GS_trauma_02.24.24

Hello and welcome to Behind the Knife. Today we will host another episode of our new global surgery series. Today with a special focus on trauma care and emergency surgical care in remote and resource limited settings. Traumatic injury remains one of the largest burdens of disease and causes of mortality.

At the international level, W. H. O. estimates that over 4. 4 million lives were lost to traumatic injuries per year, accounting for approximately 8 percent of all deaths. Notably, traumatic injuries are the top killer in Children, adolescents and young adults, compounding the patient years lost. Trauma is ubiquitous.

Accidents and injuries happen all over the world, and thus differences in trauma incidence and mortality is often a function of health systems and infrastructure. Today, we'll explore these concepts with a prominent leader in both the field of trauma surgery and global health. Specifically, we will discuss the importance of systems based interventions, not only in the hospital setting, but also in transit, in the field, and in the community that the hospital serves.

Additionally, we will talk about the challenges and successes of implementing these

concepts.

I'm John Williams, one of the Behind the Knife fellows, and with me today, I have Dr. Anthony Charles. Dr. Charles is a trauma surgeon at the University of North Carolina, Chapel Hill. Additionally, he holds professorships in the medical school and School of Public Health at UNC, as well as serving as the director of the adult ECMO program and the director of global surgery at the UNC Institute of Global Health and Infectious Diseases.

He also leads the Malawian Surgical Initiative designed to train and support local surgeons in the country of Malawi, where he has established a longstanding partnership with UNC. Having been raised in Nigeria, Dr. Charles completed medical school at the University of Lagos and subsequently underwent general surgery residency training in London at North Middlesex University Hospital and then subsequently at the Charles Drew University in Los Angeles, California.

Upon completion of trauma and critical care fellowship at the University of Michigan, he took a faculty position at UNC where he has remained since

and has grown their global surgery presence to what it is today. Dr. Charles, thank you so much for joining us. We appreciate it. Well, thank you very much for having me and I'm happy to be here.

Great. Well, I guess first I'd love to learn more about you and your inspiration that brought you to where you are today. Can you tell us more a little bit about your personal journey that brought you one into surgery in general, but also into the global surgery space? Certainly. So I have a very sort of long and unusual story.

My father was a physician, my mother is a nurse, I've got a whole load of doctors in my family, my older sister is a pediatrician, and my younger brother is in public health at the United Nations. So I feel like an underachiever really in the healthcare space. But you know, with growing up in a medical family, you know, doing medicine was kind of sort of imprinted in me from childhood.

But in medical school I, I heard a phrase from one of my professors that

says, a surgeon is an internist that has completed their medical education. And that's kind of struck me as something rather profound. And I thought, well, as a, as a surgeon really, You have to be just as good as an internist and then you can use your hands.

And and I also have an attention span of a, of a grain of rice and surgery. It's all about instant gratification. And so I I decided to do surgery. I went on to do the fellowship of the Royal College of Surgeons in Ireland and in Edinburgh for my training in the UK. And I fell in love with a Nigerian American.

I moved to the United States. I did my residency all over again in Los Angeles and came over to Ann Arbor and did critical care. I'm an accidental academic, really, because I thought I was going to go into private practice when I was done, but I said, well, let me try out, you know, academics first, if I don't like it, you know, the private world is still waiting, and I happen to be at the right place at the right time by coming to Carolina.

At the time I

came here in 2006, the University of North Carolina had been in Malawi since 89 with the HIV AIDS crisis, and they had a collaboration there. And by 2007, you know, with PEPFAR and all the funding that went into HIV, HIV became a chronic disease and they noticed that a lot of their HIV patients were dying from trauma.

And so I was tasked to go to Malawi and essentially just make an assessment and see what we can do to help. And the hospital where we work out in, it's in Lilongwe, Malawi, it's a hundred, a thousand bed hospital. And at the time they had only one surgeon, and he was 84, and it became abundantly clear to me that this is not viable, nor is it sustainable.

And the first efforts that we, when I came back and I spoke to my chair is let us see how we can essentially set up a surgical residency program for Malawi and so they can stay in the country. Historically, a lot of their physicians had been sent abroad. And they

never came back. In fact, there were more Malawian physicians in Scotland than there were in Malawi.

