgery,Salt Lake City, UT, USA 7University Of Medicine And Dentistry Of New Jersey,Surgery,Newark, NJ, USA 8Columbia University College Of Physicians And Surgeons,Surgery,New York, NY, USA 9Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 10Walter Reed Army Medical Center,Trauma Surgery And Critical Care,Washington, DC, USA

Introduction: Injury affects nearly 5.8 million people each year and causes 10% of the world’s deaths; 90% of which occur in low-and-middle-income countries. Increasingly, general surgery residents in the US are eager to confront this burden early in their career. However, formal programs are sparse. Our objective was to define the criteria for an optimal international trauma rotation for US surgical residents.

Methods: A modified Delphi technique was used to solicit consensus from a panel of global surgery program directors, academic surgeons, surgical residents, and surgeons with humanitarian surgery experience. Three rounds of questionnaires were used to create a list of criteria for an optimal international trauma rotation for US general surgical residents. Content analysis of responses was used to generate categories from the criteria.

Results: Consensus responses generated 37 criteria that could be organized into four categories. The most common criterion reported was safety in the host country (78%). The top three most commonly noted criteria for each category are: 1) host nation requirements: sustainability/long-term commitment (56%); strong local champion/mentor (56%); local residency training program and educational curriculum (67%); 2) sponsoring US institution requirements: bi-directional training (44%); strong/supportive mentorship (44%); support and credit approved by American Board of Surgery (44%); 3) surgery resident requirements: required research with scholarly work including both US/host nation authors (33%); participation in ongoing advocacy projects in host nation (22%); commitment to participate in global surgery journal club and/or grand rounds in both institutions (33%); and 4) rotation specific requirements: minimum length of 4 weeks (67%); safe and accessible accommodation/daily living (78%); exposure to breadth of injury care in resource limited settings (67%).

Conclusion: The top responses indicate that safety, minimum length of 4 weeks, exposure to breadth of injury care in resource limited settings and a local educational curriculum are the most important features of an international trauma rotation. With increasing interest among US surgical residents and programs to participate in global surgery endeavors, criteria to establish an optimal surgery resident international trauma experience were created. US institutional leadership and surgery program directors must ensure safety and an optimal educational experience for surgery residents, as well as demonstrate long-term commitment to trauma care in the resource-limited setting. A broader consensus document should be created that gives an acceptable standard for international trauma surgery rotations.

18.13 Development of a Student Surgical Interest Group Promotes a Pipeline for Women Surgeons in Zimbabwe

Posted on January 18, 2016

A. Moyo2, C. T. Mashingaidze2, P. Moyo2, F. C. Muchemwa2, S. M. Wren1 1Stanford University,Surgery,Palo Alto, CA, USA 2University Of Zimbabwe,College Of Health Sciences,Harare, HARARE, Zimbabwe

Introduction: There is a paucity of women surgeons in Zimbabwe with only 5.6% (6/108) of registered surgeons, and 7.8% (6/51)of surgery trainees being women inspite of a 33% female enrolment at undergraduate level. Interventions are critical to increase women representation within the field. Until the formation of DREAM (Dedicated to Reach, Empower, and Mentor) Zimbabwe had no specialty student interest groups; we report the early results of a novel focused interest group to support women students interested in surgical training.

Methods: The student organization; DREAM was established in 2014 as a mentorship and information-sharing platform for undergraduate women students interested in surgery. Its objectives are to reach (present surgery as an attractive career option), empower (with information, basic surgical skills and opportunities for participation) and mentor (peer, group, personal and e-mentorship) women with the goal of increasing the numbers of Zimbabwean women in surgery.

Results: Since its inception in March 2014 DREAM’s membership has increased from the founding 6 fourth year medical students (MBChB) to its current membership of 36 consisting of 3rd, 4th, 5th year medical students and 1st year interns ((58, 11, 25 and 6% respectively). 8 group mentorship sessions have been held with local and visiting surgeons from the US, Japan, China and Australia. Some of these relationships have continued in the form of personal or e-mentorship. Some members participated at the 2014 College of Surgeons East, Central, and Southern Africa (COSECSA) which is currently discussing its role in promoting the development of women surgeons in the region. DREAM organized clerkships for some of its members in Tanzania, the US and New Zealand in 2014. In July 2015 the organization hosted the first ever basic surgical skills training for medical students which was attended by 21 members. Stemming from this event the ‘sisterhood’ peer-mentorship initiative was begun in which senior female medical students provide bedside mentorship to junior students during clinical rotations.

Conclusion: Just two years after its inception; this initiative has shown great potential for increasing women’s participation in surgery in Zimbabwe. There are currently 5 graduating students and 2 first year interns committed to surgical training. Significant challenges exist that will have to be addressed. For example all Zimbabwean graduates complete 2 years as rotating house officer after which the majority become licensed independent physicians and do not pursue further specialty training. This hiatus after graduation and option to have a full-time job presents significant challenges to keep engagement and subsequent matriculation in residency training. As the organization matures we hope to address these challenges to achieve a sustained increase in women surgeons in training and practice.

