Global Burn Care

Burns are an often-overlooked health indicator in global health literature, but account for a significant global health burden in lower middle income countries. This article provides an overview of burn injury from the global health perspective. It focuses on education and research, emphasizing the appropriate role of volunteerism.

Key points

  • Burns account for a significant proportion of global health morbidity and mortality, most significantly in low and middle income countries (LMICs).

  • Global health initiatives should focus on education and research initiatives that facilitate sustainable collaborations between high income countries (HICs) and LMICs.

  • Short term medical service trips should be carried out for a specific purpose at the request of a local provider within an educational framework that promotes bidirectional exchange and includes appropriate postoperative follow-up.

  • Telemedicine is an underused technology that can improve medical care and educational collaborations.

Background

Burns are an often-overlooked health indicator in global health literature, but account for a significant global health burden in lower middle income countries (LMICs). The World Health Organization (WHO) estimates that approximately 11 million individuals required medical attention for burns in 2004, with an estimated 265,000 deaths annually. Most burns and deaths caused by burns occur in LMICs. There are 7 times as many burn-related deaths in children in LMICs compared with high-income countries (HICs). Burns are among the leading causes of disability-adjusted life years in LMICs; morbidity associated with nonfatal burns results in physical disability and societal stigma.

Burn care can be divided into acute and secondary treatment. Acute treatment involves intensive medical management and resuscitation of patients with burns as well as acute surgical treatment, including escharotomy, fasciotomy, and early excision and grafting. Team care is especially important in acute management and requires an interdisciplinary approach with physicians, intensivists, anesthesiologists, nurses, nutritionists, physical and occupational therapists, respiratory therapists, and pharmacists, among others. Secondary burn reconstruction involves contracture release and includes skin grafting, adjacent tissue transfer, tissue expansion, and flaps. Secondary burn care also requires a team approach, especially with regard to wound care, physical and occupational therapy, splinting, and psychological support.

There is a great imbalance in the distribution of plastic surgery services between HICs and LMICs. For example, there is an estimated 1 plastic surgeon per 57,000 people in the United States and Canada versus 3 plastic surgeons in the entire country of Malawi, with a population of 16.4 million. This imbalance leaves a large unmet surgical need for acute and secondary burn care. This article presents exchange models that facilitate collaboration between plastic surgeons from HICs and LMICs to improve access and quality of burn care in LMICs.

Background

Burns are an often-overlooked health indicator in global health literature, but account for a significant global health burden in lower middle income countries (LMICs). The World Health Organization (WHO) estimates that approximately 11 million individuals required medical attention for burns in 2004, with an estimated 265,000 deaths annually. Most burns and deaths caused by burns occur in LMICs. There are 7 times as many burn-related deaths in children in LMICs compared with high-income countries (HICs). Burns are among the leading causes of disability-adjusted life years in LMICs; morbidity associated with nonfatal burns results in physical disability and societal stigma.

Burn care can be divided into acute and secondary treatment. Acute treatment involves intensive medical management and resuscitation of patients with burns as well as acute surgical treatment, including escharotomy, fasciotomy, and early excision and grafting. Team care is especially important in acute management and requires an interdisciplinary approach with physicians, intensivists, anesthesiologists, nurses, nutritionists, physical and occupational therapists, respiratory therapists, and pharmacists, among others. Secondary burn reconstruction involves contracture release and includes skin grafting, adjacent tissue transfer, tissue expansion, and flaps. Secondary burn care also requires a team approach, especially with regard to wound care, physical and occupational therapy, splinting, and psychological support.

There is a great imbalance in the distribution of plastic surgery services between HICs and LMICs. For example, there is an estimated 1 plastic surgeon per 57,000 people in the United States and Canada versus 3 plastic surgeons in the entire country of Malawi, with a population of 16.4 million. This imbalance leaves a large unmet surgical need for acute and secondary burn care. This article presents exchange models that facilitate collaboration between plastic surgeons from HICs and LMICs to improve access and quality of burn care in LMICs.

Education and research

Research and education go hand in hand to fulfill the United Nations Development Program capacity development objectives and play a central role in realizing the goals of the Paris Declaration and Accra Agenda for Action. These development roadmaps underscore that neither education nor research alone is sufficient to effect lasting change in a health care system. The United Nations Development Program states that capacity development must go beyond education and training to also understand the institutions and systems within which local providers operate. By recognizing the primary role that LMIC providers play in identifying areas of clinical improvement, HIC institutions can act as valuable partners to support research and educational efforts to improve access and quality of care.

