BTK Burn Global Surgery Partnerships 1.15.25

Five billion people in the world do not have access to basic emergency surgical care. Nine out of ten people cannot access basic surgical care in low and middle income countries. 143 million additional operations are needed every year to meet this need. I'm Paul Herman, a UW General Surgery resident here to discuss approaches to sustainable engagement in global surgery.

In our recent episode on global burn surgery with Dr. Barclay Stewart and Dr. Manish Yadav, we discussed several cases at Kirtipur Hospital in Nepal to illustrate the global burden of burns and the similarities and differences in treating burns at Harborview Medical Center, a level one trauma and ABA verified burn center in Seattle, Washington.

and Kurtipur Hospital, Nepal Cleft and Burn Center in Kathmandu, Nepal. In this episode, Dr. Stewart and Dr. Yadav again join us to share insights on how to get involved in global surgery with an emphasis on sustainable participation. Dr. Yadav and Dr. Stewart, thank you for being here. Thanks, Paul. Yeah,

thanks, Paul.

Glad to be back. Well, burns is definitely a very critical topic. And we are glad to be able to share what we have learned from our partnership with the aim of developing citizens interested in health equity, reducing disparities, and to engage in global work in the most productive way. As discussed in several prior episodes by the Global Surgery Team, the focus of global surgery has shifted from episodic mission based care to a multidisciplinary field of research, study, and practice focused on delivering surgery in a way that improves health equity regardless of location.

with a special focus on underserved marginalized populations and populations in crisis. Trauma is particularly important in the field of global surgery, given the high burden of disease. Burns in particular are an important focus as burns tend to affect individuals experiencing poverty and unsafe living conditions.

In our prior episode, we had discussed that over 90 percent of the burns are in low and

middle income group countries. And this, this priority has further increased with the data published by WHO. In this episode, we'll discuss historical perspectives on global surgery and frameworks for creating and evaluating global surgery partnerships, using examples of a productive partnership between Harborview Medical Center and Kirtipur Hospital.

Dr. Stewart and Dr. Yadov, maybe you can start by sharing your first global experience with surgery and if you were immediately hooked on global surgery or what the process was and focusing your career in this area. Sure. Like most things, I think getting involved is based around having a great mentor and experience.

I had a research scholarship in Kenya, and at the time Southern Sudan, which is now independent South Sudan, working on projects related to neglected tropical disease control. Particularly in South Sudan, my eyes were opened instead to the toll that prolonged conflict has on adults, children, and the health system at large.

While there is significant aid for communicable diseases like malaria and HIV and tuberculosis, there is none for gunshot wounds, blast injuries,

burns, or the other surgical conditions affecting the population. Even simple things like appendicitis or obstructed labor. I then vowed to spend the rest of my life working to address this disparity in global health.

I worked at the Red Cross and Red Crescent supported Kanti Children's Hospital in Nepal, where I was supporting a project aimed at developing an antibiogram for their burn unit. I was drawn to the team management to burn injured children, the complexity of burn care, and the capacity development for trauma care more broadly.

I then moved to train at Harborview in a world class adult pediatric trauma and burn center, where I am still based. I'm very grateful to be still based with the help of great mentors, I have been able to continue working with people around the world, including Dr. Yadav and his team in Nepal. Dr. Yadav, how did you become involved in global burn care?

Well, for me, it was after I finished my residency training in general surgery and plastic surgery in Moscow. When I returned to Nepal, I chose to work with Dr. Sankar Manrai, who leads the Cleft and Burn Center in Kathmandu.

It was there where I saw the magnitude of burns and then the burden of burns, because we were not able to save almost all of the 40 percent burns.

And then I noted that we had a very poor understanding of the pathophysiology and the critical care management of birds. So that's why I slowly got into management of birds and critical care. Thank you both so much for sharing that background. As we get ready to discuss sustainable partnerships, I think it might be helpful to provide some historical perspective on why this focus is necessary.