18.14 Quantifying Surgical Care Needs for Refugees and Other Displaced Persons

Posted on January 18, 2016

Y. A. Zha1,2, E. Lee1,3, K. N. Remick4,5, D. H. Rothstein6,7, D. Guha-Sapir8, R. S. Groen9, D. K. Imagawa2, G. Burnham1, A. L. Kushner1,10,11 8Centre For Research On The Epidemiology Of Disasters – Université Catholique De Louvain,Brussels, , Belgium 9Johns Hopkins Hospital,Department Of Gynecology & Obstetrics,Baltimore, MD, USA 10Columbia University College Of Physicians And Surgeons,Department Of Surgery,New York, NY, USA 11Surgeons OverSeas,New York, NY, USA 1Johns Hopkins Bloomberg School Of Public Health,Department Of International Health,Baltimore, MD, USA 2University Of California – Irvine School Of Medicine,Department Of Surgery,Irvine, CA, USA 3University Of Southern California,Department Of Surgery,Los Angeles, CA, USA 4Uniformed Services University Of The Health Sciences,Department Of Surgery,Bethesda, MD, USA 5Combat Casualty Care Research Program,Ft. Detrick, MD, USA 6Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 7State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA

Introduction:
According to United Nations High Commissioner for Refugees (UNHCR), 59.5 million people worldwide were displaced from their homes due to conflict, persecution, violence, and human rights violations at the end of 2014. This vulnerable population suffers from poor health conditions, many of which are surgically treatable. The recently released Lancet Commission on Global Surgery proposed a target capacity of 5,000 operations per 100,000 people annually by 2030 to meet the demands of the global burden of surgical disease. Based on this value, we sought to estimate the minimum surgical needs of refugees, internally displaced persons (IDPs), and asylum seekers.

Methods:
Using the UNHCR database, the numbers of refugees, IDPs, and asylum seekers at the end of 2014 were identified. Data on the age and gender distribution of this population were also recorded. The numbers of displaced persons were categorized by the top countries of residence. Using the proposed annual minimum target of 5,000 operations per 100,000 population, the numbers of major surgical procedures needed per year were calculated.

Results:
For the 59.5 million displaced persons, we calculated that at least 2.98 million operations are needed each year. The minimum numbers of surgeries required per year for the countries with the largest populations of displaced individuals include: Syria (397,000 surgeries), Colombia (302,000 surgeries), Iraq (201,000 surgeries), Democratic Republic of Congo (181,000 surgeries), and Pakistan (148,000 surgeries). The numbers of displaced persons and estimated operations needed annually by category are shown in Table 1. Gender distribution for displaced individuals shows a nearly equal breakdown of males (50.2%) and females (49.8%). Additionally, 51% of refugees were children (age less than 18 years).

Conclusion:
An estimated minimum of nearly 3 million operations are required each year to meet the large surgical needs of refugees, IDPs, and asylum seekers. Obstetrical/gynecological and pediatric surgical expertise will likely be in high demand due to the large proportion of women and children among those displaced. Most displaced persons are hosted in countries with inadequate healthcare infrastructure and where surgical care is likely to fall short of the need. We recommend governments and non-governmental organizations consider these figures when providing humanitarian assistance and allocating resources. In addition, including surgical need with data collected on displaced persons can help the implementation, monitoring, and evaluation of humanitarian surgery programs.

18.08 An Application of a Geographic Information System to Evaluate Surgical Infrastructure in Zambia

Posted on January 18, 2016

M. Esquivel1, T. Uribe-Leitz1, I. Mathews6, N. Raykar2,3, E. Makasa4, K. Bowman5, T. Weiser1 1Stanford University School Of Medicine,General Surgery,Stanford, CA, USA 2Harvard Medical School,Program In Global Surgery And Social Change,Boston, MA, USA 3Beth Isreal Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 4Permanent Mission Of Zambia,Health,Geneva, GE, Switzerland 5Children’s Hospital Of Wisconsin,Division Of Pediatric General And Thoracic Surgery,Milwaukee, WI, USA 6Redivis, Inc,Mountain View, CA, USA

Introduction: Surgical health advocates recommend that countries evaluate and report on surgical services in order to understand and improve availability of surgical care. Health planners and ministries of health would benefit from this type of data to inform key decisions. We used a data visualization tool to analyze surgical infrastructure, capacity, and availability of surgical care in Zambia.

Methods: All hospitals providing surgical care in 2010 were identified in cooperation with the Zambian Ministry of Health. On-site data collection included location and type of hospital, procedure availability, human resources, and infrastructure using an adapted WHO Global Initiative for Emergency and Essential Surgical Care survey from October 2010 through August 2011. Data were geocoded using ArcGIS 10.3 and analyzed in Redivis, an online visualization platform. We analyzed time and distance to surgical services, as well as the proportion of the population covered within a two-hour travel time, as recommended by the Lancet Commission on Global Surgery.

Results: Data were collected from all 103 surgical facilities identified as providing surgical care using direct observations and 495 interviews with providers at the facilities. When including all surgical facilities (regardless of human resources and supplies), 8% of the population (1.16 million people) lived more than a 2-hour drive from surgical care (Figure 1a). When the World Health Organization criteria for minimal safety standards (the minimal complement of equipment and supplies to maintain an airway, resuscitation and sterility for surgical care) were included in the analysis, access declined; only 17 (16.5%) hospitals met the minimum standards of surgical safety, defined as the availability of a pulse oximeter, adult bag mask, oxygen, suction, intravenous fluid, sterile gloves, skin preparation solution, and a functioning sterilizer. Geospatial analysis of these 17 hospitals showed that 58% of the population (8.41 million people) lived more than a 2-hour drive from a facility with a minimal complement of infrastructure for surgical care (Figure 1b).

