2005 & Older Publications
-Overseas Volunteering: The Antidote to Managed Care.
-Overseas Volunteerism in Orthopedic Education.
-Surgical Care in a Public Health Framework.
Education and Training of the Future Trauma Surgeon in Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery.
Spain D.A. and Miller F.B. Education and Training of the Future Trauma Surgeon in Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery. American Journal of Surgery, April 2005: Vol. 190, pp. 212-217.
Abstract
Trauma surgery as a specialty in the United States is at a crossroads. Currently, less than 100 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. In order for the field to flourish, the training of future trauma surgeons must be modified to compensate for these changes. Recent medical literature regarding the training of trauma surgeons and report of the Future of Trauma Surgery/Trauma Specialization Committee of the American Association for the Surgery of Trauma. The new post-graduate trauma training fellowship of the future should be built on a foundation of general surgery. The goal of this program will be to train a surgeon with broad expertise in trauma, critical care, and emergency general surgery. This new emphasis on non-trauma emergency surgery required an image change and thus a new name; Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery.
2001 Gujarat Earthquake Experience in a Seismically Unprepared Area. The Analysis of the Medical Response at a Community Hospital.
Roy N., Shah H., Patel V., Coughlin,R. 2001 Gujarat Earthquake Experience in a Seismically Unprepared Area. The Analysis of the Medical Response at a Community Hospital. Prehospital Disaster Medicine, 2002, Vol. 17, Issue 4, pp. 186-195.
Abstract
At 08:53 hours on 26 January 2001, an earthquake measuring 6.9 on the Richter scale devastated a large, drought-affected area of northwestern India, the state of Gujarat. The known number killed by the earthquake is 20,005, with 166,000 injured, of whom 20,717 were "seriously" injured. About 370,000 houses were destroyed, and another 922,000 were damaged. A community health worker using the local language interviewed all of the patients admitted to the Gandhi-Lincoln hospital with an on-site, oral, real-time, Victim Specific Questionnaire (VSQ). The census showed a predominance of women, children, and young adults, with the average age being 28 years. The majority of the patients had other family members who were also injured (84%), but most had not experienced deaths among family members (86%). Most of the patients (91%) had traveled more than 200 kilometers using their family cars, pick-ups, trucks, or buses to reach the buffer zone hospitals. The daily hospital admission rate returned to pre-event levels five days after the event, and all of the hospital services were restored by nine days after the quake. Most of the patients (83%) received definitive treatment in the buffer zone hospitals; 7% were referred to tertiary-care centers; and 9% took discharge against medical advice. The entrapped village folk with their traditional architecture had lesser injuries and a higher rescue rate than did the semi-urban townspeople, who were trapped in collapsed concrete masonry buildings and narrow alleys. However, at the time of crisis, aware townspeople were able to tap the available health resources better than were the poor. There was a low incidence of crush injuries. Volunteer doctors from various backgrounds teamed up to meet the medical crisis. International relief agencies working through local groups were more effective. Local relief groups needed to coordinate better. Disaster tourism by various well-meaning agencies took a toll on the providers. Many surgeries may have contributed to subsequent morbidity. The injury profile was similar to that reported for most other daytime earthquakes. Buffer zone treatment outcomes were better than were the field and damaged hospital outcomes.
The University of California San Francisco Orthopedic Residency Elective in International Volunteerism.
Haskell A., Rovinsky D., Brown H., Coughlin R.R. The University of California San Francisco Orthopedic Residency Elective in International Volunteerism. CORR Vol. 396, March 2002
Abstract
International volunteerism helps remedy global inequities in orthopaedic care and provides relief for increasing professional disillusionment experienced by many orthopaedic surgeons in the United States. From 1992 to 1998, 41% of residents from the Department of Orthopaedic Surgery at the University of California, San Francisco volunteered overseas. Approximately one half of those have continued volunteering internationally after residency, including many who led later trips with residents. Based on the success of these trips, the University of California, San Francisco Department of Orthopaedic Surgery established a 1-month elective rotation in Umtata, South Africa in conjunction with Orthopaedics Overseas. Seventy-six percent of residents have chosen this opportunity since the program's inception in 1998. The University of California, San Francisco experience suggests that early exposure to international volunteerism during residency promotes continued participation in volunteer activities after graduation. By providing residents with the opportunity to volunteer overseas, the University of California, San Francisco hopes to enhance resident education, foster a lifelong spirit of volunteerism, and serve as a model for other orthopaedic training programs.
Overseas Volunteering: The Antidote to Managed Care.
