Global Surgical Frontiers Conference
The Royal College of Surgeons hosts an annual conference focused on international surgery. It aims to engage surgeons at all stages of their careers.
Global Surgical Frontiers provides the opportunity for all attendees to network with, and learn from, other members of the surgical community, both within and across specialties, who have an interest in international surgery.
Each year the conference has focused on a different facet of global surgery. Previous years have been themed:
- opportunities in surgery overseas
- global surgery, anaesthesia and obstetrics: shifting paradigms and challenging generations
- The Lancet Commission - one year on
- surgical care of the young
The Global Surgical Frontiers conference is open to surgeons at all stages of their careers, members of the surgical team, NGOs, charities, and members of the public with an interest in public health and the development of surgical care in LMICs. Those involved with GSF are completely passionate about global surgery and have a great range of experience. The conference aims to stimulate further interest and discussion around global surgery, particularly in Low and Low Middle Income Countries.
This year, the Global Surgical Frontiers Conference focused on:
Meeting challenges of trauma care in Low and Lower Middle Income Countries
Throughout the conference, our speakers raised strong reoccurring themes that identified the medical needs of Low and Lower Middle Income Countries.
With over 250 supporters and advocates attending the conference, our speakers were able to deliver a powerful message on the future of global trauma care. Bruce Biccard, (Second Chair at Groote Schuur Hospital and University of Cape Town), delivered the closing lecture, bringing together the lessons, challenges and future of improving trauma care globally.
**Please find below the transcript of Bruce Biccard’s talk that closed the 2018 GSF Conference.
The future of global trauma
University of Cape Town
Today we have heard a few strong, reoccurring themes. The first is that we are dealing with the vulnerable population, people who do not get the same level of care that patients in high-income countries receive.
The other is big theme that has come across very strongly today is the need for collaboration.
I will today be talking about:
1. The future of global trauma care
2. What would contribute most to improving trauma care globally?
3. What are the current biggest challenges?
So, the idea that ‘trauma is important’ has come across throughout the day. It is a big burden of disease; it kills, and it decimates the work force.
Mamta Swaroop (of the Northwestern Trauma and Surgical Initiative), highlighted a very good point – you need to start at the bottom and look at the data.
If we look at ASOS, we see that trauma is an independent predictor of mortality and then a multi-variable model that remains predictive, and it’s about a fifth of all severe complications and deaths in Africa followed trauma as an indication for surgery.
But Kathryn Chu (Associate Professor of Surgery, University of Cape Town), and Mamta Swaroop brought up two other points which I think we mustn’t forget.
1. Often, when you work in a trauma environment, you end treating patients with other conditions. This is something that I feel we need to embrace if you’re taking about trauma - you will make a big difference to a number of patients, not just trauma patients.
2. The next thing is that these are productive individuals. In Africa, they’re mainly young, fit men. They’re also two prognostic groups: there’s one group where about 60% of patients are having orthopaedic surgery, and they’ve got a very god prognosis. The rest of the patients are the ones who have a terrible prognosis, usually with things like neurotrauma.
The first thing for the future of global trauma care is you need care at the appropriate level facility, with resource-appropriate care, which is associated with an equal opportunity of success.
Appropriate level facility:
This is what I mean by this: the appropriate level facility, with resource appropriate care. This is what happened in ASOS (African surgical outcomes study).
- 60% of all minor surgery happened at a tertiary centre
- 64% of intermediate surgery at a tertiary
- 20% severe cases at a secondary level
The patients are going to the wrong sites. I realise that in some places, as mentioned in the field reports in the second session (by Elizabeth Tissingh, Dr Waraguru Wanjau, Mr Tony Clayson and Charles Clayton) that situation cannot occur, but if the environment allows for a difference in the level of care, we must make sure that we get the patient the right level of care, so we don’t waste limited resources.
So we need triage. We need education for triage. Elizabeth Tissingh (Kongo Central Partnership Lead, King’s College London), explained the importance of this in her talk Improving trauma outcomes in the DRC. We need a trauma system that is structured to the resources available, trying to get the patient into the right categories.