And so, so we felt, well, if we can support them in country, train surgeons in general surgery and orthopedics, which is really where the bulk of the trauma burden is then we can do something that is sustainable that can sort of change and move the needle when it comes to global surgery.

And so that's, that's how I got involved. That's great. Yeah. And I think it's, you know, kind of highlights a fascinating theme that you and a lot of other global surgery experts have touched on, which is, you know, personnel is such a big part of the equation. And a lot of times there's the best initiatives are the ones that grow personnel.

Well, thanks again for taking time to chat with us. It's been well described on the large scale that you know, Trauma is a massive burden, especially in these resource limited or low and middle income countries. Could you tell us more about some of your experiences on the ground when you were there in Malawi and what might have

brought those issues to light in a really meaningful way to you?

And were there any specific events or cases when you were there other than just seeing the sheer size of the hospital and few amount of surgeons to serve that hospital? Certainly. So, in the long way, I mean, so Malawi is a, is a poor country. It's mostly rural, but we're in the city. And every day you had about 15, 20 patients being brought in with a primary reason for admission to the surgical services being trauma.

With one surgeon, you clearly, for those that needed operative intervention, it's really, you know, matter of timing. If you show up at the right time and the surgeon was free. You get your surgery. If you don't, you have to wait. And so the mortality was actually relatively high. That's one thing. Second thing that I noticed really was that because the a gallon of gas cost around 10 and 11 the way public transportation was set up was There

really was none whereby people either walked, got on a bike or stood behind a flatbed truck to move from point A to point B.

And you can imagine where the roots are not very good. You jump over a pothole. People essentially careened off the ba flatbed truck. And mass casualty was a real problem. And LA and thirdly was the fact that. Trauma is an equal opportunity disease, right? It doesn't matter who you are, what your social standing is, it can happen to any one of us.

And I can remember there was a, there was an American couple that came to Camusia Central Hospital. They were tourists. They were involved in a motor vehicle crash. The wife was presented to us an extremist. Tachycardic. And I just got a phone call being, being a surgeon on the ground saying that, you know, there's an American here in distress.

Can you help? And it occurred to me that, one, if I wasn't around, it would have been hard for them to get the surgery and they did it in a timely manner. And secondly, she was a death's door. Luckily, she was taken to

the operating room, did a splenectomy, and she did okay. But all the other, what I'll call the accoutrements of trauma are like, CT scan and getting a plain film and making sure the blood bank had enough blood and all that was really absent.

And so it kind of sort of puts in focus just the complexity of really building a surgical ecosystem that can treat trauma. Because if you can do that, you can treat every other disease process, right? If you have a certain, if you have a healthcare system that is built on the basis of delivering surgical care.

Trauma being a major aspect of that, you can deliver all care. And that's the way I've sort of looked at it and thought about it. The other thing that was also very obvious, particularly in the field of global health, is this disproportionate emphasis on infectious diseases. And a lot of people kind of look at PEPFAR, the HIV AIDS as, you know, one of the most altruistic things that

the American government has ever done, which is good.

It's just true. Well, the truth of the matter is. Infectious diseases are looked upon as national security issues and not healthcare issues. Therefore, if a patient's got HIV in Malawi, it's better for me to treat his HIV in Malawi so that it doesn't come to, it doesn't come to Chapel Hill. If a person gets in a car crash in Malawi, well, guess what?

They got in a car crash in Malawi, everybody's Chapel Hill is fine. So we need to start to look at trauma as something that can affect anybody, us tourists in the country. And so that we can start to talk about the real financing of trauma you know, to really make a huge difference. Absolutely.

I think that concept of communicable versus non communicable disease is interesting. Whereas the roots of it. Global health initiatives have been towards communal diseases, as you've said, and, you know, I think that surgery and also trauma surgery is kind of a hard hard sell

to the stakeholders that might provide the financial or expertise backgrounds to build initiatives in low and middle income countries where surgery It's an expensive thing to provide to somebody and and like you said, you know, if it's kind of what is the what's the internal benefit for the group providing that care?

