Simulation Based Training in Basic Life Support for Medical and Non-medical Personnel in Resource Limited Settings

Medical and non-medical personnel commonly encounter victims of life threatening injuries inflicted by various causes in diverse settings. More than 90% of global deaths and disability adjusted life-years (DALYs) lost because of injuries reportedly occur in low-income and middle-income countries (LMICs). The degree of readiness and competence to manage victims of accidents is likely to vary among individual care givers for knowledge, skill and confidence which would also depend on their training status. It would thus be justified that training in basic life support and other emergency clinical skills be administered to enhance competences in resuscitating the accident victims. Whatever the scale of a mass casualty incident, the first response will be carried out by members of the local community-not just health care staff and designated emergency workers,but also many ordinary citizens. Therefore, both medical and non-medical personnel should be targeted to receive training in basic life support (BLS). In medical training, the traditional (didactic) approach has been suggested to be an efficient and well-experienced training method while with the advances in technology the use of simulation-based medical training (SBMT) is increasing since SBMT provides a safe and supportive educational setting, so that students can improve their performance without causing adverse clinical outcomes. Similarly, the use of simulation based training in BLS would not only reduce the procedural associated risks but also benefit more participants from the public domain than would be the case if the training was conducted on human subjects. Compared with the developed world set-up simulation based training in resource constrained settings may not be that well established. This paper will therefore seek to examine the role of medical simulation as a necessary advancement and supplementary method of training in basic life support for medical and non-medical personnel in resource limited settings

Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia

PURPOSE
In Zambia, more than two-thirds of female patients with breast cancer present with late-stage disease, leading to high mortality rates. Most of the underlying causes are associated with delays in symptom recognition and diagnosis. By implementing breast care specialty services at the primary health care level, we hypothesized that some of the delays could be minimized.

METHODS
In March 2018, we established a breast care specialty clinic for women with symptomatic disease within 1 of the 5 district hospitals in Lusaka. The clinic offers breast self-awareness education, clinical breast examination, breast ultrasound, ultrasound-guided breast biopsy, surgery, referral for chemoradiation, follow-up care, and electronic medical records.

RESULTS
Between March 2018 and April 2019, of 1,790 symptomatic women who presented to the clinic, 176 (10%) had clinical and/or ultrasound indications for histologic evaluation. Biopsy specimens were obtained using ultrasound-guided core-needle procedures, all of which were performed on the same day as the initial visit. Of the 176 women who underwent biopsy, 112 (64%) had pathologic findings compatible with a primary breast cancer, and of these, 42 (37%) were early-stage (stage I/II) disease. Surgery for early-stage cancers was performed at the district hospital within 2 weeks of the time of definitive pathologic diagnosis. Patients with advanced disease were referred to the national cancer center for multimodality therapy, within a similar time frame.

CONCLUSION
Breast care specialty services for symptomatic women were established in a district-level hospital in a resource-constrained setting in Africa. As a result, the following time intervals were minimized: initial presentation and performance of clinical diagnostics; receipt of a definitive pathologic diagnosis and initiation of surgery; receipt of a definitive pathologic diagnosis and referral.

Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.

Availability of ENT Surgical Procedures and Medication in Low-Income Nation Hospitals: Cause for Concern in Zambia

Background
Ear, nose, and throat (ENT) diseases are an oft overlooked global health concern. Despite their high prevalence and associated morbidity and mortality, ENT diseases have remained neglected in health care delivery. In Zambia and many other low-income countries, ENT services are characterized by poor funding, unavailable surgical procedures, and erratic supply of essential drugs.
Objective
To investigate ENT service provision in Zambia with regard to availability of surgical procedures and supply of essential drugs.
Methods
A descriptive cross-sectional survey was conducted using a piloted structured questionnaire between 17 January 2017 and 2 January 2018. Included in the study were the 109 hospitals registered with the Ministry of Health (MoH) across the 10 provinces of Zambia.
Results
Of the participating hospitals, only 5.9% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (.
Conclusion
ENT service delivery in Zambia is limited with regard to performed surgical procedures and availability of essential drugs, necessitating urgent intervention. The findings from this study may be used to direct national policy on the improvement of provision of ENT services in Zambia.

Supervision as a tool for building surgical capacity of district hospitals: the case of Zambia

Introduction
Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals.
Methods
Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using ‘top-down’ and ‘bottom-up’ thematic coding.
Results
Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision.
Conclusion
This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.

Management and outcomes following emergency surgery for traumatic brain injury – A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

Availability, procurement, training, usage, maintenance and complications of electrosurgical units and laparoscopic equipment in 12 African countries

Background: Strategies are needed to increase the availability of surgical equipment in low- and middle-income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment.

Methods: A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018.

Results: Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty-six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three-quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre.

Conclusion: Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented.This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs.The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%).Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.

Delayed access to care and unmet burden of pediatric surgical disease in resource-constrained African countries.

The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs).We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes.The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases).These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need.Retrospective study and review article LEVEL OF EVIDENCE: III.