Dr. Lin is a cardiothoracic surgeon and clinical assistant professor in the Department of Cardiothoracic Surgery at Stanford University School of Medicine. She provides the complete spectrum of surgical care for cardiac conditions, including ischemic heart disease, structural heart disease, aortic disease, and arrhythmias.
Dr. Lin's research is focused on surgical education and global disparities in surgical care. She obtained her Master of Public Health from the Harvard School of Public Health. Her research aims to decrease barriers and disparities in surgical care, including in low and middle income settings.
- Cardiothoracic Surgery
Clinical Assistant Professor, Cardiothoracic Surgery
Member, Cardiovascular Institute
Fellowship: Univ of Colorado Cardiothoracic Surgery Fellowship (2022) CO
Board Certification: American Board of Surgery, General Surgery (2020)
Residency: University of Colorado General Surgery Residency Program (2019) CO
Master of Public Health, Harvard School of Public Health (2017)
Medical Education: University of Colorado School of Medicine (2012) CO
GlobalSurgBox: A Portable Surgical Simulator for Surgical Trainees Worldwide.
Journal of surgical education
Identify barriers to surgical simulation in multiple countries across the income spectrum. Evaluate whether a novel, portable surgical simulator (GlobalSurgBox) would be valuable to surgical trainees and overcome these barriers.Trainees from high-, middle-, and low-income countries were instructed on how to perform surgical skills using the GlobalSurgBox. Participants were sent an anonymized survey after 1 week to evaluate practicality and helpfulness of the trainer.Academic medical centers in 3 countries: USA, Kenya, and Rwanda.48 medical students, 48 surgery residents, 3 medical officers, and 3 cardiothoracic surgery fellows.99.0% of respondents agreed surgical simulation was an important aspect of surgical education. Despite 60.8% having access to simulation resources, only 3 of 40 (7.5%) US trainees, 2 of 12 (16.7%) of Kenyan trainees, and 1 of 10 (10.0%) Rwandan trainees used these resources routinely. 38 (95.0%) US trainees, 9 (75.0%) Kenyan trainees, and 8 (80.0%) Rwandan trainees with access to simulation resources stated there were barriers to using them. The frequently cited barriers included lack of convenient access and lack of time. After using the GlobalSurgBox, 5 (7.8%) US participants, 0 (0%) Kenyan participants, and 5 (38.5%) Rwandan participants reported lack of convenient access as a continued barrier to simulation. 52 (81.3%) US trainees, 24 (96.0%) Kenyan trainees, and 12 (92.3%) Rwandan trainees stated the GlobalSurgBox was a good facsimile of the operating room. 59 (92.2%) US trainees, 24 (96.0%) Kenyan trainees, and 13 (100%) Rwandan trainees stated the GlobalSurgBox better prepared them for clinical settings.A majority of trainees across all 3 countries reported multiple barriers to simulation in their current surgical training. The GlobalSurgBox eliminates many of these barriers by providing a portable, affordable, and realistic way to practice skills needed in the operating room.
View details for DOI 10.1016/j.jsurg.2023.01.012
View details for PubMedID 36797147
Developing a Comprehensive Surgical Simulation Program for Medical Students in the Rwandan Context
LIPPINCOTT WILLIAMS & WILKINS. 2022: S109
View details for DOI 10.1097/01.XCS.0000893784.64464.67
View details for Web of Science ID 000867889300200
Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults
LIPPINCOTT WILLIAMS & WILKINS. 2022: S261-S262
View details for DOI 10.1097/01.XCS.0000895064.04678.10
View details for Web of Science ID 000867889300519
Insights from the thoracic surgery residents association early-career development series.
2022; 10: 298-302
View details for DOI 10.1016/j.xjon.2022.02.021
View details for PubMedID 36004214
Development of a Modular and Equitable Surgical Simulator
GLOBAL HEALTH-SCIENCE AND PRACTICE
2022; 10 (3)
There is a tremendous need for affordable and accessible surgical simulators in the United States and abroad. Our group developed a portable, modular, inexpensive surgical simulator designed for all levels of surgical trainees, from medical students to cardiothoracic surgery fellows, and adaptable to a variety of surgical specialties. Our goal is to provide a platform for innovative surgery simulation that applies to any learner or resource setting. We describe the development, assembly, and future directions for this simulator.
