Global Surery Fellowship Curriculum
This element will be provided by an experienced spiritual director/Jesuit priest who is always respectful of individual faith traditions and spiritual sensitivities. A personal conference will be available on-campus during the first year of fellowship and by WhatsApp during the second year. Although not mandatory, the guidance is provided in preparation of the demands of a developing country health care environment.
First 7 - 9 Months of Fellowship
Training will be competency based. Each module has a written test requiring a 75% passing grade, target operation requirement numbers and simulation testing for some modules. The fellow will not go onto the next module without a passing grade from the division chief based upon test scores, operative ability and simulation testing results.
Modules and milestones include (see below):
Background: Communicable diseases have come under better control and as a result life expectancy is greater in underserved countries. Global health experts now have a greater recognition of the need for improved anesthesia and surgical care. Poor perioperative care has several causes: few trained providers, unreliable access to essential medications including oxygen, limited safety monitoring and limited options for postoperative care including pain management.
The shortage in the number of anesthesiologists, especially pediatric anesthesiologists, has become apparent. The absence of oxygen monitoring and IV fluids is very problematic as well.
Both local and regional anesthetic techniques are low cost and low technology; they offer achievable proficiency and have a good safety record when basic sterile techniques are employed and key safety steps are observed.
Curriculum: These techniques plus intubations will be taught, with the intent our Fellow will teach in-country physicians, nurses and technicians the same methods when appropriate.
Target number of procedures:
- Intubation and difficult airway – 40 endotracheal intubations
- Regional blocks – 10 (femoral, brachial, interscalene, adductor, popliteal)
- Spinal anesthesia - 20
Three months - essential procedures as available
Background: Pregnancy is not a disease but a condition that carries the risk of hemorrhage and obstructed labor. The volume of maternal morbidity and death worldwide renders every pregnant woman at risk. The complications can be prevented by access to obstetrical care, but most low- and middle-income countries (LMICs) do not have birth attendants present at deliveries. Access is the problem.
Maternal mortality rates are improving, but the risk remains high, especially for adolescent pregnancies, which have up to a six percent chance of maternal death in Sub-Saharan Africa. The death has multiple impacts, including orphaned children. In addition, the family suffers due to lack of child care, a possible second income is lost and in some circumstances complete dissolution of the family occurs.
Operative vaginal delivery includes use of forceps or a vacuum device, which requires a fundamental level of training. In addition, manual digital rotation of the fetal head can facilitate vaginal delivery. The required devices are inexpensive and some can be reused. Shoulder dystocia probably will require C-section in austere circumstances. Breech and transverse presentations require identification and a C-section unless a fully trained obstetrician is present to perform pre-birth infant rotation.
Postpartum hemorrhage is a dreaded complication and can be due to uterine atony, lacerations, retained placenta, uterine rupture, uterine inversion and coagulopathy. Blood transfusion is considered part of emergency obstetrical management but is often not available in LMICs.
C-sections have associated morbidities, but can save the infant’s and mother’s life. The indications are varied and surgical training is required due to the associated complications with the surgical approach. The learning curve for uncomplicated C-sections is 50-100. The effectiveness and cost effectiveness of obstetrical surgical intervention is well proven.
- Normal vaginal deliveries – 50
- Repair of perineal lacerations - 10
- Uncomplicated C sections – 50
- Complicated C sections -15
- Post-partum hemorrhage management – 10
- D & C (not abortions) – 5
- Open total abdominal hysterectomies – 5
Curriculum: Family planning, obstetrical care including pre and post-natal care, surgical skills and task sharing training will be emphasized.
Background: Hernias are common but have associated disabilities and can cause death, especially in developing countries. Inguinal hernia mesh repair is easy to perform, learn and teach.
Curriculum: The operating performance rating scale (OPRS) training method will be used to train the Lichtenstein repair and then to train the fellow to train. The location will be the Institute for Latin American Concern (ILAC) center in Santiago, Dominican Republic or Guatemala and some training on cadavers will occur in Omaha, Nebraska.
During the week the fellow will perform up to 50 hernia operations, do 5 Lichtenstein OPRS cases with Dr. Filipi, be trained to train and utilize the OPRS technical evaluation method.
Background: Dental caries are the most prevalent health problem globally because of population aging, with periodontitis ranks sixth. The largest increase in oral disease has occurred in Sub-Saharan Africa and South Asia.
Preventive approaches for caries are brought to patients rather than patients to prevention. Water fluoridation depends on the availability of potable piped water. However, even with fluoridated water, prevention is not 100% effective. Combined salt, water, milk and toothpaste fluoridation is recommended.