Coughlin R.R. Overseas Volunteering: The Antidote to Managed Care. Hospital Physician, June 2000, pp. 67-70.
Link: http://turner-white.com/pdf/hp_jun00/overseas1.pdf
Abstract
On a flight to Johannesburg, South Africa for my 15th overseas volunteer trip as a physician—I finally connected with a defining image of my childhood. The woman sitting next to me on the airplane, whom I would later discover was a nurse going to Malawi, was reading Out of My Life and Thought by Albert Schweitzer.1 I vividly remembered being in third grade listening to my teacher lecture about this great 20th- century physician. The African pictures spoke of adventure, history, and exotic lands, but I was challenged by the deeper sense of humanitarianism. These elements continue to motivate me in my present passion for overseas volunteerism.
Overseas Volunteerism in Orthopedic Education.
Rovinsky D., Brown H.P., Coughlin R.R., et. al. Overseas Volunteerism in Orthopedic Education. Journal of Bone and Joint Surgery, March 2000, Vol. 82-A, Issue 3, pp. 433-436.
Abstract
We are entering a critical time in health care, when an increasing number of surgeons are becoming disillusioned with the practice of medicine. We are facing increasing patient-care demands with decreasing rewards. It has been shown that physicians who are involved in managed care, or who practice in areas with a high level of managed-care penetration, provide less charity care1. Encouraging early participation and decreasing the barriers are crucial to creating a culture of physician volunteerism5.
At the University of California, San Francisco, a program has been established to expose orthopaedic residents to an overseas volunteer experience during their training with the hope that they will continue involvement in such experiences throughout their careers. In this report, we discuss the need for increasing volunteerism in orthopaedic surgery and review the history of the overseas volunteer program at the University of California, San Francisco.
Cost/DALY Averted in a Small Hospital in Sierra Leone: What Is the Relative Contribution of Different Services?
Richard A. Gosselin, MD, MPH, MSc, Amardeep Thind, MD, PhD, Andrea Bellardinelli, BA. Cost/DALY Averted in a Small Hospital in Sierra Leone: What Is the Relative Contribution of Different Services?
Abstract
A cost-effective analysis (CEA) can be a useful tool to guide resource allocation decisions. However, there is a dearth of evidence on the cost/disability-adjusted life year (DALY) averted by health facilities in the developing world. We conducted a study to calculate the costs and the DALYs averted by an entire hospital in Sierra Leone, using the method suggested by McCord and Chowdhury (Int J Gynaecol Obstet 2003;81:83–92). For the 3-month study period, total costs were calculated to be $369,774. Using the approach of McCord and Chowdhury, we calculated that 11,282 DALYs were averted during the study period, resulting in a cost/DALY averted of $32.78. This figure compares favorably to other non-surgical health interventions in developing countries. We found that while surgery accounts for 63% of total caseload, it contributes to 38% of the total DALYs averted. Surgical treatment of some common pathologies in developing countries may be more cost-effective than previously thought, and our results provide evidence for the inclusion of surgery as part of the basic public health armamentarium in developing countries. However, these results are highly context-specific, and more research is needed from developing countries to further refine the methodology and analysis.
The Burden of Musculoskeletal Injury in Low and Middle Income Countries: Challenges and Opportunities.
David A. Spiegel MD, Richard A. Gosselin MD, R. Richard Coughlin, M.D., & Manjul Joshipura MD, Bruce D. Browner MD, Meena N. Cherian MD, Steven W. Bickler MD, and John P. Dormans, MD. The Burden of Musculoskeletal Injury in Low and Middle Income Countries: Challenges and Opportunities.
Abstract
Over the past few decades, in association with global economic development, the world has witnessed an epidemiologic transition in which there has been a decrease in the burden of communicable (and vaccine preventable) diseases and an increase in the burden of noncommunicable or “man made” diseases. The global burden of injury is substantial, and injuries are predicted to be a leading cause of death and disability over the next few decades. The majority of this burden will be borne by low and middle income countries, where preventive strategies are often nonexistent, and barriers to the timely and appropriate care of the injured include absent or inefficient systems for the delivery of trauma care, inadequacies in the number and the distribution of health care facilities and workers, lack of infrastructure and/or physical resources, and a lack of education and training. While surgery has previously been viewed as a high cost treatment lying outside the realm of the traditional public health model, surgical and anaesthetic services are now recognized as public health interventions aimed at the prevention of death and disability. Addressing the burden of injury in low and middle income countries has become a public health priority, and while the ultimate solution is prevention, the provision of high quality, low cost treatment is essential. This goal can only be realized by a “systems approach”, with improvements in both prehospital care and definitive care when the patient reaches a treatment facility. Our challenge as orthopaedic surgeons, in association with other stakeholders, is to design and promote effective strategies for the treatment (nonoperative and operative) of musculoskeletal injuries within these resource challenged environments. The most relevant concept is that of “essential services”, which are low cost, high yield, target major health problems, and can realistically be made available to every person in the world.