View details for DOI 10.9745/GHSP-D-21-00744
View details for Web of Science ID 000821906400001
View details for PubMedID 36332075
View details for PubMedCentralID PMC9242608
Noteworthy Cardiac Literature From 2021: Coronary Guideline Change Without New Data, Heart Transplant Donation After Cardiac Death, Covid Effects on Global Cardiac Surgery, and Attempt to Improve Dissection Remodeling
SEMINARS IN CARDIOTHORACIC AND VASCULAR ANESTHESIA
2022; 26 (2): 154-161
Cardiac surgery continues to evolve. The last year has been notable for many reasons. The guidelines for coronary revascularization introduced significant discord. The pandemic continues to affect the care on a global scale. Advances in organ procurement and dissection care move forward with better understanding and better technology.
View details for DOI 10.1177/10892532221101298
View details for Web of Science ID 000805344400001
View details for PubMedID 35591803
Triple-branched stent graft for acute non-A, non-B dissection: an interesting step, but is it forward?
The Annals of thoracic surgery
View details for DOI 10.1016/j.athoracsur.2021.12.048
View details for PubMedID 35051390
Surgical management of a collateral arch channel and aortic coarctation
JOURNAL OF CARDIAC SURGERY
2022; 37 (2): 445-448
The atretic connection between the left fourth and sixth aortic arches is a rare congenital cardiac anomaly with controversial debates on its origin. This anatomy has been previously reported with additional cardiac anomalies of maldevelopment.We present the successful surgical management of a 3-month-old female with Cornelia de Lange syndrome and coarctation of the aorta in the setting of this unique collateral channel.We review the beneficial utility and novelty of three-dimensional computed tomography angiography for this anatomic lesion while also discussing the importance of multidisciplinary preoperative planning in the coordinated management of this arch anomaly and potential concomitant comorbid conditions.The presented surgical case demonstrates the successful reconstruction of the aortic arch by coarctectomy with extended end-to-end anastomosis by a left posterolateral thoracotomy in a patient with a collateral arch channel and a hemodynamically significant aortic coarctation.Atretic connection between the left fourth and sixth aortic arches remains a rare congenital anomaly and may occur in the setting of an aortic coarctation. Unclear arch anatomy and indeterminant proximal aortic sizing on echocardiogram should prompt cross-sectional imaging with computed tomography angiography to guide surgical technique selection for aortic arch reconstruction when a collateral arch channel or unique branching pattern is suspected.
View details for DOI 10.1111/jocs.16135
View details for Web of Science ID 000717310500001
View details for PubMedID 34766377
Factors Affecting Attrition in Cardiothoracic Surgery: Survey of North American General Surgery Trainees
ELSEVIER SCIENCE INC. 2021: S41-S42
View details for Web of Science ID 000718303100055
Neonatal heart transplant outcomes: A single institutional experience
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2021; 162 (5): 1361-1368
Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years.A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease.A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively.Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.
View details for DOI 10.1016/j.jtcvs.2021.01.033
View details for Web of Science ID 000751742800014
View details for PubMedID 34099271
Operative intervention for a central pulmonary artery pseudoaneurysm
JOURNAL OF CARDIAC SURGERY
2021; 36 (12): 4762-4765
Pulmonary artery (PA) pseudoaneurysms are a rare but potentially lethal diagnosis. They can be further categorized by etiology or location and are typically successfully treated with endovascular therapies. However, they occasionally require operative intervention. Here, we present a case of a patient who presented with a central PA pseudoaneurysm on computed tomography scan with unclear etiology that was initially treated with conservative management. However, this was noted to have rapid enlargement on interval imaging necessitating urgent surgical intervention. The patient underwent a median sternotomy, anterior PA arteriotomy for exposure, exclusion of the posterior artery pseudoaneurysm with a bovine pericardial patch, and closure of the anterior arteriotomy with a bovine pericardial patch. The patient did well and was discharged on postoperative day 11 with repeat imaging showing resolution.
View details for DOI 10.1111/jocs.15999
View details for Web of Science ID 000697912600001
View details for PubMedID 34541714
Commentary: Intraoperative neuromonitoring: FAST to FASTER response to neurologic complication.
The Journal of thoracic and cardiovascular surgery
View details for DOI 10.1016/j.jtcvs.2021.08.054
View details for PubMedID 34531041
Coronary Artery Reimplantation and Berlin Heart EXCOR Rescue for Left Coronary Artery Atresia With Severe Ischemic Cardiomyopathy
WORLD JOURNAL FOR PEDIATRIC AND CONGENITAL HEART SURGERY
2021; 12 (6): 793-795
We describe a successful bridge to recovery by coronary reimplantation and Berlin Heart EXCOR left ventricular assist device in a child with left main coronary artery ostial atresia and severe ischemic cardiomyopathy.
