Reducing road traffic deaths: where should we focus global health initiatives?

BACKGROUND: Current global surgery initiatives focus on increasing surgical workforce; however, it is unclear whether this approach would be helpful globally, as patients in low-resource countries may not be able to reach hospitals in a timely fashion without formal Emergency Medical Services (EMS). We hypothesize that increased surgical workforce correlates with decreased road traffic deaths (RTDs) only in countries with EMS. METHODS: Estimated RTDs were obtained from the Global Status Report on Road Safety 2013, which estimated the RTD rate in 2010 (RTD 2010). The classification of EMS was defined by the Global Status Report on Road Safety 2009. The density of surgeons, anesthesiologists, and obstetricians (SAO density) and 2010 income classification were accessed from the World Bank. Multivariable regression analysis was performed adjusting for different countries, income levels, and trauma system characteristics. Sensitivity analysis was performed. RESULTS: One-fourth of the countries reported not having formal EMS (n = 41, 23.4%). On adjusted analysis, SAO density was not associated with changes in RTD 2010 in countries without EMS (n = 25, P = 0.50). However, in countries with EMS, each increase in SAO density per 100,000 population decreased RTDs by 0.079 per 100,000 population (n = 97, P <0.001). Income was the only other factor resulting in reduced mortality rates (P = 0.004). Sensitivity analysis confirmed these findings. CONCLUSIONS: Increases in surgical workforce reduce RTDs only when EMS exist. Surgical workforce and EMS must be seen as part of the same system and developed together to maximize their effect in reducing RTDs. Global health initiatives should be tailored to individual country need. LEVEL OF EVIDENCE: Level II (Ecological study).

Responding to a medical crisis: Lessons from the Halifax disaster 100 years ago.

One hundred years ago, a massive explosion occurred in the harbor of Halifax, Nova Scotia, destroying the city and killing more than 2,000 and injuring more than 9,000. It was the worst manmade explosion the world had ever seen, not exceeded until the atomic bomb blast over Hiroshima in 1945. An urgent appeal for assistance came from the survivors, and many volunteers responded. This report describes the prompt and remarkable medical relief effort of the citizens of Massachusetts to help their Canadian neighbors.

Development of a Comprehensive Trauma Training Curriculum for the Resource-Limited Environment.

OBJECTIVE: The goal of this project was to create a multitiered trauma training curriculum that was designed specifically for the low-resource setting. DESIGN: We developed 2 courses designed to teach principles and skills necessary for trauma care. The first course, "Emergency Ward Management of Trauma (EWMT)," is designed to teach interns the initial assessment and stabilization of trauma patients in the emergency ward. The second course for mid-level surgical residents, "Surgical Techniques and Repairs in Trauma for the Low-resource Environment" (STaRTLE), is a cadaver-based operative trauma course designed to teach surgical exposures and techniques. The courses were rolled out at Mbarara Regional Referral Hospital in the low-income country of Uganda. Precourse and postcourse tests and surveys were administered. SETTING: This study took place at Mbarara Regional Referral Hospital (MRRH). This is a hospital in southwest Uganda with a subspecialty care, a medical school, nursing school, and multiple residency programs. PARTICIPANTS: Students in the EWMT course were interns at MRRH. After 1 year of training, most of these interns will become medical officers as the only provider at a district hospital in Uganda. The students in the STARTLE course were second-year residents in the general surgery program at MRRH. RESULTS: Scores on knowledge based tests improved significantly with both courses. Survey results from the EWMT course suggest that participants feel better prepared to care for the injured patient (median Likert [IQR]: 5.0 [5.0-5.0]) and that their practice improved (5.0 [5.0-5.0]). Similarly, following the STaRTLE course we found participants felt significantly more comfortable with performing 20 of the 22 operative procedures taught. CONCLUSIONS: These courses represent a feasible, cost-effective, and resource appropriate trauma education curriculum that if standardized and implemented may improve trauma care and outcomes in the resource-limited setting.

Building a global surgery initiative through evaluation, collaboration, and training: the Massachusetts General Hospital experience.

