Trauma training course: innovative teaching models and methods for training health workers in active conflict zones of Eastern Myanmar
© Washington et al.; licensee Springer. 2014
Received: 1 November 2013
Accepted: 2 December 2014
Published: 12 December 2014
Myanmar has struggled through decades of internal conflict, which has negatively impacted the country’s health outcomes. Recent government changes have brought hope and reduced conflict. The ethnic minority groups have suffered the brunt of the health consequences and reside in regions that lack health infrastructure, resources, and providers. Due to the chronic lack of healthcare providers within conflict areas, health workers (HWs) have been trained in an effort to fill the void. Research has shown that these non-physician clinicians positively impact health outcomes in developing countries. These HWs are supported by community-based organizations in collaboration with foreign non-governmental organizations. Started in 2000, the trauma training course was developed to meet the educational needs of these HWs.
Essential procedures for HWs in conflict zones were identified, and teaching methods were adapted to develop models that were simple, reproducible, cost effective, and able to facilitate effective learning within the limitations of these challenging environments. This paper presents simulation models developed to teach trauma injury evaluation and management in resource-limited settings to HWs.
Material and construction of the models described include breathing, chest, cricothyroidotomy, circulation, wound repair, fracture/dislocation, splinting, fasciotomy/amputation, and an animal model. In 2013, a pre/post test and post-training evaluation were completed, which demonstrated an increase in understanding of the material and satisfaction with the training.
The simulation models described engage the HWs in clinical skills practice specific to injury management, which builds upon the HWs existing knowledge and facilitates an increased understanding of life-saving procedures. Through observation of the HW performance and HW feedback, these simulation models have increased the understanding of trauma management. Limitations include lack of a graduated learning system for the HWs, logistics, and time constraints. Despite the barriers faced, we feel that this is a necessary program that has reduced morbidity and mortality due to traumatic injury in the geographic areas that the HWs serve. With the changing political environment in Myanmar and the development of peace agreements between the government and the ethnic minority groups, these HWs can be integrated into Myanmar’s evolving health system.
Myanmar (formerly known as Burma) has struggled through more than 60 years of internal conflict, which has negatively impacted the country’s health outcomes. In 2000, the World Health Organization ranked Myanmar’s health system 190th out of 191 countries . In addition, decades of human rights abuses have largely contributed to the country’s consistently poor health outcomes -. Recent government changes, including a democratically elected president and peace agreements between the Myanmar military and ethnic minority groups, have brought hope and reduced armed conflict -.
The ethnic minority groups have suffered the brunt of the conflict, abuses, and health consequences ,. While dispersed throughout the country, the largest ethnic minority populations reside in Myanmar’s border regions. In these regions there is a lack of health infrastructure, resources, providers, and an abundance of internally displaced persons (IDPs; an estimated 429,000 people in 2013) ,,,. This has lead to a chronic state of health crisis in these areas. For example, in 2003, estimates of under-5 mortality rates were 26, 107, and 276 per 1,000 live births, respectively, for Thailand, Myanmar, and eastern Myanmar (a predominately ethnic minority area) ,. Landmine and gunshot wounds compose a majority of the trauma-related injuries .
Due to the chronic lack of healthcare providers within conflict areas of Myanmar, health workers (HWs) have been trained in an effort to fill the void ,,. Research has shown that these non-physician clinicians, if appropriately educated and trained, positively impact health outcomes in developing countries -. These HWs are largely supported and receive training from local community-based organizations (CBOs) such as the Mae Tao Clinic, Karen Department of Health and Welfare (KDHW), the Backpack Health Worker Teams (BPHWT), and the Shan Health Committee who have acted as a crucial part of Myanmar’s non-government associated health care system with fixed and mobile clinics ,. Additional trainings occur at camps with IDPs and refugees in Thailand. The duration of initial training ranges from 4 to 18 months and includes primary care, infectious disease, maternal-child care, first aid, trauma, and public health . These CBOs in cooperation with foreign non-governmental organizations (NGOs) have been working collaboratively over the years to increase capacity through trainings, project development, drug procurement, infrastructure building, and fundraising to support this healthcare system .