The goals for this review are the following: 1.) to provide the orthopaedic community with a “public health” perspective on the burden of injury in low and middle income countries, 2.) to consider a proactive role in advocacy to strengthen delivery of orthopaedic care globally, 3.) to characterize deficiencies in the number, distribution, and training of health workers worldwide, 4.) to provide an update on teaching/training in resource challenged environments, and 5.) to discuss information flow between economically developed and underdeveloped regions.
Orthopaedics Overseas/Health Volunteers Overseas: Building Infrastructure to Lessen Musculoskeletal Trauma Burden.
R. Richard Coughlin MD, MSc, Nancy A. Kelly MPH. Orthopaedics Overseas/Health Volunteers Overseas: Building Infrastructure to Lessen Musculoskeletal Trauma Burden.
Abstract
The impact and burden of injuries, generally, and musculoskeletal trauma, in particular, has been steadily increasing and broadly challenges an effective response from ministries of health, international societies, NGOs, and country-specific as well as globally involved academia.(1) Because of its multifactoral determinants, management and sequelae, musculoskeletal trauma requires more integrated, multidisciplinary approaches that are site and context specific.
Increasingly recognized, the significant barrier to delivery of appropriate healthcare is the inadequate availability of healthcare workers, estimated at over a million deficit in Africa alone. (2) Africa faces the greatest challenge of any region of the world - with 11% of the world’s population and 24% of the global burden of disease; it has only 3% of the world’s health workers and less than 1% of the healthcare expenditure. (3) With the advent of political will and supply of international funding for antiretrovirals, insufficient numbers of trained personnel and poor infrastructure surfaced as the main determinant for unsuccessful implementation of this strategy. Similarly, an effective response to lessening burden of musculoskeletal trauma and injury will require capacity-building especially with appropriately trained healthcare workers along with systems development which will include essential skills in administration and management.
Addressing global healthcare delivery, Orthopaedics Overseas is the founding division of Health Volunteers Overseas, a private non-profit organization dedicated to improving the availability and quality of health care in developing countries through the education of local health care providers. With its emphasis on teaching and training programs, and philosophy of “Teach a man to fish…”, Orthopaedics Overseas has addressed the enormous need for capacity-building of skilled musculoskeletal healthcare workers in the developing world. (4).
Surgical Care in a Public Health Framework.
Haile T. Debas MD, Richard Gosselin MD, MPH, Colin McCord MD, Amardeep Thind MD, PhD. Surgical Care in a Public Health Framework.
Abstract
Surgical care has not been considered a public health priority in developing countries. Yet surgically treatable conditions, such as cataracts (Javitt Jc, 1993; Liu HS et al, 1997; Maurice J, 2001; Shamanna BR et al, 1998), obstructed labor (Nelson JP, et al 2003), symptomatic hernias (RahmanGA, et al 2000; Olumide F et al 1976), osteomyelitis (Brickler et al 2002; Hilton P 2003), obits media (Whitney CG et al, 2002; Smith A, et al 1992) and various other inflammatory conditions develop into chronic conditions of ill health. These chronic conditions take a serious human and economic toll and at times lead to acute, life-threatening complications Inadequacies in the initial care of injured patients (Jat AA 2004; Hyder AA 2003; Mock C 2003; Mock C et al, 1995) and of women with obstructed labor and children with treatable congenital anomalies, such as clubfoot ( Ponsetti IV, 1996; Turco V, 1994) lead to preventable deaths and/or to chronic disabilities that negate productive employment and impose dependency on family members and society. The role of surgery as a preventive strategy in public health needs to be studied and measured.
The inclusion of a surgery chapter in this book is recognition that surgical services may have cost- effective role in population- based health care. Recent studies (McCord and Chowdhury 2003) have shown that basic hospital service, which requires no sophisticated care can be cost effective, with a cost per DALY that is much lower than would have been intuitively expected, and barely higher than estimates for other well accepted preventive procedures such as immunization for measles and tetanus, and home care for lower respiratory infection. (Armandola E, 2003; Dayan GH et al, 2004; Maolosi G et al, 2003; Ruff TA, 1999.)