Education Initiatives

The Lancet Commission has identified continuing medical education as a central facet for the development of a sustainable workforce in LMICs. The report outlines the important role that national health ministries and professional societies in LMICs play in providing this training. It also highlights the need for basic infrastructure to foster a productive educational environment, including Internet access, clinical practice resources, and access to textbooks and scientific literature. The report also points out that regional and international educational exchanges can provide valuable learning opportunities for LMIC surgeons. These bidirectional educational exchanges between HICs and LMICs seek to identify areas of need and use expertise and resources from both partners to create learning opportunities.

There are several established global health partnerships that have facilitated collaborations between plastic surgeons from HICs and LMICs. The American Council of Academic Plastic Surgeons (ACAPS) and the Plastic Surgery Educational Network (PSEN) have partnered to create the ACAPS/PSEN Global Health Scholarship for trainees in resource-limited settings. These scholarships provide access to the PSEN online resident education resources. In addition, regional collaborations allow medical students and residents to pursue postgraduate training that is not available in their home countries. International educational partnerships include the National Institutes of Health–backed Medical Education Partnership Initiative and the Research Training for Career Development of Junior Faculty programs. These programs seek to support medical education and research for African trainees with the goal of building clinical and research infrastructure. Other, smaller scale, educational exchanges are sponsored by HIC training institutions or organizations and help to provide tuition stipends for LMIC surgeons to complete advanced degrees and training in HICs that are not available in their home countries.

Nonprofit plastic surgery organizations can also support international educational collaborations. ReSurge International, formerly Interplast, in partnership with International Medical Corps, has established an international burn program that focuses on prevention, training, and advocacy. The organization has acute and chronic burn care treatment centers in LMICs. In addition, ReSurge International focuses on capacity development in LMICs by providing educational resources to local burn providers. This approach allows ReSurge International to form educational partnerships between LMIC and HIC plastic surgeons to provide comprehensive burn care to patients in resource-limited settings.

Individual HIC academic institutions can also partner with LMIC institutions to offer exchanges for trainees from both institutions and facilitate bidirectional learning. The Accreditation Council for Graduate Medical Education (ACGME) has established guidelines for international rotations. ACAPS has followed suit by promoting formal global health rotations within residency training programs. Current surveys of United States plastic surgery residency programs estimate that 64% of programs sponsor overseas short-term medical service trips (MSTs) and 41% of programs have a global health curriculum. The University of Wisconsin Division of Plastic Surgery has a 24-year partnership with the Universidad Nacional Autonoma de Nicaragua that provides educational exchanges with plastic surgery trainees in Nicaragua and the University of Wisconsin and assists with plastic surgery treatment in Nicaragua. The program has created a global health curriculum that encourages development of culturally sensitive and resource-conscious trainees. The University of Southern California partnered with Operation Smile to create the Tsao Fellowship, a 2-year fellowship program for plastic surgery residents. The program has 3 focuses: clinical research, international surgical experience, and a Master of Science in Clinical and Biomedical Investigations. Tsao fellows benefit from long-term international partnerships and an immersive educational and research experience at home and abroad.

There are well-established educational and professional benefits for HIC trainees who volunteer their time in resource-limited settings. Studies have shown a positive correlation between volunteering during training and later volunteering or practice in underserved settings. The authors found that surgeons who volunteered were 6 times more likely to have volunteered in medical school and 22 times more likely to have volunteered in residency ( Table 1 ). In addition, studies have also found that trainees gain technical skills while volunteering abroad. Campbell and colleagues reported that international volunteer trips not only promote professionalism and cultural sensitivity but also fulfill all 6 core competencies as set forth by the ACGME.

Table 1
Predictors of volunteering
Never Participated in MST as Attending (%) Participated in MST as Attending (%) OR (95% CI) P Value
Medical School
Never volunteered in medical school 40.0 60.0 Reference
Volunteered in medical school 9.8 90.2 6.12 (3.36, 12.31) <.001
Residency
Never volunteered in residency 53.5 46.5 Reference
Volunteered in residency 4.9 95.1 22.30 (12.87, 42.08) <.001
Abbreviations: CI, confidence interval; OR, odds ratio.

The authors’ research on international volunteerism among ASPS members shows that quality markers on international educational exchanges with residents are, overall, higher. Trips with residents and without residents had high use of follow-up care, medical records, and host affiliation ( Fig. 1 ). Trips with residents had higher use of international safety surgery guidelines and improved scope of practice compared with trips without residents. In addition, surgeons who traveled with residents on international trips were 3 times more likely to report the use of any anesthesiologist. Children were 3 times more likely to be cared for by a pediatric anesthesiologist on international trips with residents compared with trips without residents. However, surgeons who reported bringing residents on trips were 2 times more likely to report a death or major complication on any trip. This finding must be interpreted with caution, because it is not known whether this finding is caused by more accurate reporting, riskier cases, or resident involvement.

Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Global Burn Care
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