View details for DOI 10.1177/21501351211024662
View details for Web of Science ID 000675655300001
View details for PubMedID 34264154
Commentary: Obviously Malperfusion in Dissection Is Bad, But Severe Acidosis May Be Unsurmountable
SEMINARS IN THORACIC AND CARDIOVASCULAR SURGERY
2020; 32 (4): 681-682
View details for DOI 10.1053/j.semtcvs.2020.06.019
View details for Web of Science ID 000593999800013
View details for PubMedID 32610189
Cardiac surgery publications in Africa over the last 20 years: A literature review
SOUTH AFRICAN JOURNAL OF SCIENCE
2020; 116 (1-2)
View details for DOI 10.17159/sajs.2020/6359
View details for Web of Science ID 000510454300006
Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC)
ANNALS OF SURGERY
2019; 270 (6): 1070-1078
To identify the critical nontechnical skills (NTS) required for high performance in variable-resource contexts (VRC).As surgical training and capacity increase in low- and middle-income countries (LMICs), new strategies for improving surgical education and care in these settings are required. NTS are critical for high performance in surgery around the world. However, the essential NTS used by surgeons operating in LMICs to overcome the challenges specific to their contexts have never been described.Using a constructivist grounded theory approach, 52 intraoperative team observations as well as 34 critical incident interviews with surgical providers (surgeons, anesthetists, and nurses) were performed at the 4 tertiary referral hospitals in Rwanda. Interview transcripts and field notes from observations were analyzed using line-by-line coding to identify emerging themes until thematic saturation was achieved.Four skill categories of situation awareness, decision-making, communication/teamwork, and leadership emerged. This provided the framework for a contextually informed skills taxonomy consisting of 12 skill elements with examples of specific behaviors indicative of high performance. While the main skill categories were consistent with those encountered in high-income countries, the specific behaviors associated with these skills often focused on overcoming the frequently encountered variability in resources, staff, systems support, and language in this context.This is the first description of the critical nontechnical skills, and associated example behaviors, used by surgeons in a VRC to overcome common challenges to safe and effective surgical patient care. Improvements in the NTS used by surgeons operating in VRCs have the potential to improve surgical care delivery worldwide.
View details for DOI 10.1097/SLA.0000000000002828
View details for Web of Science ID 000503422400106
View details for PubMedID 29781847
A Cadaver-Based Course for Humanitarian Surgery Improves Manual Skill in Powerless External Fixation
JOURNAL OF SURGICAL RESEARCH
2019; 242: 270-275
General surgery residents interested in humanitarian careers may benefit from supplemental training beyond modern residency. The Colorado Humanitarian Surgical Skills Workshop is a 2-d cadaver-based course for senior surgical residents, teaching low-resource skills across multiple specialties, including orthopedics. We assessed the course's ability to transmit manual competence in a critical humanitarian surgical skill, powerless lower extremity external fixation.We created a novel standardized manual skills test of powerless lower extremity external fixation. Course participants had no prior experience with this technique. At course initiation, paired participants attempted to stabilize a proximal tibia-fibula fracture in a cadaver. Subsequently, participants received didactics from orthopedic surgeons followed by hands-on practice. At course completion, paired participants repeated the exercise. Fixator constructs were scored using standardized criteria. Precourse and postcourse surveys measured participants' level of confidence in performing external fixation.Twelve senior surgical residents were included. Average scores of external fixator constructs improved significantly (23% pre versus 75% post, P < 0.01). On pretesting, none of the participants completed the exercise within 15 min. Only one of six constructs was marginally stable, and none were aligned. On post-testing, five of six teams completed the exercise in an average of 12.4 min. Four of six constructs were stable and two of six were also well aligned. Confidence with external fixation also improved significantly.Participants in a short cadaver-based workshop demonstrated significant improvements in manual skill and confidence related to powerless external fixation. However, additional training is likely required to achieve clinical competence.
View details for DOI 10.1016/j.jss.2019.04.061
View details for Web of Science ID 000477948800038
View details for PubMedID 31121481
Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
2019; 31 (3): 166-172
Quality of care is an emerging area of focus in the surgical disciplines. However, much of the emphasis on quality is limited to high-income countries. To address this gap, we conducted a systematic review of the literature on the quality of essential surgical care in low- and middle- income countries (LMIC).We searched PubMed, Cinahl, Embase and CAB Abstracts using three domains: quality of care, surgery and LMIC.We limited our review to studies of essential surgeries that pertained to all three search domains.We extracted data on study characteristics, type of surgery and the way in which quality was studied.354 studies were included. 281 (79.4%) were single-center studies and nearly half (n = 169, 46.9%) did not specify the level of facility. 207 studies reported on mortality (58.47%) and 325 reported on a morbidity (91.81%), most commonly surgical site infection (n = 190, 53.67%). Of the Institute of Medicine domains of quality, studies were most commonly of safety (n = 310, 87.57%) and effectiveness (n = 180, 50.85%) and least commonly of equity (n = 21, 5.93%).We find that while there are numerous studies that report on some aspects of quality of care, much of the data is single center and observational. Additionally, there is variability on which outcomes are reported both within and across specialties. Finally, we find under-reporting of parameters of equity and timeliness, which may be critical areas for research moving forward.