We need to collaborate so we don’t duplicate our services. Tony Redmond (Professor of International Emergency Medicine, University of Manchester), pointed out how we can successfully predict the needs of trauma patients. Kathryn and Mamta both highlighted how obvious it is that there is so much disorganisation and duplication of services.
We really be trying to get the most minor patients into the lowest-level hospitals, and trying to get the sicker patients into a ‘trauma centre’ – what we really mean is a place where there has been an emphasis on some sort of trauma-training to optimise the outcome for the patient.
And now the last statement: trauma care which is associated with an equal opportunity of success.
We are at a divergence of care in our care pathway. That’s because we don’t have enough resources. We can’t do surgery on every trauma patient, when the outcome could be excellent (with conservative management), because we’re not providing enough surgery for surgical patients. Alan Taylor, Neurosurgeon South Africa, phrased it like this:
‘It’s not how can we dumb down modern healthcare for lower income countries, but rather how can we provide excellent care, associated with good outcomes, despite limited resources.’
This really should be the mantra we’re trying to work towards.
The divergence of care: Jes Bates (Consultant Orthopaedic Surgeon, Queen Elizabeth Central Hospital, Blantyre, Malawi), summarised it well in his talk - Developing a trauma service in low-resource settings, putting it into three considerations:
1. We can not translate healthcare in high-income countries into healthcare in low-income countries.
2. We need to consider what is actually possible at a site.
3. The workload is going to continue to increase. As we advocate for surgery, and as we’re more successful in providing education about surgery, the workload will increase, but I can’t see that this will not be met with an increase in resource.
We therefore need to address the relative benefits of the surgical versus conservative management for surgical pathologies. This is something we should be actively thinking about going forward.
So, the second part of the question 2:
What would be the biggest contribution to improve trauma care globally?
These were strong messages that came across through the conference:
2. Triage and stabilisation at retrieval
Elizabeth’s comments were very appropriate – trauma systems must be structured to the resources.
We need to document the efficacy of our interventions. The Primary Trauma Care Foundation’s work is amazing. What we need to do is collect data to show the impact it’s having. That will create more advocacy for it, and create a greater awareness for this great resource.
We do need to look to the concept of trauma centres and trauma training for patients who are triaged as a ‘high risk’.
Many speakers covered training and raised a lot of important points. Jes Bates spoke about building partnerships to build capacity in his talk - Developing a trauma service in low-resource settings.
Tony Clayson (Consultant Orthopaedic Surgeon, Chairman NOTAA), summed it up really well in his talk - Establishing a sustainable trauma service in Hawassa, Southern Ethiopia, where he discussed the concept of a reverse fellowship – the objective is not to do the work, but simply to train. And then going the other way, fellows creating advocacy for global trauma surgery
The model that is sustainable is Charles Clayton’s cascade model to ensure sustainability (Principle Investigator and Founder and Chief Executive, Primary Trauma Care Foundation). In other words, you train, and then you leave the trainees to become trainers, and perpetuate the system in the context that has been applied.
Finally, mentorship. Nigel Standfield (RCS Council Member), said in his talk that we should leave a sustainable model for training and mentorship. It is interesting to see how powerful Whatsapp has become. In fact, we also found Whatsapp really powerful when we were working with ASOS, using it locally for ward rounds and assistance, and using it internationally for support and ongoing mentorship. This is a real point of strength, and one that people should engage with more.
Now we come to 3. What are the current biggest challenges?Access is certainly still the biggest challenge with the vast majority of people with no access to surgery. The next thing is resources, and the one thing that hasn’t been mentioned on the podium today - but that has been raised through questions from the audience - is the concept of task shifting. This is a discussion we must have. We cannot increase the number of physicians providing the care that would be sufficient to meet that demand. Then finally, leadership and responsibility. Mamta summed it up: if we want to put our best foot forward, we need someone who is a force of nature, with the ability to break down barriers.
End of talk