Conclusion: A large proportion of the population in Zambia does not have access to safe and timely surgical care. Our study highlights that overall Zambia has sufficient surgical centers spread out across the country. However, human resources, infrastructure, and supplies within these facilities are limited and must be addressed to improve access to safe surgical care. The use of geospatial visualization tools assists in the evaluation of surgical infrastructure in Zambia, and can identify key areas for improvement. This type of geospatial analysis could help with health system planning across many countries and health services.

18.09 Analysis Of The Cost Of Surgical Care For Peritonitis At A Referral Hospital In Rwanda

Posted on January 18, 2016

J. Rickard1,2, C. Ngarambe1,3, L. Ndayizeye1,3, B. Smart5, R. Riviello1,2, J. Majyambere4 4Kibungo Referral Hospital,Kibungo, , Rwanda 5Rush University Medical Center,Chicago, IL, USA 1University Teaching Hospital Of Kigali,Department Of Surgery,Kigali, , Rwanda 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University Of Rwanda,College Of Medicine And Health Sciences,Kigali, , Rwanda

Introduction:

Many different surgical procedures have been shown to be cost-effective interventions. While peritonitis often requires surgical intervention, little is known regarding the associated costs, particularly in low- and middle-income countries.

Methods:

As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, hospital costs associated with peritonitis were examined. Data were collected on demographics, clinical features, and outcomes. Continuous variables were reported as means and standard deviations (SD). Costs were reported as US dollars (USD).

Results:

Over a six-month period, 281 patients underwent operation for peritonitis. Common diagnoses included: obstruction (39%), appendicitis (17%), and trauma (14%). 254 (93%) patients had government-sponsored health insurance, covering at least 90% of in-hospital costs.

Cost analyses were available for 245 patients. The mean total hospital cost was 379 USD (SD 325), which is 58% of the Rwanda gross national income per capita. Mean patient cost was 42 USD (SD 79). Medications comprised the largest proportion (37%) of total hospital costs (mean 142 USD, SD 171).

Total hospital cost varied with length of hospital stay and diagnosis. Hospital stay was longer in patients diagnosed with typhoid perforation (mean 18.1 days, SD 15.6) and cholecystitis (mean 14.3 days, SD 4.9). Higher costs were seen in patients diagnosed with cholecystitis (mean 760 USD, SD 530) and typhoid perforation (mean 726 USD, SD 442).

Conclusion:

Surgical costs for peritonitis at a Rwandan referral hospital were reasonable, though total hospital costs equate to a significant portion of gross national income per capita. Most patients were eligible for government-sponsored insurance, which minimized costs for patients and families. Decreasing the length of hospital stay and minimizing costs is critical in a low-resource setting to decrease the financial burden of disease.

18.10 Trauma First Responder Course Participant Characteristics & Experiences in La Paz & Potosi, Bolivia

Posted on January 18, 2016

M. A. Boeck1,3,4, T. E. Callese5, S. K. Nelson5, S. J. Schuetz2, C. G. Miller6, C. Fuentes Bazan7, J. R. Simons Gonzáles8, M. C. Vargas8, L. W. Ruderman8, J. L. Gallardo10, J. M. Laguna Saavedra11, N. M. Issa2, M. B. Shapiro2, M. Swaroop2 1Feinberg School Of Medicine – Northwestern University,Center For Global Health,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Division Of Trauma And Critical Care,Chicago, IL, USA 3Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 4New York Presbyterian Hospital – Columbia,Department Of Surgery,New York, NY, USA 5Wake Forest University School Of Medicine,Winston-Salem, NC, USA 6Emory University School Of Medicine,Atlanta, GA, USA 7Arco Iris Hospital,La Paz, , Bolivia 8Centro De Medicina Familiar Yawisla SRL,Potosi, , Bolivia 9University Of Southern California,Los Angeles, CA, USA 10Hospital Obrero #5 Caja Nacional De Salud,Potosi, , Bolivia 11Bolivian National Police,La Paz, , Bolivia

Introduction: Globally, a person dies every five seconds due to a traumatic injury. Effective trauma systems, including pre-hospital, hospital and rehabilitative care, lead to decreased mortality and improved functional outcomes. Yet many low-resource settings like Bolivia lack in one or more of these areas. We sought to survey trauma first responder course (TFRC) participants in La Paz and Potosi, Bolivia regarding the current state of emergency training, trauma experience and healthcare facility access.

Methods: From March to May 2013 a nominally priced, eight-hour TFRC was offered in Bolivia. Nine sessions were held in the department of La Paz, a largely populated, urban setting; and ten courses took place in seven municipalities in the Potosi region, a more rural mining community. Participants completed a baseline survey on personal demographics, prior emergency experiences, first-aid training, and health facility access. Categorical and continuous variables were analyzed by Pearson’s chi squared and Wilcoxon rank sum tests, respectively.

Results: A total of 514 participants met criteria for study inclusion: n=355 in Potosi and n=159 in La Paz. There were higher proportions of medically trained (76.8% vs. 59.5%, p<0.001) and university-educated (81.1% vs. 61.4%, p<0.001) individuals in Potosi; while participants in La Paz had more prior trauma training (71.3% vs. 51.5%, p<0.001), emergency experiences in the past six months (68.6% vs. 43.9%, p<0.001) and higher numbers of emergencies seen per respondent (median 21.5 vs. 5, p<0.001). The most common injury mechanisms across both regions were road traffic crashes (median 5, IQR 2, 15) and falls (median 3, IQR 1, 8). Sixty-six percent of individuals in La Paz had provided assistance in an emergency versus 40% in Potosi (p<0.001), while most participants had access to first aid equipment in both locations (Potosi 77.9% vs. La Paz 83.1%, p=0.20). Health centers were considered the primary emergency care facility in Potosi (43.4%) versus hospitals in La Paz (51.6%, p=0.004), despite a majority of participants in both locales reporting an estimated 10 to 30 minute travel time to the closest hospital (p=0.015). On univariable analysis, there was no significant association between assisting in an emergency and pre-test score, prior training, self-reported baseline skill confidence level or profession.