View details for DOI 10.1093/intqhc/mzy141
View details for Web of Science ID 000474262000002
View details for PubMedID 30020489
Gender-based analysis of factors affecting junior medical students' career selection: addressing the shortage of surgical workforce in Rwanda
HUMAN RESOURCES FOR HEALTH
2018; 16: 29
There is a strong need for expanding surgical workforce in low- and middle-income countries. However, the number of medical students selecting surgical careers is not sufficient to meet this need. In Rwanda, there is an additional gender gap in speciality selection. Our study aims to understand the early variables involved in junior medical students' preference of specialisation with a focus on gender disparities.We performed a cross-sectional survey of medical students during their clinical rotation years at the University of Rwanda. Demographics, specialisation preference, and factors involved in that preference were obtained using questionnaires and analysed using descriptive statistics and odds ratios.One hundred eighty-one respondents participated in the study (49.2% response rate) with a female-to-male ratio of 1 to 2.5. Surgery was the preferred speciality for 46.9% of male participants, and obstetrics/gynaecology for 29.4% of females. The main selection criteria for those who had already decided on surgery as a career included intellectual challenge (60.0%), interaction with residents (52.7%), and core clerkship experience (41.8%) for male participants and interaction with residents (57.1%), intellectual challenge (52.4%), and core clerkship experience (52.4%) for female participants. Females were more likely than males to join surgery based on perceived research opportunities (OR 2.7, p = 0.04). Male participants were more likely than their female participants to drop selection of surgery as a speciality when an adverse interaction with a resident was encountered (OR 0.26, p = 0.03).This study provides insight into factors that guide Rwandan junior medical students' speciality preference. Medical students are more likely to consider surgical careers when exposed to positive clerkship experiences that provide intellectual challenges, as well as focused mentorship that facilitates effective research opportunities. Ultimately, creating a comprehensive curriculum that supports students' preferences may help encourage their selection of surgical careers.
View details for DOI 10.1186/s12960-018-0295-7
View details for Web of Science ID 000438431000001
View details for PubMedID 29996860
View details for PubMedCentralID PMC6042316
Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum
JOURNAL OF SURGICAL EDUCATION
2018; 75 (4): 1014-1021
A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety.The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety.The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda.Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%).In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, p<0.01). All residents reported that the course would improve their ability to provide safer patient care, and 97.4% believed developing nontechnical skills would improve patient outcomes.Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global surgical safety.
View details for DOI 10.1016/j.jsurg.2017.09.014
View details for Web of Science ID 000439955800026
View details for PubMedID 29074364
American College of Surgeons Member Involvement in Global Surgery: Results from the 2015 Operation Giving Back Survey
WORLD JOURNAL OF SURGERY
2018; 42 (7): 2018-2027
Five billion people worldwide lack access to safe surgery. American College of Surgeons (ACS) members have a strong history of humanitarian and volunteer work. Since its founding in 2004, Operation Giving Back (OGB) has served as a volunteer resource portal. This study sought to understand current activities, needs, and barriers to ACS member volunteerism, and to re-assess the role of OGB.A 25-question electronic survey was sent to ACS members in August 2015. Utilizing branching logic, those who were involved or interested in volunteerism completed the full survey. Data were assessed using univariable analysis methods.Three percent (n = 1764) of those e-mailed answered the survey. Respondents were mostly men (82%), ≥50 years of age (61%), and general surgeons (70%). Fifty-three percent (n = 937) reported current or past volunteer activities, and 76.5% (n = 1349) were interested in activities within three years. Approximately 84% were interested in international volunteerism and 55% in domestic volunteerism. Few (5.7%) had both training and experience in emergency and disaster response, and only 17% had institutional salary support. Eighty-two percent wished to work with OGB, and 418 indicated organizations with whom they are involved could benefit from OGB collaboration.Interest in surgical volunteerism among ACS member survey respondents is high. OGB has the opportunity to meet member needs by developing programmatic activities, identifying volunteer prospects, facilitating multi-institutional consortia, and leading pre-deployment training. By maximizing volunteer efforts, OGB has the potential to foster sustainable and scalable ethical practices to improve basic access to surgical care globally.