A paper by Chin et al. titled Colonization and its Aftermath. Reimagining global surgery discusses some of the biases global surgery has inherited from global health. Due to the history of colonialism and neocolonialism and systemic inequalities. Well, the Global Surgery distinguishes itself from the colonial era by its focus on health systems capacities, strengthening, and integration of care pathways rather than vertical, short term, disease specific, mis focused care.

This paper

surveyed nine Global Surgery practitioners from multiple cultures, languages, and professional backgrounds spanning policy, advocacy, education, research, and research. history, nursing, midwifery, obstetrics, and gynecology and surgery. And they used a group delphi consensus building process to identify five categories of inequalities in global surgery.

Dr. Stewart, can you tell us about the categories they identified and comment on how these still affect global surgery? Sure. So the first is a very strong focus on Western epistemology, meaning we focus on Western biomedicine principles of disease. We silo our treatments to civic disease rather than interprofessional and interspecialty collaborations, and we often fail to incorporate indigenous medical systems or cultural norms into projects.

The focus has often been on the global north to global south unidirectional flow of information, creating a geography of inequity. There's been unequal participation, differences in participation by gender or specialties,

again, like surgery and even professions like physicians versus non clinicians.

Just like in the era of colonialism, there's a tendency toward resource extraction rather than delivery and local growth and an asymmetric power and control system. Generally speaking, institutions with the money by design afflict the local program and often don't consider existing priorities in the local context.

It's important that we shift global surgery towards equity inclusivity and ensure that there's governance driven by local communities to combat these categories of inequity. Thanks. Given this background, we think that Binda et al paper provides a nice framework and evaluation metrics for sustainable global surgery partnerships.

Dr. Adab, can you share a little about the paper? Sure, Paul. This paper is a survey of a group of global surgery experts to establish a consensus framework and checklist for evaluating sustainability in established global surgery partnerships or setting up a

sustainable global surgery partnership. This paper included 50 global surgery experts from 34 countries with a median experience of 9.

5 years. They used a modified Delphi technique to build consensus on definitions and associated evaluation metrics of six prior identified pillars of sustainable global surgery partnerships. The Delphi method is an iterative process that establishes consensus among groups widely applied in the healthcare setting due to flexibility, emphasis on communication and dialogue and cost effectiveness.

It's well suited to answer should questions. The three should questions they were attempting to address were, what should the pillars of sustainable global surgery partnerships be? How should these pillars be defined? What metrics should be used to evaluate them and ensure that the pillars are upheld their output after their surveys was a 47 item checklist for the evaluation of the six pillars of sustainable global

surgery partnerships.

These six pillars are stakeholder engagement. multidisciplinary collaboration, context relevant education and training, bilateral authorship, multisource funding, and outcome measurement. We don't have time to talk through their definitions and checklist items for each pillar, but we thought we'd discuss how a few of these pillars have played out in the HMC Curtipur partnership.

The first pillar that we can talk about is stakeholder engagement. We were asked by Dr. Shankar Manrai in Nepal to assist with capacity development for acute burn care, not just burn reconstruction. During that process, we wanted to really focus on improving the collaboration between all members of the burn care team in Nepal with our program here at Harborview.

To do so, we focused on engagement of residents and medical officers and nurses working to improve care quality and participation in clinical trial in Kirtipur. We also had one of our lead research assistants hired, given that they were a person living with burn

injury who provided a unique perspective to the work we were doing for community based work on burn injury prevention, we worked with leaders and communities to identify key problems and get access to populations that were otherwise difficult to access, like people living in slums.

We've worked very closely with Dr. Yadav, who's our local champion, to ensure that the projects we do and the communications we have are all aligned with his mission as the burn director of the hospital. In order to uncouple some of that financial inequity, we've ensured that all the funds provided go through a third party, which is the Public Health Concern Trust of Nepal.

And they ensure that the money is directed without bias to the people and projects we're working on together at Curtipur. Given that we have multiple research fellows a year, including fellows from the United States and from Nepal, we wanted to ensure that we had a mentorship plan that included a strategy for arbitrating conflicts between our group.

And this has spilled over to our entire partnership to ensure that the ultimate voice in the

decisions we make are done by Dr. Yadav and his team. The next category is bilateral authorship. We've created the 50 50 rule, which is 50 percent of the publications and presentations that we have are performed by Nepalese.