Conclusion: The baseline TFRC survey captures fundamental information on existing local emergency response resources, workforce experiences and injury patterns. Participants reported a significant exposure to trauma cases, with variable access or ability to provide appropriate and timely medical care, highlighting a gap in basic emergency skills and supply availability in the community. This confirms the need for sustainable improvements in pre-hospital care in Bolivia, including additional training, resources and systems planning, to eventually decrease injury morbidity and mortality.

18.05 Participant Evaluation of a Novel, Layperson Trauma First Responder Course in La Paz, Bolivia

Posted on January 18, 2016

T. E. Callese1,2, S. K. Nelson1, M. Boeck2,3,4, S. J. Schuetz5, C. F. Bazan6, J. Mauricio P. Saavedra Laguna7, M. B. Shapiro5, N. M. Issa5, M. Swaroop2,5 1Wake Forest University School Of Medicine,Winston-Salem, NC, USA 2Northwestern University,Center For Global Health, Feinberg School Of Medicine,Chicago, IL, USA 3Brigham And Women’s Hospital, Center For Surgery And Public Healt,Boston, MA, USA 4New York Presbyterian Hospital, Columbia Department Of Surgery,New York City, NY, USA 5Northwestern University,Division Of Trauma And Critical Care, Feinberg School Of Medicine,Chicago, IL, USA 6Arco Iris Hospital,La Paz, LA PAZ, Bolivia 7Bolivian National Police,La Paz, LA PAZ, Bolivia

Introduction: Trauma is a significant cause of death and disability worldwide; especially in low- and middle-income countries (LMICs) where over 90% of injury mortalities occur. Bolivia is a LMIC that lacks a cohesive emergency response system and accessible pre-hospital care, including adequately trained first-responders. The World Health Organization (WHO) considers layperson first-responders as an essential component of effective trauma systems in low-resource settings to increase the emergency medical workforce capacity. This study sought to analyze participant evaluations on a novel trauma first-responder course (TFRC) offered in La Paz, Bolivia.

Methods: The TFRC was offered for a nominal fee to adults in the department of La Paz. An American surgeon and medical student led nine separate eight-hour sessions in March and April 2013. There were didactic and practical components that built upon existing training course models with local stakeholder input, ensuring the covered material accounted for local area needs and treatment resources. At the conclusion of the course participants completed a program evaluation, which included a self-assessment of knowledge and skill acquisition, course reflections and individual session ratings.

Results: One hundred fifty-nine participants completed evaluations for analysis, of which 97.5% rated the course as useful and 96.7% believed they would apply the skills learned in the future. Median participant self-confidence ratings in first aid skills (range 0-5) showed an upward trend from baseline to post-course (4 vs. 5). Ninety-one percent of participants deemed the depth of training appropriate, with only 3.2% and 5.8% rating it as too basic or overly technical, respectively. The majority of respondents were in favor of introducing more topics and increasing the length of practical sessions in future course offerings. The 13 didactic and four practical sessions were individually graded on quality, resulting in median scores of 4 or higher on a five-point scale, where five indicates excellent.

Conclusion: This study represents the first offering of a novel TFRC in a resource-limited setting that received largely positive evaluations from course participants. Responses were almost unanimously affirmative on course usefulness, as well as suitable subject depth and coverage of context-appropriate topics. Participant feedback suggests offering more didactic sessions on locally relevant topics and increasing the length of practical sessions in future iterations. While a majority of medical personnel attended these initial TFRCs, future work will aim to expand enrollment to layperson first-responders whom the WHO identifies as critical components of pre-hospital care in LMICs. All of which strongly support the further development and expansion of this TFRC throughout Bolivia, filling the gap in basic trauma training and moving towards improved care of the injured.

18.06 Intestinal obstruction at a national referral hospital in a resource-poor area: a prospective study

Posted on January 18, 2016

A. Muzira1, S. Kijjambu1, P. Ongom1, T. Luggya1, D. Ozgediz2 1Mulago Hospital,Kampala, , Uganda 2Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Bowel obstruction is one of the most common surgical emergencies faced in the low-income setting. In this Ugandan tertiary hospital, an average of 50 patients per month are admitted with bowel obstruction, with 31 operations performed in the emergency OR. Previous work confirmed that intestinal helminths accounted for over half of cases of intestinal obstruction in this hospital, but deworming programs have decreased this burden over the last decades. Meanwhile, adhesions are the predominant cause in high-income settings. . This study aimed to characterize the presentation of these patients and the causes of bowel obstruction, to compare with past data, and with high-income settings. We also examined factors associated with outcome.

Methods:
This was a prospective study from December 2013 to May 2014 of patients admitted with a suspected diagnosis of bowel obstruction, to this tertiary hospital in Kampala, Uganda. Inclusion criteria required at least one imaging study suggestive of partial or complete intestinal obstruction. Ethical approval was obtained from the hospital and university IRB. A questionnaire was developed and piloted before being revised and used. Univariate analysis was performed of age, gender, marital status, religion, education, and income level along with presenting symptoms, and signs to assess association with ‘favorable’ or ‘unfavorable’ outcomes.

