The importance of broad surgical skills in low resource settings

As a trauma and acute care surgeon at University of Pittsburgh Medical Center (UPMC), Dr. Juan Carlos Puyana can call on a team of world-class surgical specialists to assist in complex cases. “Here, I have round-the-clock access to plastic surgeons, vascular surgeons, cardiothoracic surgeons — you name it. It’s quite a luxury that is common in high resource, high volume medical centers such as UPMC,” he says.

The same is not true in low resource settings, such as his native country of Colombia. In those locations, a singular surgeon may be responsible for every urgent or emergent case that arrives at the clinic or a rural hospital. In any given week, a surgeon may treat a postpartum hemorrhage, a broken femur, a perforated appendix, and a gunshot wound. 

Dr. Puyana, who is one of the judges for the Global Surgical Training Challenge, has worked in underserved hospitals in Latin America designing training courses for emergency care. He says that in low resource areas, particularly rural communities, there is less structure and specialization. This means that surgeons must have the ability to treat a wide variety of acute and emergency needs or at least implement lifesaving temporary measurements until the patient can be transferred to a higher level of care an strategy commonly refer to damage control interventions. 

“Simulation training can be a critical adjunct to traditional training methods, in order to keep skills up to date,” he says. “We need innovative ways to teach or maintain these surgical skills.” He adds that surgeons must also be able to perform these procedures in adverse environments, and that the simulations should mimic such restricted scenarios. “For example, can the surgeon perform an emergent operation  let say with untrained personnel to assist or without an assistant; or perhaps with less than ideal or fewer instruments or in areas with poor  low lighting? Or faster than usual because of less than ideal anesthesia support in otherwise precarious circumstances ?” 

Common challenges that surgical practitioners face in these settings are  the ability to maintain surgical skills for procedures that they may not see often. Research has demonstrated the correlation between high volume and patient outcomes. Simulation training may provide surgeons with opportunities to practice or refresh skills in order to be prepared when real cases present in the clinic or hospital.

He sees the Global Surgical Training Challenge as a unique opportunity for new interactions that bring experts together from many different backgrounds. The most exciting aspect about this challenge award if the opening of doors for skillful individuals each in their own field to enter a new space and see new possibilities by sharing experiences that until now were not shared. Computer experts, developers, programmers, will have direct contact to the realities that some of these surgeons face every day. Such interactions must become fertile ground for great team work and truly new thinking generated outside all boxes!.

“There is an enormous amount of innovation in these settings already,” he says. “True global surgeons that are accustomed to work under low resource settings are constantly innovating to overcome these challenges. They develop clever solutions and work-arounds for very difficult contexts. It should be very interesting to see what teams develop for this challenge, which we can then share with other communities.”