Topics covered by the TTC
Anatomy and physiology
Recognition and management of airway and breathing injuries
Recognition and management of shock
Health worker safety/situational awareness
Limb injury management including orthopedic care
Safe field blood transfusions
Secondary trauma survey
Mortality/morbidity reducing procedures
Trauma in special populations (children, pregnant, elderly)
Compartment syndrome identification and management with fasciotomy
Trauma mental health care
There has been an increased emphasis on simulation throughout the development of the TTC. Simulation is used throughout medical education -. Benefits of simulation training include the opportunity to learn and practice in a safe environment without risks to the student or patient and the ability for instructors to provide feedback in a reduced stress and danger-free environment ,,-. Studies have shown improved surgical skills through simulation in a variety of settings ,. In rural areas, training using simulation models is of particular interest because traditional clinical training methods are often not available.
While it is widely accepted that simulation-based education and training has many advantages, creating a medical model that closely resembles its clinical counterpart can be challenging. In resource-limited settings, competing financial priorities necessitate low-cost medical models. Our trainers have worked over the years to develop and refine medical models that are simple, reproducible, cost effective, and able to facilitate effective learning within the limitations of these challenging environments. This paper presents simulation models developed to teach trauma injury evaluation and management in resource-limited settings to HWs.
Essential procedures for HWs in a resource-limited and conflict setting were identified. Over the last 13 years, clinical simulation models have been borrowed, developed, and refined to make certain the models depict the basic concepts necessary for diagnosis and management of traumatic injury. Literature from Maurice King (Primary Surgery, Oxford University Press, New York, USA), Hans Husum, (Save Lives, Save Limbs, Third World Pres, Ritoe, Norway), and the American College of Surgeons (Advanced Trauma Life Support, Illinois, USA), in addition to the decades of experience of our staff, have served as cornerstones for the simulation models and training concepts. From the start, there was a focus on building low-cost models with locally available resources or items easily brought from abroad.
The TTC is organized into training modules, each focusing on a particular essential procedure. All training modules begin with a review of anatomy and physiology, followed by discussion on injury patterns, diagnosis, and management. Simulation models are used to engage the HWs and to further facilitate an understanding of the anatomy, physiology, and management of injuries. Each training module is supported by a single or multiple simulation models, ultimately leading to an animal model that incorporates the skills and concepts from the non-animal models utilized throughout the course.
To gain insight into the HWs conceptualization of the skills learned on simulation models to live patients, HWs were asked to provide a summary of their cases in the field from the prior year. Additionally, a post-training evaluation and pre/post test were completed by the 26 HWs that attended the TTC in 2013.
Results and discussion
Wound repair model
Other teaching aids
Other teaching aids used in the TTC include a human skeleton, human simulation, and critical action cards (laminated cards that highlight the key actions for each procedure). A primary survey dance was created to reinforce the steps of primary survey (assessing for danger, the casualty’s responsiveness, airway, breathing, circulation, disability check, and exposure) in a rhythmic series of motions accompanied by chants. Stressful situations can lessen the ability to think clearly and trainers and training course directors found the dance helped HWs to recall each discrete action of the primary survey.
Selected HW cases from 2012, including age, gender, presentation, management, and patient outcome
The patient suffered a landmine injury while fishing 2 days prior to presentation. The patient had a traumatic right foot amputation. The patient subsequently was given a blood transfusion and a below the knee amputation was performed with ketamine. The patient was given antibiotics. The patient has returned to school and has been referred for a prosthesis.
The patient suffered a penetrating bamboo wound to his right leg. He presented 3 days after the injury with fever, pain, erythema, swelling, and anorexia. The medic performed a fasciotomy, removed the retained bamboo, and debrided the surrounding necrotic muscle with tramadol. The patient received antibiotics and stayed at the clinic for 7 days, before being discharged.
The patient was being chased by a wild boar, he climbed a tree, the branch broke and the pig bit him in his groin and legs. The patient presented to the clinic 3 h after the bite. The wounds were cleaned, packed, and he was given antibiotics.
The patient suffered distal tibia and fibula fractures while playing football (soccer). The medic was on scene when the accident occurred. The medic noted the significant deformity and performed a closed reduction with tramadol. The leg was immobilized with a splint and the patient was referred for definitive management.
The patient suffered a landmine injury. He had a complex open right ankle fracture. The wound was cleaned and packed and he was given tramadol and antibiotics. He was subsequently referred to a hospital.
The patient suffered a gunshot wound to the right elbow. He presented to the clinic 4 h later. The wound was cleaned and the patient was given IVF and antibiotics. The medic advised an amputation, but the patient refused. The wound was debrided and packed. The patient is still unable to move his hand.