OBJECTIVE: The Massachusetts General Hospital (MGH) Department of Surgery established the Global Surgery Initiative (GSI) in 2013 to transform volunteer and mission-based global surgery efforts into an educational experience in surgical systems strengthening. The objective of this newly conceived mission is not only to perform advanced surgery but also to train surgeons beyond MGH through international partnerships across disciplines. At its inception, a clear pathway to achieve this was not established, and we sought to identify steps that were critical to realizing our mission statement. SETTING: Massachusetts General Hospital, Boston, MA, USA and Mbarara Regional Referral Hospital, Mbarara, Uganda PARTICIPANTS: Members of the MGH and MRRH Departments of Surgery including faculty, fellows, and residents RESULTS: The MGH GSI steering committee identified 4 steps for sustaining a robust global surgery program: (1) administer a survey to the MGH departmental faculty, fellows, and residents to gauge levels of experience and interest, (2) catalog all ongoing global surgical efforts and projects involving MGH surgical faculty, fellows, and residents to identify areas of overlap and opportunities for collaboration, (3) establish a longitudinal partnership with an academic surgical department in a limited-resource setting (Mbarara University of Science and Technology (MUST) at Mbarara Regional Referral Hospital (MRRH)), and (4) design a formal curriculum in global surgery to provide interested surgical residents with structured opportunities for research, education, and clinical work. CONCLUSIONS: By organizing the collective experiences of colleagues, synchronizing efforts of new and former efforts, and leveraging the funding resources available at the local institution, the MGH GSI hopes to provide academic benefit to our foreign partners as well as our trainees through longitudinal collaboration. Providing additional financial and organizational support might encourage more surgeons to become involved in global surgery efforts. Creating a partnership with a hospital in a limited-resource setting and establishing a formal global surgery curriculum for our residents allows for education and longitudinal collaboration. We believe this is a replicable model for building other academic global surgery endeavors that aim to strengthen health and surgical systems beyond their own institutions.

Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting?

BACKGROUND: Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. METHODS: Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test. RESULTS: A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays. CONCLUSIONS: The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.

Lessons learned from a landslide catastrophe in Rio de Janeiro, Brazil.

INTRODUCTION: On January, 2011, a devastating tropical storm hit the mountain area of Rio de Janeiro State in Brazil, resulting in flooding and mudslides and leaving 30,000 individuals displaced. OBJECTIVE: This article explores key lessons learned from this major mass casualty event, highlighting prehospital and hospital organization for receiving multiple victims in a short period of time, which may be applicable in similar future events worldwide. METHODS: A retrospective review of local hospital medical/fire department records and data from the Health and Security Department of the State were analyzed. Medical examiner archives were analyzed to determine the causes of death. RESULTS: The most common injuries were to the extremities, the majority requiring only wound cleaning, debridement, and suture. Orthopedic surgeries were the most common operative procedures. In the first 3 days, 191 victims underwent triage at the hospital with 50 requiring admission to the hospital. Two hundred fifty patients were triaged at the hospital by the end of the fifth day. The mortis cause for the majority of deaths was asphyxia, either by drowning or mud burial. CONCLUSION: Natural disasters are able to generate a large number of victims and overwhelm the main channels of relief available. Main lessons learned are as follows: 1) prevention and training are key points, 2) key measures by the authorities should be taken as early as possible, and 3) the centralization of the deceased in one location demonstrated greater effectiveness identifying victims and releasing the bodies back to families.

Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents.

Terrorists' use of explosive, biologic, chemical, and nuclear agents constitutes the potential for catastrophic events. Understanding the unique aspects of these agents can help in preparing for such disasters with the intent of mitigating injury and loss of life. Explosive agents continue to be the most common weapons of terrorists and the most prevalent cause of injuries and fatalities. Knowledge of blast pathomechanics and patterns of injury allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents, their attendant clinical symptoms, and recommended management strategies is an important prerequisite for optimal preparation and response to these less frequently used agents of mass casualty. Orthopaedic surgeons should be aware of the principles of management of catastrophic events. Stress is less an issue when one is adequately prepared. Decontamination is essential both to manage victims and prevent further spread of toxic agents to first responders and medical personnel. It is important to assess the risk of potential threats, thereby allowing disaster planning and preparation to be proportional and aligned with the actual casualty event.

Disasters and mass casualties: I. General principles of response and management.

