Designing, developing and deploying a brachial plexus skills development in Cambodia
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A design and development approach to skills development in resource-limited countries. Our experience with BPI in Cambodia
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Designing, developing and deploying a brachial plexus skills development in Cambodia
- 1. Teaching and training in Resource-limited settings Vaikunthan Rajaratnam
- 2. Cambodia • Population 16.8M 50% under 22 years old. • Highest motorcycle death rate in South-East Asia • 79.3 deaths per 100,000 motorcycles in 2011 Roehler DR, Ear C, Parker EM, Sem P, Ballesteros MF. Fatal motorcycle crashes: a growing public health problem in Cambodia. Int J Inj Contr Saf Promot. 2015;22(2):165-171. doi:10.1080/17457300.2013.876050
- 3. Consequences of Brachial Plexus Injuries • physical limitations • psychological stress • Social discrimination • Economic hardship Useless Limb -> Assisting Limb
- 4. Surgical Volunteerism • 5 billion people – no access to optimal surgical care • volunteerism for surgical care and training o free-willed behaviour, o no material reward, o helping strangers/beneficiaries, and o carried out on a long-term basis or in a formal setting Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569- 624. doi:10.1016/S0140-6736(15)60160-X
- 5. Most extensive hand surgery service – congenital hand deformities – neurological problems (CP and TBI) – trauma-related hand injuries – brachial plexus injuries Model in surgical volunteerism – Identify and train committed local surgeons – Use a targeted curriculum – Incorporating local resources – Identify health needs of the community – Targeted context-appropriate training p – Supported by the visiting surgeons – Enabled by technology – Dedicated /committed international faculty Caring for the disabled in Cambodia Cheok S, Dong C, Lam WL, Gollogly J, Rajaratnam V. A model for surgical volunteerism: a qualitative study based in Cambodia. Trop Doct. 2020;50(1):53-57. doi:10.1177/0049475519884442
- 6. Methodology Instructional design ADDIE Model • Community-oriented curriculum • Needs analysis of surgeons • Personalised programme • Targeted training • Feedback and Practice • Assessment • Evaluation of the programme Severe burn contractures
- 7. Community-oriented Curriculum DELIVER Curriculum (Pedagogy Specific to Cambodia) Assessments INDEPENDENT PRACTICE & TEACH OTHERS DESIGN Curriculum (around Training Needs) Targeted Competency Based DISCERN Community Needs Visiting Centre Plan Training Needs based on Community Needs
- 8. Discerning the Community Needs: Six trips by hand surgeons Cases Percentage Burn and trauma deformity 36 40% Congenital 18 18% Nerve Injuries 23 24% Tumour 3 3% Brachial Plexus 16 16% Total: 96 100%
- 9. Designing the Curriculum TOPICS LEARNING PROCESS TIME Basic Science Hand Assessment Workshop 6 months Deformity 1: Burn contractures Flap design workshop 1-2 yrs Deformity 2: Tendons Tendon workshop 6 months Deformity 3 Fracture and dislocations Osteomyelitis Fracture fixation workshop 1 yr Nerve 1: Paralysis, cerebral palsy and spasticity Micronueral workshop 1-2 yrs Nerve 2: Brachial plexus Micronueral workshop 1-2 yrs Congenital Hand Deformities Lectures, tutorials, supervised operating 2-3 yrs ✔
- 10. Learning needs analysis of surgeons • Identify surgeon • Assess skill level • Develop personalized training program • Show and Supervise • Assess independent practice
- 11. Results BEFORE AFTER THE FUTURE 1.375 4.46 4.875 DEFORMITY BEFORE AFTER THE FUTURE 1.625 4.41 4.5 CONGENITAL HANDS BEFORE AFTER THE FUTURE 1.25 4.375 4.28 BRACHIAL PLEXUS INJURIES Not confident Very confident 1 2 3 4 5
- 12. Personalised program • Plexus assessment - CBD • Decision making and planning - CBD • Surgical option generation – Lectures, CBD • Selection/execution under supervision - DOP • Deliberate practice/Feedback – simulation • Independent performance/assessment - DOP
- 14. CSC Reconstructive Strategy Total Plexus Injury (C5-T1) < 6 months Reconstructive Strategy: SHOULDER ABDUCTION: • Spinal accessory nerve -> Suprascapular Nerve ELBOW FLEXION: • Phrenic Nerve -> Sural Nerve Graft -> Branch to Biceps (Musculocutaenous nerve) • Long Phrenic Nerve -> Br to Biceps HAND SENSATION / Finger flexion • Contra C7 -> VUNG -> Median N (4) hours of operating time
- 15. Method – 4. Selected Nerve Transfers (CSC Reconstructive Strategy for Upper Plexus Injury (C5,6 +/- 7) < 6 months) Reconstructive Strategy: SHOULDER ABDUCTION: • Spinal accessory nerve -> Suprascapular Nerve • Triceps branch to axillary nerve ELBOW FLEXION: • Ulnar nerve fascicle to biceps branch (Oberlin) Weak Limb -> Useful Limb
- 16. Results (18) 0 1 2 3 4 5 6 Pan Plexal Upper Plexus May 2013 Dec 2013 May 2014 Nov 2014 Feb 2015 May 2015
- 17. Watch video of interview with patients
- 21. Dr Meas Sophal
Editor's Notes
- Good morning Mr Chairman, ladies and gentleman. My name is Ratha Soum and I am a surgeon at the CSC in Cambodia. It is my honour to present my experience of how I received hand surgery training from visiting surgeons to CSC.
- So what can we do for them? Well, as most of you know, BPI is a very serious injury. A pan plexus injury leads to a flail arm, a useless limb, with no sensation or power. Without treatment, or if they present too late, the treatment is shoulder fusion and amputation We cannot do a lot, but what we try and do is to give them two things: elbow flexion, and shoulder abduction. So that the useless limb can become an assisting limb.
- So how do we teach them how to fish? Well, by developing a curriculum, and making sure we are intentional about it. So that we do not just go there to do the work and neglect the training. We develop a three part process of discerning, designing and delivering the curriculum, so that the curriculum we developed is relevant to the needs of the community, and not just what we want to teach, with the eventual aim to facilitate independent practice.
- How do we do this? Our preferred recon strategy for a total plexus injury…total avulsion of all 5 nerves, no motor function, no sensation, completely useless arm is: XI to SS Phrenic to musculocutaneous Elbow flexion Such an operation takes on average two hours in experienced hands.
- How do we do this? Our preferred recon strategy for a total plexus injury…total avulsion of all 5 nerves, no motor function, no sensation, completely useless arm is: XI to SS Phrenic to musculocutaneous Elbow flexion Such an operation takes on average two hours in experienced hands.