View details for DOI 10.1007/s00268-017-4448-y
View details for Web of Science ID 000434470100014
View details for PubMedID 29411067
The Colorado Humanitarian Surgical Skills Workshop: A Cadaver-Based Workshop to Prepare Residents for Surgery in Austere Settings
JOURNAL OF SURGICAL EDUCATION
2018; 75 (2): 383-391
Interest in humanitarian surgery is high among surgical and obstetric residents. The Colorado Humanitarian Surgical Skills Workshop is an annual 2-day course exposing senior residents to surgical techniques essential in low- and middle-income countries but not traditionally taught in US residencies. We evaluated the course's ability to foster resident comfort, knowledge, and competence in these skills.The cohort of course participants was studied prospectively. Participants attended didactic sessions followed by skills sessions using cadavers. Sample areas of focus included general surgery (mesh-free hernia repair), orthopedics (powerless external fixation), and neurosurgery (powerless craniotomy). Before and after the course, participants answered a questionnaire assessing confidence with taught skills; took a knowledge-based test composed of multiple choice and open-ended questions; and participated in a manual skills test of tibial external fixation.The Center for Surgical Innovation, University of Colorado School of Medicine.A total of 12 residents (11 general surgical and 1 obstetric) from ten US institutions.After the course, participants perceived increased confidence in performing all 27 taught procedures and ability to practice in low- and middle-income countries. In knowledge-based testing, 10 of 12 residents demonstrated improvement on multiple choice questioning and 9 of 12 residents demonstrated improvement on open-ended questioning with structured scoring. In manual skills testing, all external fixator constructs demonstrated objective improvement on structured scoring and subjective improvement on stability assessment.For senior residents interested in humanitarian surgery, a combination of skills-focused teaching and manual practice led to self-perceived and objective improvement in relevant surgical knowledge and skills. The Colorado Humanitarian Surgical Skills Workshop represents an effective model for transmitting essential surgical principles and techniques of value in low-resource settings.
View details for DOI 10.1016/j.jsurg.2017.08.009
View details for Web of Science ID 000430136800019
View details for PubMedID 28864266
Contextual Challenges to Safe Surgery in a Resource-limited Setting A Multicenter, Multiprofessional Qualitative Study
ANNALS OF SURGERY
2018; 267 (3): 461-467
Safe surgery should be available to all patients, no matter the setting. The purpose of this study was to explore the contextual-specific challenges to safe surgical care encountered by surgeons and surgical teams in many in low- and middle-income countries (LMICs), and to understand the ways in which surgical teams overcome them.Optimal surgical performance is highly complex and requires providers to integrate and communicate information regarding the patient, task, team, and environment to coordinate team-based care that is timely, effective, and safe. Resource limitations common to many LMICs present unique challenges to surgeons operating in these environments, but have never been formally described.Using a grounded theory approach, we interviewed 34 experienced providers (surgeons, anesthetists, and nurses) at the 4 tertiary referral centers in Rwanda, to understand the challenges to safe surgical care and strategies to overcome them. Interview transcripts were coded line-by-line and iteratively analyzed for emerging themes until thematic saturation was reached.Rwandan-described challenges related to 4 domains: physical resources, human resources, overall systems support, and communication/language. The majority of these challenges arose from significant variability in either the quantity or quality of these domains. Surgical providers exhibited examples of resilient strategies to anticipate, monitor, respond to, and learn from these challenges.Resource variability rather than lack of resources underlies many contextual challenges to safe surgical care in a LMIC setting. Understanding these challenges and resilient strategies to overcome them is critical for both LMIC surgical providers and surgeons from HICs working in similar settings.
View details for DOI 10.1097/SLA.0000000000002193
View details for Web of Science ID 000429103500036
View details for PubMedID 28257319
Using Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial
JOURNAL OF SURGICAL EDUCATION
2018; 75 (1): 231-237
There is a severe surgical workforce shortage in Rwanda. Innovative educational tools must be introduced to train more residents and increase surgical capacity. Touch Surgery (TS) is a smartphone application that offers trainees the opportunity to practice operations; however, its effect is unknown in low- and middle-income countries. Our objectives were to determine the training effect of TS and its feasibility for use in surgery education in a low-resource setting.We performed a randomized control trial of University of Rwanda surgical residents. Participants were blocked by postgraduate year and randomized to textbook or TS for learning tendon repair surgical technique. After the learning period, participants performed a tendon repair simulation, evaluated by blinded expert raters. Presimulation and postsimulation questionnaires tested their knowledge of tendon repair.The study was conducted at the simulation center of the University Teaching Hospital of Kigali, a tertiary referral and teaching hospital.The study included University of Rwanda surgery residents. A total 27 of 51 surgery residents (52.94%) were enrolled. Participating residents represented the following specialties: general surgery (51.85%), orthopedics (40.74%), and urology (7.41%).TS users scored 89.7% on tendon repair simulation, compared to textbook users who scored 63.4% (p < 0.001). Postsimulation questionnaires showed a significant improvement in cognitive scores for TS users (38.6%, p < 0.001), as compared to nonsignificant improvement for textbook users (15.9%, p = 0.304). About 92.3% of TS users reported that TS represents a useful training tool, and 61.5% reported that it would be a good or very good required part of the curriculum.TS is a useful tool to improve both technical skills and knowledge of tendon repair procedure steps; however, its role may be limited to a supplemental tool as it does not improve the theoretical knowledge. TS has the potential to be implemented in a surgical academic curriculum in low- and middle-income countries.