And half of the authors of each of these publications are Nepali. We've also identified and promoted Nepali trainees for international fellowships, including those funded by the National Institutes of Health and the U. S. Department of State, so that they can ultimately start their journey toward becoming independent investigators as well.

And then lastly, we wanted to ensure sustainability by having multi source funding. It's obviously critical for funding to be from multiple sources in case funding from one source dries up, which is obviously quite common in the shifting political winds of global health. We've layered funding through our university, through non governmental organizations like Research and Mission Plasticos.

From U. S. based federal funding, from NIH and the Department of Defense, and through philanthropy.

Although we don't have enough time to go into the supplemental checklist and how we can evaluate our program, they did do a great job of distilling the experience of 50 global surgery practitioners. All of the pillars and components that they described were really focused on health system strengthening and capacity building.

There are three definitions and concepts I think are important that our listeners take home from this episode, and these are vertical programming, horizontal programming, and diagonal programming. for listening. So vertical programming refers to the concept that initiative is focused on a specific disease like malaria or HIV or a health condition like pregnancy.

They frequently focus on only one aspect of care such as prevention or detection. And they are also often focused on one part of the overall issue, like health financing, human resource development, or information management. These programs tend to be donor driven, and they often rarely interact with other components of the health system.

The horizontal approach refers to resource

sharing across disease and population groups. It usually includes efforts to strengthen the health system as a whole or address system wide constraints like shortages of trained healthcare workers or inadequate healthcare facilities. The diagonal approach or the more modern strategy combines these two perspectives with a focus on prioritizing interventions that strengthen the overall structure and function of health systems.

So, instead of focusing exclusively on a disease or addressing generic health system constraints, diagonal interventions tackle disease specific priorities while addressing the gaps experienced across an entire system. Some examples of this include focusing on emergency and trauma care across a continuum helps not only injured patients, but those with sepsis or maternal hemorrhage.

Others include focusing on improved access to safe blood, which can improve treatments of multiple diseases, incorporating acute rehabilitation into pediatric burn care, improves access to these services for all kids, and advancing surgery for cleft lip and palate requires strengthening of interdisciplinary services that

enrich the surgical system as a whole.

That's excellent, Dr. Stewart. Thanks for sharing those definitions. Another approach is twinning. Dr. Udab, I wondered if you could describe twinning and your experience with this. Certainly. The way we engaged in Longitudinal diagonal development was by training with the Harvard Field Medical Center with a focus on health systems strengthening.

Examples of shared initiatives include quality improvement and working through the QI cycle, development of the rounding list in the brain ICU, discussion of critical care cases, and real time WhatsApp collaboration for issues Also, development of the burn resuscitation protocol, which is a two hourly protocol.

Thanks for sharing, Dr. Udab. It's interesting to hear real world practical examples of specific improvements in burn care with things we may not think of, like using a WhatsApp collaboration for real time feedback or things we might take for granted, such

as rounding lists. I'm curious how your partnership has affected the burn resuscitation protocols in Kirtipur.

We found that hourly modifications couldn't be carried out due to the nurse patient ratio. So, upon discussion with the nursing leaders, nurses on duty in the floor, we came up with this two hourly resuscitation protocol. And that seemed to work. to work quite well. During the 20th process, we didn't want to take things that worked here at Harborview and try to replicate them in Kirktipur.

As mentioned, the nursing ratio problem was significant. The difference between nurses empowerment and their ability to run resuscitations rather than having the medical officers do it specifically and that took lots of cultural change and education of the nursing staff over time. The second thing that, you know, it's quite common is that people either can't afford IVs or central lines or they don't get one early in their care from smaller hospitals when they're transferred up to Côte d'Ivoire.