Yeah. The other thing one must also notice, of course, is that trauma victims are usually those between the ages of 15 these are people who are the prime of their productive lives. In Sub Saharan Africa, the average age is less than 18. Right. Mm-Hmm. , right? Life expectancy is roughly between 55 and 60. So if the most productive members of your society are being struck down by trauma, then it certainly is gonna affect the economic health of your of the country.

It's gonna affect not just individuals, but families and the extended families gonna affect agriculture, particularly where subsistence farming is the

mainstay and the sequelae and the downstream effects of trauma is just tremendous. Absolutely. You mentioned something a little bit earlier about the, this concept of, you know, I think the pattern of trauma disease and trauma care is so highly influenced by the infrastructure of the general area outside of the healthcare systems itself, folks sitting on the back of flatbed trucks to get there, get to work every day, lack of public transportation, lack of, you know, Reliable pedestrian paths versus roads and things like that.

Have you either been part of or have kind of seen success and initiatives that are centered around kind of pre hospital trauma care, whether that be prevention or triage and. And getting these patients to a center where they can get the care they need. Yes. So, so interestingly, you know, so I mean, the key, I think we all know this, the key to, to, to trauma is prevention and primary prevention strategies are

particularly difficult in trauma because really you're asking for a change in behavior.

Right. And so, so that, that is always very difficult to, you know, difficult to do as a surgeon, right? That is not our area of expertise. All right. You know, secondary interstitial prevention is really what, where we focus our efforts. And one of the, one of the biggest things is okay, the trauma has happened.

How are you going to get a patient from the site of injury to where they can get definitive care? So we've worked with the World Bank the World Bank has an initiative whereby they tried to essentially start a pre hospital service and also try to upgrade all of the, what I'll call the tertiary care facilities in the country, such that, you know, if a motor vehicle crash occurs, you know, an ambulance can be called.

That is stationed all across the highway and then the patient can be brought either to the closest hospital or a hospital for definitive care. Just like everything else, you know,

the amount of money they thought they were going to need to do it and the amount of money that was actually available there was a huge gap.

So, so it ultimately wasn't very successful, but what it did do was essentially bring trauma to, to, to the attention of the ministry of health. And there were some resources brought into essentially enhancing sort of the trauma bay, making sure resources were available, making sure, you know, cervical collars were available.

The second thing that we've also done Is the fact that the majority of trauma victims are brought in by the police. And so having an initiative that actually trains the police in basic life support, basic trauma care was what we believe was going to be helpful. Now, showing whether or not it's helpful has been challenging because we clearly need data and the amount of trauma is is significant.

The third thing we actually have as a unique advantage in Malawi that we have set up is that every death. Whether it

happened in the field, or at the site of injury, or before hospital, it has to be brought to the hospital. To be declared and certified and so we know the just the just the shared number of trauma related deaths that are happening because all the all the all the bodies have to be have to come through the for the casualty departments.

And so we have a fair idea of trauma but we also know based on that that trauma mortality has gone down, given the increase in personnel, and if showed up to the hospital. So we haven't we haven't altered pre hospital deaths, but we certainly have altered in hospital deaths by increasing our trauma education, trauma personnel, access to the operating room, access to blood banking, and so forth.

Very interesting. I remember being an intern myself, and I think a lot of our trauma surgeons really hammer home this concept of kind of like the three spikes of trauma deaths that were, you know, the first spike is before they ever, you know, right on the scene before they ever see a

care provider. The 2nd is in that immediate resuscitative period.

And the 3rd is at some point down the road when maybe they made it through that initial presentation, but they're in the ICU. So, I guess my next question is about in hospital trauma care. This is kind of a nice segue to that. Considering in hospital trauma care in places like Malawi, do you think that this should look identical or similar to in hospital trauma care in the United States and the Western world?

You know, we have well established advanced trauma life support training. We have trauma center distinctions that are provided by governing bodies of our profession. Or are there some aspects of this systematic approach of in hospital trauma care that need to be tailored to these areas? That, I mean, that's a great question.

I think there are two, two ways to, for me to answer your question. And the first thing I'll say is that human physiology is the same regardless of where you are, right? And so, you know, as someone with hypovolemic shock in Malawi and someone in hypovolemic

shock in the United States is one or the same.

