Tarek Razek, Director, Adult Trauma Program at the MUHC,describes how international work benefits patient care at home. —Report from a presentation at the 2012 conference of the MUHC-ISAI

Dr. Razek and colleagues work as war surgeons with the International Committee of the Red Cross and with the Federation of Red Cross and Red Crescent Societies; the group provides disaster response and emergency response services and staffs field hospitals.

It would be almost unimaginable, as trauma surgeons, not to engage with large organizations in foreign environments that experience significant events on a regular basis. Trauma and injury are often underappreciated areas of medicine, despite the fact that injury represents more years of life lost and disability-adjusted life years lost than TB, HIV and malaria combined.

Trauma systems

I am involved in several longer-term partnerships in system development with organizations elsewhere who are struggling with the same problems we face here. We have learned how to reduce the incidence of injury, and the impact of injury by instituting a regionalized trauma system. In 1993, the mortality rate for moderate injury in Québec was 50%. With the institution of a regionalized designated trauma centre system, and an organized flow of patients to designated centres of expertise, we have reduced that mortality rate to about 7% in 2007.

There is a huge amount of knowledge in our environment about how to do this well and we engage with partners to transfer that systems-level expertise. We work with partners in eastern Ukraine, Ramallah, Kigali in Rwanda, Dar es Salaam in Tanzania, and Port au Prince in Haiti on long-term trauma collaborations to transfer some of this knowledge.

Simplifying solutions

The systems approach we have implemented in Québec relies on measurement of improved performance. We have worked with partners in these other countries to develop simplified injury databases, because they lack the infrastructure to collect the same kind of data we collect here. As we work with them, we begin to understand what kind of data can be collected in a given environment, find ways to simplify data collection, and develop tools to analyze the data that allow quality performance to be gauged on a standardized model, just as we did here but with much less sophisticated information requirements.

We are now working with the World Health Organization (WHO) to deploy this process in environments around the world, and it is proving very powerful as a policy-driving tool. Once you have good information about current performance and the tools to analyze outcomes, improvements can be tracked. These tools have been validated and were found to be superior at predicting performance and outcomes to the complex tools we use here.

The collaboration has enabled us to learn how to deploy systems to manage injury in a more austere environment, and we are now deploying that simpler system in Northern Québec, where small clinics are unable to collect the robust type of data we can collect in a tertiary health system.

Low-tech, high-impact training

Some of these partnerships involve training, and we are invited to participate with local leadership in the local context. For example, the Chief of Surgery in Kigali invited us to come and discuss how we can help them with surgical training and injury management systems. We have several simplified training paradigms that use low-tech simulation techniques, based on the same principles we use here but adapted to more austere environments. We then benefit, along with our partners, from that novel approach.

We also bring our own trainees to Kigali to engage with trainees there and help them ramp up their capacities in academic medicine, which incorporates research on the databases described earlier. Our trainees gain a lot from that experience.

We will only work alongside local project leaders. These are not our programs, but programs that they want to implement in their own environment that we can help them with. Our contribution is often simply the human resources and some of the skills we have developed thanks to the phenomenal training environments we have. There are only 13 general surgeons in Rwanda and they cannot do the clinical work and training, and develop academic research programs alone, much as they want to do all of those things.

There is always a kernel of significant expertise that we can then help to flourish through train-the-trainer type programs that quickly render them independent. In a first visit, we develop the trainers and run a course to teach them to run the program. On a second visit, we supervise them conducting the program. After that, they continue to run the program independently. There are now key groups in place in Dar es Salaam and Kigali. The group from Kigali has travelled to Dar es Salaam, where the program has been in place for more than 10 years, to learn how to expand their program further.

Supports for international collaboration

Dr. Razek and his MUHC colleagues, Dr. Renzo Cecere and Ms. Patricia O’Connor, were asked how their organizations could help them develop international collaborations and implement the innovations they bring back. Here are their main prescriptions:

• No high-level institution in North America has the redundancy to deliver high-level care halfway around the world on a consistent basis. Partnerships across faculties within the university, across hospitals within a city, and across universities within North America become essential.
• To bring innovation back into the home institution, initiatives need to align with other agreed-upon corporate priorities.
• Global collaboration needs to be very highly respected by the hospital and university. Recognition of the bipartisan benefits achieved through partnership would give physicians and nurses greater “permission” to undertake these activities.
• Support from the executive team is essential for new ideas to be implemented. That requires focus over a considerable period of time. It cannot just be the “flavour of the month.”
• The vision of the academic health centres must expand to include global collaboration and be shared by all levels of management, right up to the Ministry of Health. This is essential to ensure the level of human resources required to conduct these activities while never threatening the core mission of caring for patients at home.
• Incubators and think tanks should be promoted within the institution to enable like-minded people to come together to generate innovative ideas for the international community.