Periodontitis, similar to dental caries, has been successfully treated with mechanical therapy for more than 100 years, including scaling and root planning with or without subsequent surgery. Added antibiotic therapy results in better clinical outcomes. Antibiotic use in a public health context raises concerns about several issues: quality, affordability and antibiotic resistance. In underserved countries without professional dentistry, short term metronidazole and amoxicillin may be the only effective and efficient method.
Noma, necrotizing ulcerative gingivitis stomatitis gangrenosa is a destructive ulceration of the gingival-oral mucosa that spreads extra orally. Noma is commonly described as the “face of poverty” because of its facial location and prevalence among children. Malnutrition and recent respiratory or intestinal illnesses are thought to cause it. Improved nutrition and antibiotics are the treatment if caught early. For those that survive, facial reconstruction is necessary.
Delivery models for prevention include the fit for school approach. Teachers implement daily group hand washing with soap, daily group tooth brushing with fluoride toothpaste and biannual deworming according to WHO guidelines. Clean water is of course best but not always available. WHO recommends in middle- and low- income countries health care provider preventive care, triage prevention, extractions and innovative methods to increase access to care at all levels. Focused mobile extraction services and dental prevention services integrated with other health initiatives are to be considered.
Curriculum: The conditions above emphasize primarily prevention and extractions. The curriculum is thus focused on helping the fellowship graduate innovate preventive measures and perform rudimentary extractions services when indicated. Training will take place at Creighton University School of Dentistry and the University of Nebraska Medical Center Oral Maxillofacial Surgery Department.
Targeted number of OMF operations/procedures to be performed
- Regional nerve blocks – 15 cases
- Safe leveraged tooth extractions – 30 cases
- Different techniques – 5 cases
- Incision and drainage of odontogenic and facial abscesses – 3 cases
The Global Surgery Fellow will learn the core principles of dental public health and its application to the global stage.
Learning Modules: Complete the Smiles for Life National Oral Health Curriculum
Instruction on tooth cleaning, cavity filling and root canal.
Background: The musculoskeletal system is the most common site of residual disability from trauma. Musculoskeletal injuries are managed successfully by sophisticated treatment algorithms in high-income countries (HIC), but because of insufficient personnel, training, rehabilitation services and equipment, low-income country (LIC) practitioners have no choice but to use only casting, traction and splinting with predictably worse outcomes.
Hip fractures are the primary orthopedic problem in low-middle income countries (LMICs), the fractures healing most often without operative intervention. Hip injuries have doubled to tripled in Asia over the last 30 years as the population ages from improved infectious disease control. Surgery for hip fractures has proved more cost effective than conservative management because of the avoidance of disability and complications related to prolonged bed rest, including decubitus ulcers and deep vein thrombosis.
Open fractures can result, if treated inappropriately, in osteomyelitis and sepsis. In LMICs, about half are open severe tibia fractures. The interval to definitive therapy and bone union is prolonged. External fixation remains the safest choice of skeletal stabilization, particularly when contamination is high. Intermedullary devices for open fractures are not readily available. Early surgical intervention is imperative, but ready availability to X-rays and sterile operative conditions are necessary.
Clubfoot, a relatively rare condition but one with significant morbidity if untreated, can be cared for conservatively and inexpensively using the Ponseti method.
Curriculum: Open fracture immediate surgical intervention, pinning of hip fractures, external fixation, basic non-operative orthopedic care, the Ponseti method and systems prevention of fractures will be emphasized in this curriculum.
Targeted number of procedures:
- External fixation – 5 cases
- Open fractures – 10 cases
- Internal fixation - 15 cases
- Hip nail/ hip screw – 2 cadaver cases
- Casting - 30 cases with physician assistant supervision
- Casting - 5 clubfoot patients
Background: The Arizona Burn Center is one of the largest burn centers in the U.S. The referral area for the Arizona Burn Center includes the entire state of Arizona, western New Mexico, Nevada, western California, southern Colorado, southern Utah, and northern Mexico
Organization of the Service: There are four attending/teaching surgeons on the Burn Service: Drs. Foster, Matthews, Peck, and Jain. There are typically two attending/teaching surgeons on the service at a time. One covers the inpatient service and the burn emergency department, and the other covers cases in the operating room. The attendings usually rotate on service for one month at a time.
There are six allied health professionals: LouAnn Jones NP, Steven Mouch PA-C, Brooke Velasquezm PA-C, Tahsia Pest PA-C, Lara Bennett PA-C, and Tiffany Haynie PA-C. The PA’s assist on the floor, in clinic, and in the OR. All six assist in covering the burn ED. Each of the allied health professionals has a wealth of experience in burn care, and carries the authority of the attending/teaching physicians. You should respect them and respond to them accordingly.