Results:
110 patients were enrolled, with 72% males and 41% were children under 12 years old. 50% of the patients presented 72 hours after symptom onset with 25% receiving initial management in a lower level health center before reaching the tertiary hospital, while 7% presented within 24 hours of symptom onset. Colicky abdominal pain, vomiting, distension and relative constipation were the most common presenting symptoms. The most common causes were obstructed hernias (21%), volvulus (12%), and adhesions and tumors (9%). Among children (<13), the most common causes were intussusception (9%), anorectal malformations (8%) and atresia (6%). 48% of patients underwent surgery without imaging. Laparotomy with bowel resection and anastomosis was required in 82% cases, and 62% of the patients with obstructed hernias required herniorraphy. Male gender, extremes of age (<1 or >50), marital status (single), and symptoms were associated with unfavorable outcomes (p<0.05) on univariate analysis. In multiple logistic regression, only symptoms were associated with unfavorable outcomes (p<0.05).

Conclusion:
Men more frequently presented with intestinal obstruction, with typical symptoms. Obstructed hernias are the most common cause of bowel obstruction now, compared to previously, when intestinal worms were more common. Children comprise a significant portion of the burden, underscoring the need for pediatric emergency surgical services. Clinical symptoms have a greater degree of association with unfavorable outcomes than demographic factors.

18.07 Barriers and Facilitators to Surgical Care at a Regional Referral Hospital in Uganda.

Posted on January 18, 2016

O. C. Nwanna-Nzewunwa1, M. Ajiko2, F. Kirya2, J. Epodoi2, F. Kabagenyi2, I. Feldhaus1, R. A. Dicker1, C. Juillard1 1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA 2Soroti Regional Referral Hospital,Surgery,Soroti, SOROTI, Uganda

Introduction: Thirty percent of the global disease burden is surgical; yet, 71% of the world’s population lacks access to basic surgery. As a key component of universal health coverage, there is a critical need for a comprehensive assessment of existing surgical care. This study uses a mixed methods approach to evaluate the barriers and facilitators of quality surgical care delivery at a regional referral hospital in rural Uganda.

Methods: From 1st May to 22nd June 2015, we conducted quantitative and qualitative research activities to assess emergency surgical care at a regional referral hospital. The Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas was used to evaluate surgical capacity. We reviewed hospital records from 1st May to 22nd June , 2015 to determine surgical inpatient volume and occupancy rates. Emergency surgical care processes were observed prospectively over 53 consecutive days using time-and-motion methodology. Descriptive statistical analyses were conducted on all quantitative components. Thematic analysis was conducted on four semi-structured focus group discussions with 18 purposively sampled providers involved in the process of surgical care delivery.

Results: The PIPES tool revealed severe deficiencies in personnel and infrastructure. Major barriers to quality were lacking infrastructure, inadequate skills and workforce, and large numbers of patients' attendants. Surgical inpatient volume was high, with wards booked beyond maximum bed capacity 83% and 60% of the time for males and females, respectively. Equipment, supplies, and procedures were generally available. Teamwork and dedication among providers were the main facilitators of quality care; challenges are tackled with teamwork, task sharing and innovative life-saving improvisations for lacking equipment (eg. underwater seal, chest tub) and processes. The median decision-to-intervention time (DIT) (n-31) was 2.5 hours [0.1 – 95]. However, 48.4% of subjects experienced delays. The median DIT delay was 14.8 hours [0.1 – 71.9].

Conclusion: The Regional Referral Hospital faces severe limitations in infrastructure, workforce, and skills required to adequately address the surgical needs of its population. We advocate for an increase in surgical workforce and training opportunities in conjunction with the expansion of the surgical wards and theater, in order to enhance the surgical capacity and cater for the huge surgical demand. There is a place for symbiotic partnerships with international development partners to improve surgical capacity and quality. The role of local policy and governance will be critical in creating an enabling environment for quality surgical care delivery and for sustainability.

18.02 First glimpse at Wilms Tumor in Iraq: a Genetic and Epidemiologic Characterization

Posted on January 18, 2016

N. Corbitt2, J. Pierce1, B. Li3, Q. Wei3, R. Flores1, H. Correa1, S. Uccini4, H. Frangoul1, A. Alsaadawi5, S. F. Al-Badri5, A. F. Al-Darraji5, R. M. Al-Saeed5, M. F. Al-Jadiry5, S. A. Al-Hadad5, H. N. Lovvorn1 1Monroe Carell, Jr Childrens Hospital,Department Of Pediatric Surgery,Nashville, TENNESEE, USA 2Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TENNESSEE, USA 3Vanderbilt University School Of Medicine,Department Of Molecular Physiology And Biophysics,Nashville, TENNESSEE, USA 4Sapienza University,Department Of Clinical And Molecular Medicine,Rome, , Italy 5Childrens Welfare Teaching Hospital,Department Of Pathology And Oncology,Baghdad, , Iraq 6Wasit University College Of Medicine,Oncology Department,Wasit, , Iraq

Introduction: Wilms tumor (WT) is the most common childhood kidney cancer worldwide, yet its survival rate varies drastically between developed and developing countries. Affected children of non-Caucasian ethnicities residing in resource-challenged countries often demonstrate advanced stage disease at presentation and experience dismal survival from WT. However, poverty and limited access to healthcare may not entirely explain these disparate findings, as ethnic variations in the genetic profile of WT could too contribute to its tumorigenesis, disease progression, treatment resistance, and overall poor survival. Interestingly, the survival rate from WT in the impoverished nation of Iraq was a mere 51% at last report in 2008, but no genetic or epidemiologic explanation for this unacceptably low survival was provided. The aim of this study was to characterize the genetic profile of WT in Iraqi children as a foundation to identify novel therapeutic targets.

