Preparation: The IHCV team transports all surgical supplies

1
General Surgery Resident Elective in Kumasi,
Ghana Sharita Nagaraj 1 1Department of
Surgery, Robert Wood Johnson Medical School,
Piscataway, NJ 08854
Conclusions Surgical residents gain considerable
benefit from international electives in
developing countries. These electives teach
residents cost-effective management, basic
surgical technique, improve clinical acumen, and
introduce them to the world of global public
health, where surgery is increasing its presence
as an important issue. Future efforts can be
expanded to include bidirectional exchanges and
training of local surgeons to improve access to
surgical care. Challenges include a lack of
political and economic support for systems
improvement but can be overcome by collaboration
between non-profit governmental organizations and
ministries of health, as well as increased
support and funding from international health
organizations.

• Preparation The IHCV team transports all
  surgical supplies drapes, gowns, gloves,
  suture, instruments, mesh, drains, etc. and
  medications that will be required for the
  mission. Residents are involved in packing for
  the mission so they learn to anticipate equipment
  and supply needs for various operations. These
  supplies are stored and inventoried upon arrival
  and upon departure (seen below), with extra items
  donated to the hospital.
• Residents learn to ration these supplies for the
  expected number of cases during the mission,
  picking only what is necessary for each case.
  Certain items which are usually deemed
  disposable in the United States may be reused
  after chemical sterilization, such as bovie
  electrocautery, drapes, and suction tubing.

• Introduction
• Surgery has long been neglected in the global
  public health arena 1, but evidence is accruing
  for the enormous global burden of surgical
  disease 2. At the same time, interest has been
  growing among both practicing and future
  surgeons-in-training to improve access to
  surgical care in developing countries. A national
  survey administered to resident members of the
  American College of Surgeons showed that 92 of
  respondents would be interested in an
  international elective during residency, and 85
  plan to offer volunteer services during their
  future practice 3. Several formal, structured
  international surgery rotations have been
  implemented within U.S. surgical residencies, and
  other fellowship and volunteer opportunities for
  global surgery are emerging 4.

• Productivity During the 2012 IHCV mission, we
  performed 6 inguinal hernia repairs, one in a
  pediatric patient, 1 umbilical hernia repair, 4
  skin and soft tissue excisions, 1 thyroidectomy,
  and 1 laparoscopic cholecystectomy at KNUST
  hospital. One laparoscopic cholecystectomy had to
  be aborted to due lack of carbon dioxide for
  insufflation. Our productivity was limited
  compared to prior missions due to an
  unanticipated nurses strike which reduced the
  availability of operating room, recovery room,
  and inpatient staffing, but we were able to
  complete some work with the help of local
  volunteers.
• Pathology International electives offer
  residents exposure to a broader range of
  pathology such as hydatidosis, salmonella typhi
  intestinal perforations, and advanced stage
  malignancies and hernias.
• During our mission, inguinal hernias were the
  most common pathology we encountered. Due to
  limited access to surgical services, asymptomatic
  juvenile hernias, which are typically repaired in
  Western populations, often develop into large,
  chronically incarcerated hernias containing
  omentum, small or large bowel, or bladder. They
  present a significant surgical dilemma due to the
  loss of abdominal domain, especially in Ghanian
  patients who have a thin body habitus. We
  performed the majority of inguinal hernia repairs
  with mesh, however local surgeons usually do not
  use mesh in their repairs as it is a costly
  resource not widely available in the country.

Background In 2012 the General Surgery Residency
Review Committee implemented criteria for ACGME
approval of international general surgery
electives. The Robert Wood Johnson general
surgery residency program has obtained this
approval for a PGY-3 or above to participate in
the annual mission with International Healthcare
Volunteers (IHCV) and each year one of our
residents has traveled with the group to help
provide surgical services while learning about
healthcare delivery in a developing country. Here
we present the results of our two-week experience
in September 2013 at Kwame Nkrumah University Of
Science Technology (KNUST) hospital in Kumasi,
Ghana. KNUST hospital (seen below) is the main
teaching hospital in its region and a high volume
center providing medical, surgical, and
obstetrical services for over 200,000 people in
30 surrounding communities. Two operating room
theatres are available as well as anesthetic,
radiologic, and lab services. Patients in need of
ICU care are transferred to the nearby Cape Coast
Hospital.

• References
• 1. Farmer PE, Kim JY. Surgery and global health
  a view from beyond the OR. World J Surg
  200832533-6.
• 2. Ozgediz D, Jamison D, Cherian M, McQueen K.
  The burden of surgical conditions and access to
  surgical care in low- and middle-income
  countries. Bull World Health Organ 200886646-7.
• 3. Powell AC, Casey K, Liewehr DJ, Hayanga A,
  James TA, Cherr GS. Results of a national survey
  of surgical resident interest in international
  experience, electives, and volunteerism. J Am
  Coll Surg 2009208304-12.
• Leow JJ, Kingham TP, Casey KM, Kushner AL. Global
  surgery thoughts on an emerging surgical
  subspecialty for students and residents. J Surg
  Educ 201067143-8.

Resident Clinical Experience All surgical
residents participate in outpatient activities
that include a complete pre-operative evaluation
of all patients who will undergo surgery during
the time period of the rotation. Outpatient
encounters take place in the OR holding area as
well as in the medical clinic when surgical
consults are requested. Residents assist with
surgeries under the mentorship of a U.S.
board-certified or board eligible surgeon in
collaboration with local surgeons and staff.
Lastly, patients requiring an inpatient stay
postoperatively are seen on morning and afternoon
rounds (seen below).