The chief resident on the Burn Service is a PGY-3 resident. He/she rotates on Burn for three consecutive months. The chief resident is the initial go-to person on the Burn Service. He/she in conjunction with the allied health professionals is responsible for the day-to-day running of the service, covering OR cases, scheduling cases, covering clinic and the ED, conducting Burn/Trauma/ICU Conference on Thursday, and facilitating multidisciplinary rounds on Tuesday mornings. Any and all concerns for the Burn Service should be brought to the chief resident’s attention initially.
A simple organization chart is shown below:
Background: Hydroceles in tropical regions are often caused by lymphatic filariasis. Mosquitoes carry the filarial parasite and the hydroceles can be either acute or chronic. The acute form is often due to death of the adult worms after medical treatment whereas the chronic form is associated with dilation and malfunction of the lymphatics. Approximately 1/7 of the world’s population is at risk including Haiti, the Dominican Republic and Brazil. The social burden of this disease is significant and includes depression and sexual dysfunction. The surgical management of even idiopathic hydroceles can be complex because of a high postoperative complication rate. For Filarial hydroceles the postoperative infection rate after hydrocelectomy is as high as 30 percent. Full sac excision, however, has a lower recurrence rate but attention to careful hemostasis is important.
Urinary incontinence (UI) is prevalent with a worldwide incidence of 25-45% in females. Stress urinary incontinence is the most prevalent. Colovesicalvaginal fistulas from obstructed labor, pelvic organ prolapse due to aging, high parity, smoking and depression are some of the more common causes in developing countries.
Urethal strictures occur more often in males with pelvic fracture urethral disfraction and fall astride injuries being the most common causes in developing countries. Many of these patients present with urinary retention and urethral dilation is the mainstay of treatment. Direct visual urethectomy or urethroplasty may be appropriate. Strictures in developing countries are also caused by gonorrhea and still by syphilis in tropical Africa.
Urolithiasis in developing countries has changed from a predominantly lower tract site in the mid 1980s to the upper tract.. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease in these countries.
Urethral calculi are reported to be fairly common in developing countries, particularly in the Middle and Far East because of the high prevalence of bladder calculi. Most urethral stones in patients in developing countries are thought to consist of struvite and uric acid, and of calcium oxalate or cystine.
Urinary bladder cancer (UBC) burden of disease is predicted to increase in less developed areas of the world. This is attributed to global changes in exposure to risk factors such as tobacco and growth and aging of the world population. Lower rates and absolute numbers are seen in less developed regions like Asia and almost all of Africa. Part of this variability is artificial, however, and can be explained by differences in the definition and registration of urinary bladder cancer. Nevertheless the incidence is increasing and developing country surgeons can anticipate more UBC patients.
Similarly prostate cancer is a disease of increasing incidence worldwide. In many industrialized nations such as the Unites States, it is one of the most common cancers and among the leading causes of cancer deaths. In developing countries it is less common, however, its incidence and mortality is on the rise.
The rate of adult and pediatric circumcision in developing countries is inversely related to the incidence HIV. For this reason circumcision will be taught to fellows.
The conditions above all have surgical or endoscopic forms of treatment and will be emphasized in the curriculum.
Director: - Dr. Michael Feloney
Targeted number of operations/procedures
- Cystoscopies - 20
- Hydrocelectomy – 5
- Urethral dilation – 5
- Pericutaneous supra-pubic cystostomy – 1
- Open supra-pubic cystostomy - 2
- Cystoscopy and urethral stent placement – 3
- Circumcision – 2
Background: A low income country (LIC) first level hospital will put the fellow in very austere circumstances where the need for a trained surgeon is most needed. Teach operations to available practitioners and provide an opportunity for health care system analysis and development - the two aspects of the first curriculum year. Emotional, spiritual support will be necessary for the fellow and family during this year.
Performing surgery under supervision and then autonomously, plus training a GP or nurse to perform essential operations are the goals.
The lack of pediatric anesthesia in developing countries is why adult inguinal hernias are so large and dangerous. Anesthetizing a child in austere circumstances by a nurse or anesthesia “technician” have found to be a dangerous proposition because there is no satisfactory education. This creates a tragic problem for children with chronic tonsillitis, incarcerated/strangulated umbilical or inguinal hernia, an imperforate anus, pyloric stenosis, bowel obstruction etc. Many infants and children die as a result of untreated conditions or misguided intubation attempts.
This rotation will allow the fellow to do numerous intubations of children of all ages under direct supervision by an experienced MD pediatric anesthesiologist. If done after the adult anesthesia rotation, a minimum of 5 under 6 month old intubations in addition to other intubations is the target.
The purpose of this rotation is for the global surgery fellow to
- Gain hands on experience with pediatric and infant intubation and airway management.