So we really wanted to lead the way on how to operationalize

internal or oral resuscitation as a way to mitigate the risk of people being under resuscitated for such a long period of time between injury and arriving at a burn center like Côte d'Ivoire. But we decided together that we didn't want to jump in and start doing that.

teaching or modifying care at first level hospitals because it's quite a complex intervention, frankly. So, instead, we wanted to focus at Curtipur, figure out how to operationalize it, implement oral resuscitation, and then develop a protocol that could be disseminated to first level hospitals. So, what we've done is created both a research and a clinical protocol that we've merged together that have randomized patients to oral rehydration solution.

or intravenous solution for their resuscitation fluid. And we've noticed a few things. One is that people can tolerate internal resuscitation at fluid rates commensurate with the Parkland formula without aspiration, without risk of pneumonia, and without excessive vomiting, although vomiting and GI intolerance do happen at slightly higher rates in people who are internally resuscitated.

We found that we can

resuscitate kids and adults up to about 40 to 60 percent total body surface area injured with oral resuscitation alone, but that there are patients who do need IV fluids to augment oral resuscitation, particularly those that have already been in shock, have developed either oxygen debt or Ischemial reperfusion syndrome from being so hypovolemic and then being resuscitated and then obviously needing a lot much more fluid that they wouldn't have required otherwise.

We're really proud of what we've been able to do together and hopefully these results as we complete the trial will demonstrate that there's no difference in renal failure, no difference in other negative outcomes. It's safe, it's effective, it's very implementable. Even in very low resource settings, particularly when led by nursing colleagues and medical officers without a lot of burn training.

And this would be a wonderful strategy that we can disseminate to smaller hospitals within Nepal and beyond. That's really interesting. I think that just speaks to how productive these types of partnerships can be. Enteral resuscitation is something that I think could be used in low

resource settings, even in the U.

S. It seems like a project that is really broadly applicable and is going to teach us something just about physiology and burn resuscitation. that goes across all contexts. Yeah, a couple of the groups that have done more preclinical work on this and large animal models, including the U. S. military and research groups out of China have demonstrated the importance of early fluid resuscitation in the gut leads to better gut perfusion, better gut immune function, less collapse of the intestinal microbiome to pathologic negative rods and yeasts, and then ultimately we, we think that it might reduce the risk of bacterial translocation or bacterial byproduct translocation.

which is one of the leading causes of multisystem organ failure in burn injured patients. Part of this project isn't just learning how to do internal resuscitation and its potential physiologic and operational benefits, but also how do we implement it, and how do we teach non burn experts at first level hospitals or health posts how to do it.

Dr. Yandev, an extraordinary student from New York who worked with us for a

while, who is a specialist in narrative medicine, Worked to help us develop an interoacestation flip book to help train first level hospital non burn specialists in the techniques involved in burn acestation broadly, but interoacestation specifically.

Yeah, it was so wonderful. It was during the collaboration with Harborview. We had had her in Nepal for a couple of weeks. She made it a project to make this flipbook. In Nepal, we are using this flipbook to generate awareness among the participants who attend our burn course, which is spread over six days.

It's a full time course. And then we use that to spread awareness. I'm curious to hear a little bit more about the flipbook. So it's like a physical handout that has things that she learned from talking to burn providers at first level hospitals. How to start the resuscitation, or is it? It's a common training aid that people are used to seeing.

It's usually on cardstock and a trifold that's quite tall, so it sits up on a desk. So you can look at it and teach in real time, looking at the same flipbook

together. We use lots of participatory research methodology. in order to ensure the feedback by end users was incorporated from the design all the way through to the final outcome.

Both in terms of design, metaphors, for instance, people wanted to tie the concept of dehydrated plants, dry plants, to that of the under resuscitated patients with, quote, dry kidneys. In addition, they also wanted very simplified ways to determine if a burn was big or not big, start with cestation or not, as opposed to very specific about TBSA calculations.

So, we used a lot of this feedback very early on to design the flipbook. We tweaked it over time with their input, and then because they feel like true stakeholders in the flipbook in the end, it'll make dissemination to small hospitals much easier. That's awesome. I'm curious if there's been feedback on how things are going with the flipbook.

Are there any studies ongoing to see how it affects outcomes, or are you just hearing from first level providers their experience? Yeah, thank you. We have this burn training course.

It's training of trainers and the participants are mostly health workers, nurses. Before we even had the doctors participate in this training.

