General Surgery Resident Elective in Kumasi Ghana Sharita

General Surgery Resident Elective in Kumasi, Ghana Sharita Nagaraj 1 Department of Surgery, Robert Wood Johnson Medical School, Piscataway, NJ 08854 1 Introduction Surgery has long been neglected in the global public health arena 1, but evidence is accruing for the enormous global burden of surgical disease 2. At the same time, interest has been growing among both practicing and future surgeons-in-training to improve access to surgical care in developing countries. A national survey administered to resident members of the American College of Surgeons showed that 92% of respondents would be interested in an international elective during residency, and 85% plan to offer volunteer services during their future practice 3. Several formal, structured international surgery rotations have been implemented within U. S. surgical residencies, and other fellowship and volunteer opportunities for global surgery are emerging 4. Preparation: The IHCV team transports all surgical supplies – drapes, gowns, gloves, suture, instruments, mesh, drains, etc. – and medications that will be required for the mission. Residents are involved in packing for the mission so they learn to anticipate equipment and supply needs for various operations. These supplies are stored and inventoried upon arrival and upon departure (seen below), with extra items donated to the hospital. Residents learn to ration these supplies for the expected number of cases during the mission, picking only what is necessary for each case. Certain items which are usually deemed “disposable” in the United States may be reused after chemical sterilization, such as bovie electrocautery, drapes, and suction tubing. KNUST hospital (seen below) is the main teaching hospital in its region and a high volume center providing medical, surgical, and obstetrical services for over 200, 000 people in 30 surrounding communities. Two operating room theatres are available as well as anesthetic, radiologic, and lab services. Patients in need of ICU care transferred to the nearby Cape Coast Hospital. performed 6 inguinal hernia repairs, one in a pediatric patient, 1 umbilical hernia repair, 4 skin and soft tissue excisions, 1 thyroidectomy, and 1 laparoscopic cholecystectomy at KNUST hospital. One laparoscopic cholecystectomy had to be aborted to due lack of carbon dioxide for insufflation. Our productivity was limited compared to prior missions due to an unanticipated nurses’ strike which reduced the availability of operating room, recovery room, and inpatient staffing, but we were able to complete some work with the help of local volunteers. Pathology: International electives offer residents exposure to a broader range of pathology such as hydatidosis, salmonella typhi intestinal perforations, and advanced stage malignancies and hernias. During our mission, inguinal hernias were the most common pathology we encountered. Due to limited access to surgical services, asymptomatic juvenile hernias, which are typically repaired in Western populations, often develop into large, chronically incarcerated hernias containing omentum, small or large bowel, or bladder. They present a significant surgical dilemma due to the loss of abdominal domain, especially in Ghanian patients who have a thin body habitus. We performed the majority of inguinal hernia repairs with mesh, however local surgeons usually do not use mesh in their repairs as it is a costly resource not widely available in the country. Background In 2012 the General Surgery Residency Review Committee implemented criteria for ACGME approval of international general surgery electives. The Robert Wood Johnson general surgery residency program has obtained this approval for a PGY-3 or above to participate in the annual mission with International Healthcare Volunteers (IHCV) and each year one of our residents has traveled with the group to help provide surgical services while learning about healthcare delivery in a developing country. Here we present the results of our two-week experience in September 2013 at Kwame Nkrumah University Of Science & Technology (KNUST) hospital in Kumasi, Ghana. Productivity: During the 2012 IHCV mission, we Resident Clinical Experience: All surgical residents participate in outpatient activities that include a complete pre -operative evaluation of all patients who will undergo surgery during the time period of the rotation. Outpatient encounters take place in the OR holding area as well as in the medical clinic when surgical consults are requested. Residents assist with surgeries under the mentorship of a U. S. board-certified or board eligible surgeon in collaboration with local surgeons and staff. Lastly, patients requiring an inpatient stay postoperatively are seen on morning and afternoon rounds (seen below). Sustainability: Collaborating with local surgeons (seen above) and staff ensures that mission efforts offer continuity of care for patients, who follow-up with local surgeons, as well as sustainability of the effort as local surgeons learn new techniques such as hernia repairs with mesh and laparoscopic approaches. Local surgeons also offer their experience working in a limited resource setting, relying on clinical acumen for diagnosis in the absence of advanced laboratory or radiologic services, dissection without electrocautery, and creative but effective solutions such as using foley catheters for drainage when surgical drains are not available. Conclusions Surgical residents gain considerable benefit from international electives in developing countries. These electives teach residents cost-effective management, basic surgical technique, improve clinical acumen, and introduce them to the world of global public health, where surgery is increasing its presence as an important issue. Future efforts can be expanded to include bidirectional exchanges and training of local surgeons to improve access to surgical care. Challenges include a lack of political and economic support for systems improvement but can be overcome by collaboration between non-profit governmental organizations and ministries of health, as well as increased support and funding from international health organizations. References 1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533 -6. 2. Ozgediz D, Jamison D, Cherian M, Mc. Queen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ 2008; 86: 646 -7. 3. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg 2009; 208: 304 -12. 4. Leow JJ, Kingham TP, Casey KM, Kushner AL. Global surgery: thoughts on an emerging surgical subspecialty for students and residents. J Surg Educ 2010; 67: 143 -8.