View details for DOI 10.1016/j.jsurg.2017.06.016
View details for Web of Science ID 000424535400029
View details for PubMedID 28712686
Are American Surgical Residents Prepared for Humanitarian Deployment?: A Comparative Analysis of Resident and Humanitarian Case Logs
WORLD JOURNAL OF SURGERY
2018; 42 (1): 32-39
Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment.We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets.US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases (p < 0.01) and fewer orthopedic cases (p < 0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation.Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.
View details for DOI 10.1007/s00268-017-4137-x
View details for Web of Science ID 000418579500006
View details for PubMedID 28779383
Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda
BMC PREGNANCY AND CHILDBIRTH
2017; 17: 242
In low-resource settings, access to emergency cesarean section is associated with various delays leading to poor neonatal outcomes. In this study, we described the delays a mother faces when needing emergency cesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda.This retrospective study included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labor prior to hospital admission, travel time from health center to district hospital, time from admission to surgical incision, and time from decision for emergency cesarean section to surgical incision. Neonatal outcomes were categorized as unfavorable (APGAR <7 at 5 min or death) and favorable (alive and APGAR ≥7 at 5 min). We assessed the relationship between each type of delay and neonatal outcomes using multivariate logistic regression.In our study, 9.1% (40 out of 401) of neonates had an unfavorable outcome, 38.7% (108 out of 279) of neonates' mothers labored for 12-24 h before hospital admission, and 44.7% (159 of 356) of mothers were transferred from health centers that required 30-60 min of travel time to reach the district hospital. Furthermore, 48.1% (178 of 370) of cesarean sections started within 5 h after hospital admission and 85.2% (288 of 338) started more than 30 min after the decision for cesarean section was made. Neonatal outcomes were significantly worse among mothers with more than 90 min of travel time from the health center to the district hospital compared to mothers referred from health centers located on the same compound as the hospital (aOR = 5.12, p = 0.02). Neonates with cesarean deliveries starting more than 30 min after decision for cesarean section had better outcomes than those starting immediately (aOR = 0.32, p = 0.04).Longer travel time between health center and district hospital was associated with poor neonatal outcomes, highlighting a need to decrease barriers to accessing emergency maternal services. However, longer decision to incision interval posed less risk for adverse neonatal outcome. While this could indicate thorough pre-operative interventions including triage and resuscitation, this relationship should be studied prospectively in the future.
View details for DOI 10.1186/s12884-017-1426-1
View details for Web of Science ID 000406690300001
View details for PubMedID 28743257
View details for PubMedCentralID PMC5526290
An institutional analysis of unplanned return to the operating room to identify areas for quality improvement
AMERICAN JOURNAL OF SURGERY
2017; 214 (1): 1-6
Unplanned return to the operating room (uROR) has been suggested as a hospital quality indicator. The purpose of this study was to determine reasons for uROR to identify opportunities for patient care improvement.uROR reported by our institution's American College of Surgeons National Surgical Quality Improvement Program underwent secondary review.The uROR rate reported by clinical reviewers was 4.3%. Secondary review re-categorized 64.7% as "true uROR" with the most common reasons for uROR being infection (30.9%) and bleeding (23.6%). Remaining cases were categorized as "false uROR" with the most common reasons being inadequate documentation (60.0%) and not directly related to index procedure (16.7%).Strict adherence to NSQIP definitions results in misidentification of true uROR. This raises concerns for using NSQIP-identified uROR as a hospital quality metric. Improved processes of care to prevent infection and hemorrhage at our institution could reduce the rate of true uROR.