We have just started. I think we have covered about three or four groups of them. We have had the flipbook and it's pretty informative because it's illustrative as well and then it has all the instructions. It's a small size book which has been printed and it's in color and it gives them a visualistic idea of how things go.

So it's really, really good. Great, thank you for sharing. What other projects are ongoing or what are, what are the next steps? We have also discovered that as Burns and Burns. affect patients that come from the low socio economic strata, the nutritional status is very poor. And poor nutrition leads to delayed own healing, infection, and also increases mortality rate.

So now the next step is that we are focusing on naturopathic feeding to assess the nutritional status and to build up on the nutrition. So that is the next

project we are trying to work on. So, Dr. Stewart, are there other things you've learned at Curtipur that have changed your practice here at Harborview?

Lots of things, frankly. One is high voltage electrical injuries are much more common in Nepal as people try to tap into the electrical grid. The management styles and how aggressive they are about early wound debridement, management of peripheral nerve function, and coverage of complex soft tissue defects, they do very, very well.

And we've learned a lot from them at Harborview. The second thing is the technical skills of harvesting skin grafts with Humvee knives rather than a Dermatome, and meshing skin grafts by hand rather than with a mesher, which is a very unique skill that is certainly something that's important for us to think about in other low resource settings.

About 80 percent of burn injuries in the world happen due to unsafe cooking arrangements, and we've done population proportional cluster randomized household surveys of households in rural, slum, and urban communities and across the ecological strata of Nepal. One of the things we found was that about One in five

households had active gas leaks and liquid propane gas stoves, and about one in ten households had someone's clothes catch on fire within the last year, which all demonstrates the importance of burn injury prevention.

In the United States, and particularly post COVID, major urban burn centers are seeing about one in four, one in five of their patients are unhoused or living homeless. The reasons that they get injured are quite similar. Unsafe cooking practices, challenges keeping warm in the propane or LPG tank explosions are related to gas leaks.

So a lot of what we learned in Nepal, we're trying to figure out how to incorporate into injury prevention efforts amongst people living unhoused or in encampments here in the United States. So as an example of this twinning experience and global partnership, I wanted to share that Dr. Yadav recorded the first part of this episode by Zoom in Italy as part of a international rotating fellowship there.

The second portion, he was in Nepal recording with us and now we have him sitting with us here in the flesh at Harborview. He's just spent a month with us here.

So I'm curious, Dr. Dab, what you've gotten to see this past month that you want to share. So one thing what I've seen is the proactive approach in burns management and excellent nutritional management.

Even the rounds, the totally detailed patient protocols and recording of all the data and the research and the analysis of wounds. So the standard that is seen here, which I would love to have in the places where it's needed most. Thank you, Dr. Yadav. I really appreciate you being here and taking the time to share your perspective.

I'm curious, is there room for trainees to go to Kharagpur? Do you see any future rotations developing there? Paul, I think it's really important that we send trainees internationally, but done so in an ethical and equitable way. Obviously, you can imagine the ramifications if they're not carefully thought through on how a U.

S. trainee could negatively impact the trainees of a host organization. The medical legal

responsibilities of having a trainee work on or work with patients or providers with conditions or work styles that they're not used to working with. And we want to be sure that we not put our trainees in positions where they are uncomfortable or out of their competence.

So the answer is yes, we should definitely send trainees internationally, but we should do so in a structured way. And the Association of Program Directors in Surgery has a global surgery task force and they surveyed 62 programs. A few findings I think are illustrative of the current trend and what we need to think about when we send trainees internationally.

One in three programs were about a month long. About only a third of those. had a formal curriculum that residents participating in international electives were training within. And that the cost ranged somewhere between around 5, 000 and upwards of 50, 000 for the programs. Importantly, there's lots of interest for programs who don't have global surgery programs to start one.

About 83 percent of those that responded as not having one were interested in starting one. And only four programs had bi directionality built into their training

paradigm. Those that did have faculty supervision, which was very, very rare, faculty from the U. S. institution that is, about half of those were using vacation time or unfunded time.

