Non-Doctors as Trauma Surgeons? A Controlled Study of Trauma Training for Non- Graduate Surgeons in Rural Cambodia

Introduction:Due to the accelerating global epidemic of trauma, efficient and sustainable models of trauma care that fit low-resource settings must be developed. In most low-income countries, the burden of surgical trauma is managed by non-doctors at local district hospitals. Objective: This study examined whether it is possible to establish primary trauma surgical services of acceptable quality at rural district hospitals by systematically training local, non-graduate, care providers. Methods: Seven district hospitals in the most landmine-infested provinces of Northwestern Cambodia were selected for the study. The hospitals were referral points in an established prehospital trauma system. During a four-year training period, 21 surgical care providers underwent five courses (150 hours total) focusing on surgical skills training. In-hospital trauma deaths and postoperative infections were used as quality-of care indicators. Outcome indicators during the training period were compared against pre-intervention data. Results: Both the control and treatment populations had long prehospital transport times (three hours) and were severely injured (median Injury Severity Scale Score = 9). The in-hospital trauma fatality rate was low in both populations and not significantly affected by the intervention. The level of post-operative infections was reduced from 22% to 10.3% during the intervention (95% confidence interval for difference 2.8–20.2%). The trainees’ selfrating of skills (Visual Analogue Scale) before and after the training indicated a significantly better coping capacity. Conclusions: Where the rural hospital is an integral part of a prehospital trauma system, systematic training of non-doctors improves the quality of trauma surgery. Initial efforts to improve trauma management in low-income countries should focus on the district hospital. Heng YV, Davoung C, Husum H: Non-doctors as trauma surgeons? A controlled study of trauma training for non-graduate surgeons in rural Cambodia. Prehospital Disast Med 2008;23(6):483–489. Background The epidemic of trauma is accelerating. Currently, injury is the fourth leading cause of global deaths, and the World Health Organization (WHO) estimates a 40% increase in global deaths from injury from now to 2030. Approximately 75% of trauma fatalities occur in low-income countries.1,2 Who will manage this heavy trauma load during disasters and chronic emergencies such as the landmine epidemic? Studies of Western trauma scenarios consistently report that Level-1 Trauma Centers and reduced prehospital transport times are essential components of a good trauma care system.3,4 However, high-cost surgical centers are not feasible in countries in which the majority of citizens live in rural areas with poor communication systems and high prehospital transit times. Lowcost, prehospital trauma systems reduce trauma mortality in such settings.5 However, this leaves the question open: who should provide primary surgery to the prehospital survivors? One option is to establish Western-model surgi-