And if you do not treat either in a timely manner. the results are going to be the same, right? And so on the one hand, there's a basic necessary requirement in order to manage trauma anywhere in the world that has to be available. So access to IV fluids, access to, to you know, intravenous cannulas, access to timely blood.

Okay. And access to basic trauma care in terms of knowledge. and access to ultrasonography. I think those are the basic things. Now, do I need to CT scan everybody in Malawi? Absolutely not. I think with good clinical exam and timely access to things I've previously listed, I think you can move the needle.

That's one thing. The advantage we have in the United States is we have plenty of personnel, not just surgeons, right? So if trauma shows up, you go to the emergency department, the ED folks evaluate you, a trauma surgeon comes along, you have critical care and intensivists, you have plenty of nurses, you have non commissioned physicians.

Well, on the other hand, in

Malawi, if we were to wait to have enough surgeons to be able to provide adequate trauma care, we'll wait a lifetime. All right, that will never happen. And so the emphasis is really on training physicians and non physician clinicians alike to be able to provide trauma care and general surgery care, not just at the central tertiary referral centers, but also in the district hospitals.

And also understanding and giving them the notion of, you know, who do I refer? Who do I hold on to? And what are my capacities and capabilities? So, to answer your question directly, I do not think that you would need all the bells and whistles that we have in the United States to change and move the needle, but I think there's a basic minimum set that you need.

You need people you need the patients to arrive in a timely manner in the right place, right? And then you need all the, all the resources that, that a hospital should bring to bear

water, electricity, supplies, disposables, blood and given the fact that the mortality is high right now, it does not going to take a lot to actually bring the mortality down.

Now, we may never get it to that of the United States, but we certainly can, can bring it close. Absolutely. So the basic supplies and also the people that know how to use them sounds like. Correct. So, yeah, I think that's interesting when you mentioned, you know, I think in the United States there needs to be a trauma surgeon present to take care of a trauma patient.

But I think that's, like you mentioned, it's unrealistic in a lot of places of the world. What does that outreach look like in your experience with the Malawian Surgical Initiative to spread the knowledge and the basic amount of training to Physician and non physician providers that are not surgeons and have no intention to be a primary, primarily a surgeon, but really need to provide this care to people.

So certainly, so we've been very lucky that we've

worked closely with the medical school, and so we have a pipeline of physicians that are going to be joining a residency program. And then there's also something called a clinical officer surgical training. It's called the cost program, where essentially the equivalent of PAs and NPS can be trained in surgery, and they're the ones that are gonna be located in what I'll call the community hospitals or the district hospitals, and essentially teaching them something not, you know, so it's the equivalent of the A TLS Life.

It's called the International Trauma Life Support Educational Basic trauma course. And we've done that. I think it's been moderately successful. I think one of the things we forget is when you have a healthcare system that has more non clinician providers than clinicians, there has to be oversight.

Right. So for instance, you will never let a PA remove your appendix here

at the University of Michigan, right? That's never going to happen. It's not going to happen in our lifetime. Okay. And so if that is unacceptable to you, then what it should also be similarly unacceptable to our colleagues and our partners in Africa.

But the reality is sometimes if they are adequately trained and There's someone who is available should they get in trouble, you know, that I think, you know, placing emphasis on non clinical providers would work. And so it's really about having clinician oversight to everything they do in order to be able to get similar results.

We've looked at this specifically in pediatric surgery, in trauma. Very well trained non clinical physicians can provide. Similar care with similar results, right? But understanding where you draw the line in terms of complexity, right? It's really surgical judgments. That is hard to train someone, right? So you need a bit of oversight.

And so we've done that. But it's really the key is repeated

training. And it's really, it's a constant training. So we train them now, they go out there for two years. You have to bring them back in and so refresh, having frequent refreshes. And that's where the difficulty is trying to convince them to come back has been challenging.

I see. For these training paradigms and these, you know, establishing these standards of trauma training for these providers, what did that process look like to make that training program? Was there trial and error? Were there times where the team realized that we need to do this differently or we need to do this at a higher frequency or anything in that regard?

Well, trial and error will be more accurate in terms of. You just have to see whether or not you are getting through to folks and see whether they understand what you're doing. So, so All the bells and whistles, you know, a thumber splint and all that that we'll have doing ATLS in the United States is not

available, but you could improvise, right?