So, there's still lack of guidelines or criteria that we base global surgery programs on and as we learn how to do this well and how to make impact with our trainees and with trainees from our partnered institutions, yeah, I think sharing those in forums like this as well as publishing that experience so that we can harmonize hopefully at the ACGME and ABS level how global surgery programs are organized.

One of the things we've done in response to concerns about sending trainees internationally early in the residency programs is think more carefully about the relationship between rural surgery in the United States and surgery internationally. Some of the same issues that Dr. Yadnev and I have talked about with regard to access to care and working in lower resource environments and some of the the challenges related to very complex pathologies that often rural providers

and international providers face are, you know, are common in rural America.

The importance of maintaining a general surgery understanding that spans beyond what most urban academic residency programs teach is important so that surgeons that graduate from residency programs across the country can serve populations in rural areas and quite frankly maintain the viability of rural hospitals and rural health systems.

We've developed training programs with the Billings Clinic in Montana, as well as Alaska Native Medical Center in Anchorage, Alaska, so that we can have our trainees learn from American Board of Surgery certified surgeons on how to address the complexity of general surgery so that whether they are in rural America or internationally, they are more clinically adept at managing these complex problems, even if they don't have the breadth of support around them.

What we hope to do is by having strong, broad, general surgery clinicians doing quality improvement projects and health system strengthening initiatives

and research can then turn what's a passion for care, whether it's in rural America or internationally, into ways to provide long term sustained capacity building.

We hope it works. I think time will tell. I'm curious, as medical students look for training programs, or trainees that are currently in residency look for opportunities, or even licensed surgeons look for opportunities, are there organizations you direct us to? Yeah, I think For any of those cadres, having a good mentor and a good ambassador like I have in Dr.

Yadev and his mentor Dr. Shankar Manrai and Dr. Pham here, you know, those relationships and mentorship models are vital. It makes sure that we have connections that are meaningful and are ways to stay connected and to organizations and opportunities over time. And students and residents and other faculty certainly can be connected through networks like that and they exist all around the country for people in the surgical community.

For students, the Global Surgery Student Alliance does a great job identifying mentors for students interested in specific topics

and Creating a network of community of people interested in global surgery. During residency, the American College of Surgeons Resident Associates Society has a global surgery working group that's a home for opportunities, building curriculums, sharing examples of how programs are developed.

For both students and residents interested in research, the Fogarty International Center, And the Fogarty Fulbright program both offer funded one year research opportunities that connect you with a mentor in global surgery dedicated to specific topics. There's lots of different opportunities to get involved with specific projects.

And then once you're involved and you practice as a surgeon, there is an opportunity through the American College of Surgeons Operation Hope. Was Operation Giving Back, but it's Operation Hope more recently, and they have opportunities listed, ways to get involved in education, clinical outreach, and capacity building.

So lots of avenues depending on where you are in your career. As a trainee with some knowledge and skills, but still quite a ways to go before being an independent surgeon. How can I get involved and what key concepts should

learners and surgeons at various points along the way keep in mind as they search for global surgery opportunities?

As I mentioned at the start, Paul, it's really about mentorship and experience. Setting off on your own is rarely successful regardless of our level of training, even people later in their careers. It's easy to actually be a burden on local system if you're not integrated carefully. It's more efficient and effective to be plugged into an existing network.

With a great mentor and be flexible and grow with it over time, but also be strong enough to overcome the barriers and roadblocks that certainly people face working in global health. Lastly, if you and your team prioritize system changes rather than quick fix band aids, it'll be a more rewarding experience that leads to longer lasting partnerships.

Thanks, Dr. Stewart. Manish, what are your take home points for our listeners? As you engage in your partnership project, first of all, you have to be observant, be curious and inquisitive. Also, at the same time,

be respectful of local values. Then you need to integrate within the local system, collaborate and focus on locally derived projects.

And when you are able to integrate well and form a responsive team, then you can innovate. Develop contextually relevant projects with local partners to strengthen the health system. So in a nutshell, it would be observe, integrate, innovate. Thank you all for listening. Until next time, dominate the day.