The patient was gored by a buffalo and suffered multiple broken ribs and abdominal injuries. He was seen at the clinic 5 h after the injury. The patient was unconscious upon arrival to the clinic. He was given IVF and antibiotics. He was subsequently referred to a hospital.
The patient suffered left open tibia and fibula fractures. The medic performed a left below the knee amputation.
The patient who suffered an infected groin injury from a water buffalo 1 month prior to presentation. The patient had his penis amputated with ketamine and was given antibiotics. The patient was referred to Thailand for additional management, but he refused. On follow-up, the patient was able to urinate.
The patient was cleaning a gun and it backfired, causing him an ulna fracture. The patient presented to the clinic 4 days after the injury. The medic performed a reduction with tramadol. The patient was then splinted and given antibiotics.
The patient suffered a wild boar attack to his abdomen and had evisceration. The medic responded within 30 min. On arrival the patient was in severe shock and despite intravenous fluids and direct pressure the patient expired.
The patient sustained left face, right chest, and left leg injuries from a wild boar attack. The patient presented 3 h after the attack. The wounds were cleaned and packed. The patient stayed in the clinic for 10 days and recovered well.
A post-training evaluation was conducted in 2013, and of the 26 HWs that attended the TTC, 75% (18/24) of HWs felt confident in applying the skills they learned during the training. Almost all of the HWs felt that the training was relevant to their work (96%, 25/26), a valuable use of their time (100%, 26/26), and felt the training objectives were met (100%, 25/25). Furthermore, 96% (25/26) HWs indicated that they felt the training simulation models helped them learn and gain skills (96%, 25/26).
The TTC has continued to develop and refine trauma simulation models to facilitate an understanding of the basic knowledge necessary for the HWs to perform their skill set in a resource-limited setting. These models can be adapted and applied to the training of HWs in other settings. The simulation models described engage the HWs in clinical skills practice specific to injury management, which builds upon the HWs existing knowledge and facilitates an increased understanding of life-saving procedures. Through observation of the participant performance and obtaining feedback from HWs, trainers and training course directors have found that the simulation models increase the understanding of clinical skills of the HWs beyond what is achieved solely with a lecture-based format. Additionally, it is of paramount importance to recognize the relationship developed between the training course directors and the KDHW over the years. This longitudinal relationship has facilitated an understanding of each other’s experiences, culture, and knowledge, which serves as another conduit for adapting the training and simulation models to fit the needs of the HWs.
Limitations to the TTC have been identified. First, standard training programs for HWs are a graduated learning system starting with physiology and mechanisms of injury/disease, progressing to simulation, supervised patient care, and then finally independent practice. However in the context of the current situation in eastern Myanmar, this system is not viable. Barriers to implementation include lack of financial and human resources, ongoing armed conflict, governmental mistrust, and poor health infrastructure. Second, there are consistent requests to make the TTC longer. This is a challenge due to logistics and time constraints of the HWs and international trainers, HW coverage while attending the training, and the safety of participants as they travel across international borders. To address this, a major goal of the TTC is to transition to a training of trainers model. Currently during the trainings, senior HWs participate as clinical instructors and peer-to-peer teachers. In the future the senior HWs should teach the TTC with reduced presence of international instructors. Finally, despite 13 years of training, data regarding HWs knowledge retention and use of skills is sparse and mostly anecdotal. Improvement in data collection, including morbidity and mortality figures from the field, is currently being addressed.
The TTC has provided training to HWs in a resource-limited conflict setting over the past 13 years. We feel that every year our training course and models improve. Despite the barriers faced, we feel that this is a necessary program and has reduced morbidity and mortality in areas that the HWs serve, although the data is mostly anecdotal. With the changing political environment in Myanmar and the development of peace agreements between the government and the ethnic minority groups, these HWs can be integrated into Myanmar’s evolving health system. With their robust skill set, they can provide essential services that are unlikely to be met in the short or medium term by other providers in the rural areas they serve.
We would like to thank the HWs who work in the border zones of Myanmar. They provide care in challenging conditions and risk their personal safety to do so. We would also like to thank the staff of the Karen Department of Health and Welfare, Mae Tao Clinic, Backpack Health Worker Teams, the Shan Health Committee, Planet Care/Global Health Access Program/Community Partners International, and Access Aid International who have actively participated in the TTC. A special thanks to Richard Hahn, MD, who helped develop the TTC. Dr. Voravit Suwanvanichkij (Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University) has provided expert technical assistance over the years.
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