A C collar is a C collar anywhere, right? It doesn't have to be the beautiful C collars we use here, there are other ones that are simple and cheaper that can, that achieve similar things, but really is we trying to gauge the baseline knowledge of the trainees is most challenging. And some people are going to get it right away and they're going to excel.

And they just, you know, they've got it. And other people are just going to take their time and they're going to have to do it again and again and again. And understanding that not everybody's kind of oscillates now the same pace is really the biggest challenge. And that's number two. is sometimes their language barriers, you know, the, you know, because even though Malawi is a former British colony, English is the, you know, the language of business, not everybody speaks English.

And so, you know, things may be lost in translation. And so that that's another challenge, but more importantly we have to test, you know, and do scenarios with our trainees to make sure they get

it. And that's the only way to do it. Definitely. It's kind of the the age old training challenge that rings true regardless of the medical setting that you're in is every learner is different and you know, there's no cookie cutter, one size fits all training program.

That's right. And some people will just never be good and you just have to recognize and let them know that maybe this is not the best thing for them, but that's okay. Absolutely. Absolutely. Absolutely. Well, kind of zooming out, I know we talked a lot about personnel training and establishing the basic resources required for trauma care.

Now that you've been involved with the Malawi Surgical Initiative for some time, what are the key challenges that you see that remain today versus the ones that you feel like we've made a lot of ground on for the ongoing improvement of trauma care in that setting? So the greatest challenge to global surgery pertaining to trauma is having the local ministries

of health understand the importance of providing and supporting and financing surgical care and trauma care and the impact of.

Doing that on the overall national economy and GDP and until they understand that they are more likely to just assume that, you know, trauma is somebody else's problem, and we don't even, we don't need to spend money on it, or we will only respond to our donors and most of the donors are all infectious diseases.

Supported projects, and that has been the greatest challenge. I mean, I mean, our experience in Malawi, the acknowledge and recognize the impact of having a surgical training program. They acknowledge the impact of low and mortality, but they're yet to fund it. And so at some point in time, it may no longer become sustainable because they have to have a pattern.

I think the key to any successful

global program is having your local partners buy in and having your local partners set the agenda. And in our experience that has been the greatest challenge, you know, not that they don't want to set the agenda, but they don't want to. Pay for it, and financing, financing global surgery has mostly been philanthropic.

Even the NIH doesn't have enough grants to to see, you know, this is a global surgery as an entity to force to be able to change the paradigm on the ground. A lot of the funding comes from philanthropic organizations. Industry has helped Johnson and Johnson has been a great partner with us in doing this.

And so trying to project forward is, you know, we need a much more sustainable funding structure, either with philanthropy on our end or the Minister of Health on, on, on our partners end to make it work, work. And who should be the ones that are advocating for that, right?

You know, I feel like it's,

It seems like it's a little bit challenging for somebody to come from the United States and then preside over the Ministry of Health in Malawi and say, I know what's right, and you should agree with me. What does that advocacy side look like as the? Sure. So, so one of the things, you know, you know, that we've all been grappling with is what is the role of the WHO?

Because the World Health Organization has a lot of sway on the Ministry of Health and in each country. And what is the role of the World Health Organization when it comes to surgical care and trauma care? In reality, WHO doesn't really have much of a large budget. And the Office of Global Surgery there is probably one of the smallest parts of the WHO.

I mean, we have one person there right now. And so, so, so it's challenging. And so WHO is also, it's almost like, it also needs aid from individual countries to function. And so if monies are not coming to WHO, then there's very little that can happen on the ground, but I think what should happen really is that we can make a financial, if we can make a financial arguments for why it is important.

For a country that is so desperately in need of health care resources or finance or money for health care to, to protect its own people if they were, if they are going to come out of poverty. So having a, you know, having a cost benefit analysis of trauma care is important. Making a financial arguments, not just to the minister of health, but the minister of finance.

And that has to come, that's, that's what I believe is the next step. And that's what we can help them with. You know, if we can show, right, if a thousand people are dying from trauma every day, right, and each of them is a disease of men, right, and they've all have a wife and three children on average, that is a significant amount of loss, right, for the community and for the country.