Methods: WT patients (n=154) who were treated at the Children’s Welfare Teaching Hospital in Baghdad, Iraq between June 2008 and March 2014 were selected for potential molecular evaluation. Tissue samples from 35 patients could be located given the political challenges in that region during this time. Genomic DNA from formalin-fixed, paraffin-embedded tissue samples was analyzed using next generation sequencing (NGS) to identify single nucleotide variations, insertions, and deletions in ten target genes documented to promote Wilms tumorigenesis (WT1, CTNNB1, WTX, and IGF2) or disease maintenance (TP53, MYC-N, CITED1, SIX2, CRABP2, and TOP2A). Immunohistochemical analysis was performed to evaluate expression of proteins (WT1, CTNNB1, NCAM, CITED1, SIX2, and TP53) fundamental to WT biology.

Results: Using NGS, we detected mutations in previously identified loci of WT1 and CTNNB1 as well as novel loci that may be unique to the Iraqi population. Immunohistochemistry for 6 marker proteins (WT1, CTNNB1, NCAM, CITED1, SIX2, and p53) of WT showed expression patterns typical of blastemal-predominant specimens, a poor prognostic feature in certain regions of the world. The median clinical follow up was 40.5 months (range, 6-78 months). Only one child, whose WT contained mutations in both WT1 and CTNNB1, was confirmed dead from disease among this cohort despite the healthcare and socioeconomic challenges unique to the Iraqi population.

Conclusion: This study is the first to report the molecular characterization of WT in Iraqi children. Although limited by small sample size due to regional challenges, our analysis suggests that WT obtained from this Iraqi cohort shares some biological features of specimens observed in other nations but also exhibits potentially distinguishing genetic features. Once validated in a larger series, these findings will direct the future development of targeted molecular therapies that may improve WT survival in Iraq and other impoverished nations in the Middle East.

18.03 Efficacy of TAP Block for Early Postoperative Analgesia after Open Cholecystectomy in LMICs

Posted on January 18, 2016

A. Mansoor1, A. Scholer1, B. D. Patrick1, D. Grech1, Z. C. Sifri1 1New Jersey Medical School,Newark, NJ, USA

Introduction: Pain management after surgery is difficult in low middle income countries (LMICs) due to limited availability of narcotics. The transversus abdominis plane (TAP) block is designed to eliminate somatic incisional pain and is used at times during short-term surgical missions (STSM) to LMICs .We hypothesized that TAP would decrease both early narcotic consumption and postoperative pain during STSM.

Methods: A retrospective chart review was conducted of patients who underwent open cholecystectomy during STSM. All patients were treated with Tylenol 800- 1000 mg PO, Tramadol 50 mg PO, and Toradol 30 mg IV (standard postoperative analgesic regimen). TAP blocks were performed on select patients with 20 ml 0.5% Ropivacaine under ultrasound guidance 30 minutes post op. Data collected included age, gender, ASA, duration of anesthesia and surgery, initial post-op pain score. Outcomes measured included Visual Analog Scale (VAS) pain score at rest (30 mins -2 hrs post-op), intravenous (IV) narcotic doses administered and hospital length of stay (LOS). A comparative analysis was then performed using Student’s T-test (mean ± SD).

Results: 22 patients underwent open cholecystectomy, of those, 11 (50%) received a TAP block. Gender, ASA, and duration of anesthesia were not significantly different among the groups. Age, duration of surgery, and initial pain score were significantly different (Table). Patients who received a TAP block had a 46% decrease in narcotics administered and a 30% shorter LOS when compared to the standard group (Table). No significant difference was noted in the pain scores between the TAP and the standard group (5.2 ± 1.2 vs. 4.7 ± 2.2, respectively, p > 0.5) and no complications from the TAP procedure were reported.

Conclusion: TAP block after open cholecystectomy reduces narcotic usage and shortens LOS during STSMs. TAP block is safe and effective adjunct to standard pain regimen in the early postoperative course in LMIC. Larger prospective studies are needed to confirm these findings.

18.04 The Burnden of Overly Complex Data: Simplification of the American Society of Anesthesiologists Score

Posted on January 18, 2016

J. D. Bohnen1,2, G. A. Anderson1,3, R. T. Spence2,4, K. Ladha5, D. Chang1,2 1Massachusetts General Hospital,General Surgery,Boston, MA, USA 2Massachusetts General Hospital,Codman Center For Clinical Effectiveness In Surgery,Boston, MA, USA 3Harvard School Of Medicine,Program For Global Surgery And Social Change,Brookline, MA, USA 4University Of Cape Town,General Surgery,Cape Town, WESTERN CAPE, South Africa 5University Of Toronto, Toronto General Hospital,Department Of Anesthesia,Toronto, Ontario, Canada

Introduction:
The focus of many data collection efforts in the U.S. centers on creating more granular data. The assumption is that more complex data collection is equal to more accurate data and therefore allows better predictions of outcomes. We hypothesized that data is often needlessly complex and that complexity can be a burden to those collecting and analyzing the data. Moreover, it is a barrier to data collection in Low and Middle Income Countries (LMIC’s). We sought to demonstrate this concept by examination of the American Society of Anesthesiologists (ASA) physical classification system.