Disaster planning and response to a mass casualty incident pose unique demands on the medical community. Because they would be required to confront many casualties with bodily injury and surgical problems, surgeons in particular must become better educated in disaster management. Compared with routine practice, triage principles in disasters require an entirely different approach to evaluation and care and often run counter to training and ethical values. An effective response to disaster and mass casualty events should focus on an "all hazards" approach, defined as the ability to adapt and apply fundamental disaster management principles universally to any mass casualty incident, whether caused by people or nature. Organizational tools such as the Incident Command System and the Hospital Incident Command System help to effect a rapid and coordinated response to specific situations. The United States federal government, through the National Response Plan, has the responsibility to respond quickly and efficiently to catastrophic incidents and to ensure critical life-saving assistance. International medical surgical response teams are capable of providing medical, surgical, and intensive care services in austere environments anywhere in the world.

International medical response to a natural disaster: lessons learned from the Bam earthquake experience.

An earthquake measuring 6.5 on the Richter scale devastated Bam, Iran on the morning of 26 December 2003. Due to the great health demands and collapse of health facilities, international aid could have been a great resource in the area. Despite sufficient amounts and types of resources provided by international teams, the efficacy of international assistance was not supported in Bam, as has been experienced in similar events in other countries. Based on the observations in the region and collecting and analyzing documents about the disaster, this manuscript provides an overview of the medical needs during the disaster and describes the international medical response. The lessons learned include: (1) necessity of developing a national search and rescue strategy; (2) designing an alarm system; (3) establishing an international incident command system; (4) increasing the efficacy of the arrival and implementation of a foreign field hospital; and (5) developing a flowchart for deploying international assistance.

An update on the surgeons scope and depth of practice to all hazards emergency response.

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

Earthquakes.

Major earthquakes have the potential to be one of the most catastrophic natural disasters affecting mankind. Earthquakes of significant size threaten lives and damage property by setting off a chain of events that disrupts all aspects of the environment and significantly impacts the public health and medical infrastructures of the affected region. This article provides an overview of basic earthquake facts and relief protocol for medical personnel.

Disaster management teams.

PURPOSE OF REVIEW: All disasters, regardless of cause, have similar medical and public health consequences. A consistent approach to disasters, based on an understanding of their common features and the response expertise they require, is becoming the accepted practice throughout the world. This strategy is called the mass casualty incident response. The complexity of today's disasters, particularly the threat of terrorism and weapons of mass destruction, has increased the need for multidisciplinary medical specialists as critical assets in disaster response. A review of the current literature emphasizes the expanding role of disaster management teams as an integral part of the mass casualty incident response. RECENT FINDINGS: The incident command system has become the accepted standard for all disaster response. Functional requirements, not titles, determine the organizational hierarchy of the Incident Command System structure. All disaster management teams must adhere to this structure to integrate successfully into the rescue effort. Increasingly, medical specialists are determining how best to incorporate their medical expertise into disaster management teams that meet the functional requirements of the incident command system. SUMMARY: Disaster management teams are critical to the mass casualty incident response given the complexity of today's disaster threats. Current disaster planning and response emphasizes the need for an all-hazards approach. Flexibility and mobility are the key assets required of all disaster management teams. Medical providers must respond to both these challenges if they are to be successful disaster team members.

Planning for mass civilian casualties overseas: IMSuRT-International Medical/Surgical Response Teams.

The increased likelihood of mass casualties involving Americans living abroad has prompted the development of a mobile, civilian medical and surgical unit available for rapid deployment overseas. Using past experience derived from the National Disaster Medical Service, and from recent rescue efforts following the African embassy bombings in 1998, an International Medical-Surgical Response Team was developed. Organized under the Department of Homeland Security, it is staffed by civilian professionals from medical and bioengineering fields. Initial deployments to the World Trade Center (2001) and Guam (2002) have shown the ability to rapidly mobilize appropriate manpower and equipment to a mass casualty site, whether domestic or international. The goals of this organization are to work in cooperation with local authorities at the mass casualty site to provide rapid assessment and medical stabilization of injured persons. When the mass casualty is overseas, rapid evacuation of casualties is accomplished by the responding military air evacuation service.

New horizons for OR nurses--lessons learned from the World Trade Center attack.

The terrorist attacks of Sept 11, 2001, we a horrifying wake-up call for the United States and the rest of the world. The attacks led to the deployment of the disaster medical assistance team (DMAT) from Massachusetts General Hospital in Boston. In this article, members of the team outline what they did during the days after Sept 11 and the lessons they brought back to better prepare their DMAT for the next disaster.