And if you're going to come out of poverty, you need people to work. And if trauma, I mean, even a simple, even if you don't die from trauma, I say you have a fracture of femur, that that's it, right? You cannot, you can no longer walk on the farms. And so, so that has, we have to make a

financial argument so that it is, you know, incontrovertible that if you invest in trauma your return investment.

Is worth it. And that's what has to happen. And that's what that's where we need to spend our time on. As surgeons, we're not experts in that, but we certainly can partner with experts to help us convince the governor, the governments and the partners we're working with to to make that argument.

Very interesting. This concept of traumatic injuries are a health burden, but they are an economic burden, maybe even more so too. to these countries. Final question is for folks like myself, trainees, students, young early career surgeons who are interested in and inspired any words of wisdom for getting involved in global surgery work?

Certainly. I will say the first thing you have to do is. Know yourself. That is, ask yourself, what is my motivation for global surgery

or global health as a whole? And, you know, I can also categorize the three types of trainees or surgeons who are wanting to do global surgery. They're mercenaries, they're missionaries, and they're misfits.

And you have to ask yourself, which one are you? Okay. And once that is clear in your mind, right? Because invariably, if you go to a lot of sort of developing countries, you see all kinds of people there. There's some people are just there to find themselves. Some people are there to find Jesus. And some people are there to get paid, there's something they're trying to extract from the from the country.

But there's a fourth group, and I call that academic medical centers, which I think do global surgery the best. Where you want to train, because training is what we do, education is key. We're coming from an academic and educational center, right? You want to deliver clinical care, we already do that. I want you to do research.

To really find out and ask those tough questions. And so I'll tell people, if you're really interested in global surgery, you should partner or affiliate yourself with an academic

medical center that already does it and does it well, and where the entire resources of that institution and the warm embrace of that institution can protect you when you're on the ground.

And you don't really have to reinvent the wheel. I think there have been a lot of great institutions that have done this. Trying to do this by yourself is hard. You know, trying to do mission trips is expensive. I'm not quite sure it's worth the return on investments, but having a long term partnerships where you can deliver care, you can train the future generation of surgeons in that country, and you can do research whereby you're asking the most pertinent questions and trying to find solutions.

I think that's the way to go. All right, so just to wrap up well, I'll kind of highlight some key points from our great conversation. First is that often the pivotal first step to improving trauma care. in a resource limited setting is to increasing trained personnel, both at the physician level and at the non clinician level, so that there's a lot of bandwidth to provide the trauma care that

folks need.

And so training initiatives are obviously very meaningful in this space and more sustainable in terms of styles of initiatives that can be made. Second, if you can build a trauma system that treats trauma patients well, it turns out that that also that can translate to treating all other medical conditions well too.

It kind of is the tide that rises all ships in terms of healthcare and at the in hospital setting. Another key to improving trauma care is that it is a multi setting initiative. So that includes prevention of disease, of course, safety measures, pre hospital care, triaging and transporting patients appropriately.

And of course the in hospital care with standardized protocols to manage the patient with traumatic injuries. It takes more than just surgeons to improve trauma care in the global setting. Thus, Both clinician and non clinician training is critical and requires a lot of outreach and tailoring of training paradigms to train folks that aren't just surgeons.

And finally the economic side of the

coin is possibly even more important, and there needs to be support from local governing bodies to understand the importance of trauma care and invest in it. Trauma is a medical burden, but it's also a financial burden on these countries. And that financial burden is possibly the most convincing argument in terms of allowing for economic incentive and support to improve trauma care systems worldwide.

Thank you, Dr. Charles. That was a great summary. I think you hit all the nails on all the heads. Well, thank you. Well, thanks again, Dr. Charles. I think all of us in our listeners have learned so much from your perspectives and your experience on trauma care delivery in Malawi And on the global stage, we absolutely appreciate your time and your work.

If you enjoyed this episode, be sure to keep an eye out for future Behind the Knife Global Surgery Series episodes. If you're interested in more topics or have suggestions in regards to our global surgery content, please feel free to contact us at hello at

behind the knife. org. That concludes our episode.

We hope you're much more familiar with how the field has grown so rapidly over the years. and the influence that we can all have on the global scale in terms of trauma surgery. We appreciate your listening and until next time, dominate the day.