View details for DOI 10.1016/j.amjsurg.2016.10.021
View details for Web of Science ID 000403941000001
View details for PubMedID 28057294
Using the Consolidated Framework for Implementation Research to implement and evaluate national surgical planning
BMJ GLOBAL HEALTH
2017; 2 (2): e000269
The Lancet Commission on Global Surgery defined six surgical indicators and a framework for a national surgical plan that aimed to incorporate surgical care as a part of global public health. Multiple countries have since begun national surgical planning; each faces unique challenges in doing so. Implementation science can be used to more systematically explain this heterogeneous process, guide implementation efforts and ultimately evaluate progress. We describe our intervention using the Consolidated Framework for Implementation Research. This framework requires identifying characteristics of the intervention, the individuals involved, the inner and outer setting of the intervention, and finally describing implementation processes. By hosting a consultative symposium with clinicians and policy makers from around the world, we are able to specify key aspects of each element of this framework. We define our intervention as the incorporation of surgical care into public health planning, identify local champions as the key individuals involved, and describe elements of the inner and outer settings. Ultimately we describe top-down and bottom-up models that are distinct implementation processes. With the Consolidated Framework for Implementation Research, we are able to identify specific strategic models that can be used by implementers in various settings. While the integration of surgical care into public health throughout the world may seem like an insurmountable challenge, this work adds to a growing effort that seeks to find a way forward.
View details for DOI 10.1136/bmjgh-2016-000269
View details for Web of Science ID 000408746500012
View details for PubMedID 29225930
View details for PubMedCentralID PMC5717928
Maternal predictors of neonatal outcomes after emergency cesarean section: a retrospective study in three rural district hospitals in Rwanda.
Maternal health, neonatology and perinatology
2017; 3: 11
BACKGROUND: In sub-Saharan Africa, neonatal mortality post-cesarean delivery is higher than the global average. In this region, most emergency cesarean sections are performed at district hospitals. This study assesses maternal predictors for poor neonatal outcomes post-emergency cesarean delivery in three rural district hospitals in Rwanda.METHODS: This retrospective study includes a random sample of 441 neonates from Butaro, Kirehe and Rwinkwavu District Hospitals, born between 01 January and 31 December 2015. We described the demographic and clinical characteristics of the mothers of these neonates using frequencies and proportions. We assessed the association between maternal characteristics with poor neonatal outcomes, defined as death within 24h or APGAR<7 at 5min after birth, using Fisher's exact test. Factors significant at alpha=0.20 significance level were considered for the multivariate logistic regression model, built using a backwards stepwise process. We stopped when all the factors were significant at the alpha=0.05 level.RESULTS: For all 441 neonates included in this study, 40 (9.0%) had poor outcomes. In the final model, three factors were significantly associated with poor neonatal outcomes. Neonates born to mothers who had four or more prior pregnancies were more likely to have poor outcomes (OR=3.01, 95%CI:1.23,7.35, p=0.015). Neonates whose mothers came from health centers with ambulance travel times of more than 30min to the district hospital had greater odds of having poor outcomes (for 30-60min: OR=3.80, 95%CI:1.07,13.40, p=0.012; for 60+ minutes: OR=5.82, 95%CI:1.47,23.05, p=0.012). Neonates whose mothers presented with very severe indications for cesarean section had twice odds of having a poor outcome (95% CI: 1.11,4.52, p=0.023).CONCLUSIONS: Longer travel time to the district hospital was a leading predictor of poor neonatal outcomes post cesarean delivery. Improving referral systems, ambulance availability, number of equipped hospitals per district, and road networks may lessen travel delays for women in labor. Boosting the diagnostic capacity of labor conditions at the health center level through facilities and staff training can improve early identification of very severe indications for cesarean delivery for early referral and intervention.
View details for DOI 10.1186/s40748-017-0050-4
View details for PubMedID 28630744
Using satellite imagery and GPS technology to create random sampling frames in high risk environments
INTERNATIONAL JOURNAL OF SURGERY
2016; 32: 123-128
Health surveys are important tools for assessing needs and informing policy decisions. However, obtaining representative samples is challenging in environments without traditional infrastructure or census data. We describe a method using satellite imagery, geographic information systems and GPS technology to obtain an accurate sample of such a population.The Kerenik Camp in Darfur is a conflict-heavy environment with 25,000 internally displaced persons (IDPs). We requisitioned high-resolution satellite imagery of the camp prior to arrival. Structures identified as potential domiciles were geocoded with a unique ID and coordinate. A random selection of ID numbers formed the representative sample. Researchers visited these coordinates using handheld GPS devices and administered surveys to the inhabitants.2219 geocoded points were visited. Of these, 1655 (74.6%) proved to be unique domiciles. Our survey participation rate was 87.1%. The overall effective rate of completed survey per geocoded point visited was 39.1%.Our sampling technique offers several advantages when surveying vulnerable populations. It permits the establishment of a sampling frame without need for traditional infrastructure, such as addresses or telephones. Sampling frames can be constructed remotely and prior to survey initiation, important considerations for insecure environments where time on the ground may be limited.This technique can be used for any setting requiring a random sample, but is especially useful in insecure environments and survey areas without accessible census data, postal addresses, or telephone numbers. Sampling frames can be constructed remotely and prior to survey initiation, important considerations for environments where time on the ground may be limited.