Methods:
We created every possible two, three and four category combinations of the current five category ASA score. This resulted in 14 combinations of simplified ASA with 2, 3 or 4 categories. We then compared the predictive ability of these simplified scores for post-operative outcomes on all patients in the NSQIP database from 2006-2012 (2.3 million patients). We created unadjusted and adjusted logistic regression models using these 14 different combinations of simplified ASA scores as the predictor variable. Individual model performance was assessed by comparing Receiver Operator Characteristic (ROC) curves for each model with the standard ASA model using the outcomes of in-hospital and 30-day mortality and any morbidity.

Results:
Two of our 4-category models (ASA 1&2, 3, 4,5 and ASA 1, 2, 3, 4&5) and one of our 3-category models (ASA 1&2, 3, 4&5) had ability to predict all outcomes equivalent to standard ASA. Two of the 2-category variables (ASA 1&2&3, 4&5 and ASA 1&2, 3&4&5) provided good estimates that were only slightly worse than standard ASA. These results held for all outcomes and on all subgroups tested. The performance of the 3 best simplified ASA scores were also equivalent to the standard ASA score in the univariate analysis and multivariate analysis.

Conclusion:
Currently there is a desire to strive for the most granular data and use the largest number of variables for risk-adjusted predictions. This complexity is often at the expense of utility. We have used the single best predictor in surgical outcomes research to show this is not necessarily the case. In this example of the ASA scoring system our data show that one can simplify ASA into a 3-category variable without losing any ability to predict patient outcomes. Further research is needed to determine whether other commonly used scoring systems can be simplified without compromising their discrimination ability. When working in LMIC’s simple systems that operate just as well as more complex ones will help to facilitate the spread of surgical data collection and thereby lead to improvements in patient care.

17.20 Myth Busting: The Use of Makeshift Tourniquets In Extremity Vascular Trauma

Posted on January 18, 2016

A. A. Haider1, B. Joseph1, A. Hassan1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, D. J. Green1, R. S. Friese1, P. Rhee1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction: Tourniquets are life saving devices and its practice has extended to the civilian setting. Improvised or makeshift tourniquets are frequently applied after extremity vascular trauma however; inappropriate application of a non-standardized tourniquet may incompletely occlude arterial inflow and worsen bleeding. The aim of this study was to assess the effectiveness of makeshift tourniquets after extremity trauma.

Methods: We performed a 5-year retrospective analysis of all trauma patients presenting to our level I trauma center with an extremity vascular injury. We matched patients who arrived with a non-standardized/makeshift tourniquet applied to those who arrived without a tourniquet using propensity score matching in a 1:1 ratio controlling for age, gender, mechanism of trauma, region of vascular injury (arm, forearm, thigh leg), operative intervention, Injury Severity Score (ISS), and Extremity Injury Severity Score (Ext-AIS). Primary outcome measure was transfusion requirement; secondary outcome measures were hemodynamic parameters on arrival, admission hemoglobin, complications (wound infection, ischemic, re-bleeding), amputation rate, and nerve deficits.

Results:A total of 66 patients (No-Tourniquet: 33, Tourniquet: 33) were included. There was no difference in age (p=0.4), gender (p=0.7), ISS (p=0.8), Ext-AIS (p=0.8), thoracic AIS (p=0.74), mechanism of trauma (p=0.8) and region of vascular injury (arm p=0.7, forearm p=1.0, thigh p=1.0, and leg p=1.0) between the two groups. Outcomes are shown below in Table 1.

Conclusion:Although tourniquets are life saving devices, the use of non-standardized tourniquets is associated with greater blood transfusion requirement. The practice of non-standardized tourniquet use in extremity vascular trauma should be discouraged.

17.21 The Impact of Do Not Resuscitate Status on Outcomes in Critically Injured Trauma Patients

Posted on January 18, 2016

M. Kisat1, T. Orouji1, P. Rhee1, T. O’Keeffe1, N. Kulvatunyou1, R. S. Friese1, H. Phelan2, B. A. Joseph1 1University Of Arizona,Tucson, AZ, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction: Do not resuscitate (DNR) status affects end of life decision making. Physicians often initiate or participate in discussions regarding DNR status for patients whose care is considered futile. However, the impact of this decision on patient outcomes is poorly understood. The aim of this study was to evaluate the impact of DNR status on mortality and rate of complications.

Methods: A two year (2011-2012) retrospective analysis of the National Trauma Data Bank (NTDB) was performed. Trauma patients older than 65 years, admitted to the Intensive Care Unit, and who underwent a major surgical procedure were included. Patients who were transferred, intoxicated, arrived with no vital signs, or died in the ED, were excluded. Patients with DNR status were identified based on advanced directives for end of life care. Matched no-DNR controls were identified using propensity score matching, controlling for age, gender, race, injury severity score, comorbidities, abbreviated injury score for head, and admission vitals. Primary outcomes were mortality, complications, and failure to rescue (FTR). FTR was defined as death after complication. Missing data was accounted for by using missing value analysis and multiple imputation.

Results: A total of 3,744 patients (DNR: 1,872 vs No-DNR: 1,872) were included in the analysis. Average age was 81 ± 6 years (mean ± SD) and 47% of patients were male. Median (IQR) Injury Severity Score was 13 (9 – 21). Overall mortality rate was 27%, complication rate was 49%, and FTR rate was 17%. Patients with DNR status had significantly higher mortality rates (36% vs. 17%, p < 0.001), complication rates (53% vs. 44%, p < 0.001), and FTR rates (23% vs. 10%, p < 0.001) compared to the No-DNR group. On sub-analysis of complications, FTR was higher in DNR patients for major (13% vs 6%, p <0.001) and minor (10% vs. 4%, p < 0.001) complications.