- Become familiar with pre-operative assessment and intra-operative management of pediatric anesthesia for commonly seen pathologies,
- Practice common anesthesia procedures encountered in pediatric anesthesiology.
Goal and Objectives by competency
- Learn the proper utilization and technique of infant and pediatric intubation.
- Demonstrate knowledge of appropriate preparation for pediatric general anesthesia cases.
- Understand the utilization of various instruments and methods for difficult pediatric airway management.
- Understand the side effects of anesthetic agents used on pediatric patients.
- Understand physiologic and anatomic differences between adult and pediatric patients in relation to anesthesia management.
The fellow will be either under direct supervision or indirect supervision with direct supervision immediately available by a board certified pediatric anesthesiologist. Individual study is not supervised, however, faculty are available to answer questions.
A Practical Approach to Pediatric Anesthesia – Holzman RS, et al.
A Practice of Anesthesia for Infants and Children – Cote CJ, et. al
The fellow is expected to perform the following pediatric anesthesia procedures
A 10 question multiple choice test will be given with a required score of 80% for passing. The test should be sent to Dr. Filipi with the answer key. The test will be administered by the global surgery fellowship coordinator and faculty and the fellow will be given the results.
This rotation will be immediately after the obstetrics rotation. Nurse practitioners work both in obstetrics and the NICU and therefore getting to know them and gain their trust and respect before the NICU experience is strongly advised if the fellow is to assume significant neonatal care responsibility. Emphasis will be on malnutrition and bubble CPAP ventilation.
Xray machines are available in most developing country district hospitals but they are often out of date, limited in capacity and fluoroscopy is almost never available. Often an upright chest Xray, abdominal films and extremity films are all that can be obtained. Ultrasound machines are available in many developing country hospitals now and are especially used for labor and delivery. Because ultrasound is not dangerous, painful or invasive it is often the preferred imaging modality and some interventional procedures can be performed with ultrasound guidance.
Interpretation of the films is often not as difficult as obtaining a good image and interpretation can be obtained remotely from our 24/7 365 day radiology consultant. Therefore obtaining an optimal image will be the primary focus of this rotation. Technicians can help with that and the radiology department at the Creighton Alegent campus is enthused to help with instruction.
Many developing country operations are different. For instance a bowel anastomosis in the US is often done with stapling devices. There are no staplers in developing countries. Suture material is limited, cautery may or may not be available, the nearest blood bank may be 200 miles away and in Tanzania there is only one trained neurosurgeon for the entire country – if a burr hole is necessary the fellow will have to do it.
We purchase a lightly embalmed cadaver that allows soft tissue dissection for 10 days after arrival. The Creighton University medical school cadaver laboratory is ideal and has personnel to help with preparation, cleaning and scheduling. Surgical instrumentation for each procedure will be available. Key to the cadaver laboratory training success is fellow preparation and having an experienced surgeon instructor. Please see the below procedures planned with the instructor’s name. Other operations can be added depending on time, an available mentor and the fellows’ needs. Scheduling is sometimes difficult so weekend dissections/operations may be necessary.
|Skin flaps, free skin grafts, and tendon repairs||Dr. Collen Stice, Plastic surgeon|
|Burr holes||Dr. Charles Taylon, Neurosurgeon|
|Eye enucleation||Dr. Joe Townley, Ophthalmologist|
|Psoas hitch, open prostectomy, bladder conduit||Dr. Michael Feloney, Urologist|
Dr. Larry Siref, Urologist
|Rapid splenectomy and fasciotomies|
|Chest tube placement, rapid cricothyroidotomy, inguinal hernia hernioraphy and how to train and hand sewn bowel anastomoses||Dr. Charles Filipi, General Thoracic Surgeon|
The primary purpose of the fellowship is to prevent avoidable surgical deaths and for sustainability of effect, to train a local health care provider who will stay in the rural area. Operations to be taught are appendectomy, hernia repair, C sections, repair of perforated bowel and management of open fractures.
15 – 17 month International Rotation Goals:
- Training a GP or nurse to perform essential operations
- Surgical clinic care - 2,000 patients or more
- 300 or more major operations to be performed
- One health care system development
During the fellowship second year, the fellow will develop a health care system that will positively impact 200 or more patients. After implementation, a final written report and an evaluation by the fellowship director will determine in-country benefit. A passing grade for system development, operative numbers and a low complication rate are required for final fellowship certification.
Professional and Undergraduate Curriculum
The Creighton Global Surgery fellowship is intended to change Creighton University curriculums, the goal being to establish a supervised site for dental students, Project CURA students, third and fourth year medical students, undergraduates and physical therapy, nursing and occupational therapy students.