View details for DOI 10.1016/j.ijsu.2016.06.044
View details for Web of Science ID 000381724000020
View details for PubMedID 27392719
Global Surgery 2030: a roadmap for high income country actors
BMJ GLOBAL HEALTH
2016; 1 (1): e000011
The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.
View details for DOI 10.1136/bmjgh-2015-000011
View details for Web of Science ID 000408711200022
View details for PubMedID 28588908
View details for PubMedCentralID PMC5321301
A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures
LIPPINCOTT WILLIAMS & WILKINS. 2016: 187-192
Previous studies of surgical stabilization of rib fractures (SSRF) have been limited by small sample sizes, retrospective methodology, and inclusion of only patients with flail chest. We performed a prospective, controlled evaluation of SSRF as compared with optimal medical management for severe rib fracture patterns among critically ill trauma patients. We hypothesized that SSRF improves acute outcomes.We conducted a 2-year clinical evaluation of patients with any of the following rib fracture patterns: flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. In the year 2013, all patients were managed nonoperatively. In the year 2014, all patients were managed operatively. Outcomes included respiratory failure, tracheostomy, pneumonia, ventilator days, tracheostomy, length of stay, daily maximum incentive spirometer volume, narcotic requirements, and mortality. Univariate and multivariable analyses were performed.Seventy patients were included, 35 in each group. For the operative group, time from injury to surgery was 2.4 day, operative time was 1.5 hours, and the ratio of ribs fixed to ribs fractured was 0.6. The operative group had a significantly higher RibScore (4 vs. 3, respectively, p < 0.01) and a significantly lower incidence of intracranial hemorrhage (5.7% vs. 28.6%, respectively, p = 0.01). After controlling for these differences, the operative group had a significantly lower likelihood of both respiratory failure (odds ratio, 0.24; 95% confidence interval, 0.06-0.93; p = 0.03) and tracheostomy (odds ratio, 0.18; 95% confidence interval, 0.04-0.78; p = 0.03). Duration of ventilation was significantly lower in the operative group (p < 0.01). The median daily spirometry value was 250 mL higher in the operative group (p = 0.04). Narcotic requirements were comparable between groups. There were no mortalities.In this evaluation, SSRF as compared with the best medical management improved acute outcomes among a group of critically ill trauma patients with a variety of severe fracture patterns.Therapeutic study, level II.
View details for DOI 10.1097/TA.0000000000000925
View details for Web of Science ID 000375234800001
View details for PubMedID 26595710
Unplanned Return to the Operating Room: An Institutional Analysis to Identify Areas for Improvement
ELSEVIER SCIENCE INC. 2015: S79-S80
View details for DOI 10.1016/j.jamcollsurg.2015.07.177
View details for Web of Science ID 000361119700154
Vitamin D deficiency does not increase the rate of postoperative hypocalcemia after thyroidectomy
AMERICAN JOURNAL OF SURGERY
2012; 204 (6): 888-893
Hypocalcemia is a frequent complication of thyroidectomy. Although typically mild and temporary, it can lead to an increased length of stay, readmission, and in some cases be permanent. Controversy exists as to whether vitamin D deficiency (VDD) contributes to post-thyroidectomy hypocalcemia.This is a retrospective study of 152 patients who underwent thyroidectomy. Patients with or without VDD were compared. Data were analyzed for demographics, operative procedure, calcium levels, and complications of hypocalcemia.There was no difference in the rates of biochemical or symptomatic hypocalcemia or in the need for readmission between the VDD and non-VDD groups. A multivariate analysis controlling for central neck dissection, parathyroid autotransplant, and preoperative diagnosis confirmed no association between VDD and post-thyroidectomy hypocalcemia.Despite VDD being common in patients undergoing thyroidectomy, our results do not suggest that this increases the rate of hypocalcemia. Thus, preoperative evaluation/repletion of VDD is unlikely to reduce post-thyroidectomy hypocalcemia rates.
View details for DOI 10.1016/j.amjsurg.2012.10.001
View details for Web of Science ID 000312803000017
View details for PubMedID 23231931