Conclusion: DNR status is a patient’s or their surrogate’s wish to prohibit end of life cardiopulmonary resuscitation; however, findings of our study suggest less aggressive treatment followed by higher mortality and failure to rescue in patients with DNR status. Patients and families should be informed of ensuing higher complications and mortality associated with DNR status when discussing goals of care.

17.22 Building Trauma Capacity in Mozambique through Medical Student Education

Posted on January 18, 2016

A. Merchant1, C. Lyon1, K. Mcqueen1, M. Sidat2, O. Gunter1 1Vanderbilt University,Trauma And Surgical Critical Care,Nashville, TN, USA 2University Of Eduardo Mondlane,Maputo, MOAZAMBIQUE, Mozambique

Introduction:

Trauma remains the leading cause of death and disability worldwide. Over half of trauma deaths in low-income countries are the result of airway compromise, respiratory failure, or uncontrolled hemorrhage; all three conditions can be addressed using simple first-aid measures. As medical students in developing countries graduate and go directly into practice, they require basic trauma skills that are not incorporated into the curriculum. Basic trauma resuscitation training in modified ABCD (airway, breathing, circulation, disability) techniques can be easily learned and applied to increase trauma capacity in developing countries.

Methods:

In Mozambique, 102 medical students were trained in basic trauma resuscitation skills that utilized resources available to them in both urban or rural areas. This ABCD training at the University of Eduardo Mondlane in April 2015 included both lectures and skill development over 2.5 hours. The sessions included a pre-test, intervention, and post-test to evaluate and demonstrate first response skills.

Results:
Prior to the trauma education intervention, a mean test score of 32% (SD=19, N=102) was observed. We observed an 18% increase in test scores following the intervention, with medical students scoring a mean 50% correct (SD=19, N=102). A paired t-test showed significant difference between the pre- and post-intervention test scores (p<0.01). Despite only 18% increase in test scores, all 102 participants were able to demonstrate the basic trauma resuscitation skills taught in the training session.

Conclusion:

Basic trauma resuscitation techniques were taught to medical students who provide direct care for trauma patients immediately after graduation. This course provided new information to participants; these results led to the development of a new standardized trauma curriculum for medical students in Mozambique. It can be used as a framework to build trauma capacity in countries with limited resources.

18.01 A Pilot Orthopedic Trauma Registry to Assess Needs and Disparities in Ugandan District Hospitals

Posted on January 18, 2016

D. K. Kisitu1, L. Eyler2, I. Kajja3, G. Waiswa3, T. Beyeza4, I. Feldhaus2, C. Juillard2, R. Dicker2 1Mbarara University Of Science And Technology,Department Of Surgery,Mbarara, , Uganda 2University Of California – San Francisco,Center For Global Surgical Studies, Department Of Surgery,San Francisco, CA, USA 3Makerere University College Of Health Sciences,Department Of Orthopaedics,Kampala, , Uganda 4Mulago National Referral And Teaching Hospital,Kampala, , Uganda

Introduction: Musculoskeletal injury is a growing but neglected public health problem that disproportionately affects low- and middle-income countries like Uganda. Evidence-based policies for injury prevention and management in the districts of Uganda are hindered by the lack of available data regarding patterns of musculoskeletal injuries presenting to district hospitals. Our pilot orthopedic trauma registry establishes a framework for broader district hospital injury surveillance systems.

Methods: We collected data via patient interview, examination, and x-rays from all patients presenting to Mityana, Entebbe, and Nakaseke Hospitals with musculoskeletal injuries from October 2013 to January 2014. We compared patient demographics to the 2011 Ugandan Demographic and Health Survey (DHS) dataset and determined predictors of delayed presentation for care greater than 24 hours after injury via multivariate logistic regression.

Results: Men, adults, and individuals with post-secondary education were more common among patients than in the DHS population. Common causes included road traffic injuries (RTI) (48.5%) and falls (25.1%). Closed, simple fractures comprised 70% of injuries. The major extremity long bones comprised 84% of fractures. Patients suffering assaults or falls were more likely delayed to care than victims of RTI, with OR 3.97 (95% CI: 1.41, 11.16) and OR 2.34 (95% CI: 1.21, 4.55), respectively. Compared to the self-employed, subsistence farmers (OR 2.99, 95% CI: 1.15, 7.91), motorcycle taxi drivers (OR 10.50, 95% CI: 1.92, 64.57), and pre-school children (OR 4.24, 95% CI: 1.05, 17.39) were significantly more likely to be delayed to care after adjustment for covariates. Subsistence farmers were more likely than other occupations to seek care from traditional bonesetters prior to seeking hospital care (23% v 7%, p=0.001). All patients who visited bonesetters were delayed to hospital care, compared to 28% of patients who sought hospital care first (p<<0.001).

Conclusion: Understanding patterns of musculoskeletal injury at district hospitals facilitates allocation of limited resources for orthopedic provider training, referral protocols, and trauma systems strengthening. To promote the safety of all Ugandans, policies should target interventions aimed at improving access to timely care to vulnerable groups such as subsistence farmers, motorcycle taxi drivers, and pre-school children. Effective policy can only be enacted by engaging local stakeholders such as traditional bonesetters in the advocacy conversation. Development of evidence-based national injury prevention and orthopedic healthcare policies would similarly benefit from district hospital data from across Uganda, in the form of a national trauma registry.

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