Designing, developing and deploying a brachial plexus v2
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This document summarizes the design, development, and deployment of a brachial plexus surgery service in Cambodia. It describes a community-oriented training program that included: 1) Discerning community surgical needs through local visits which identified burn/trauma deformities as most common. 2) Designing a personalized, competency-based curriculum around these needs, with topics like nerve transfers taught through workshops over 1-2 years. 3) Training local surgeons through skills assessments, supervised surgery, and independent practice with feedback to establish an independent brachial plexus surgery service in Cambodia.
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Designing, developing and deploying a brachial plexus v2
- 1. Designing, Developing and Deploying a Brachial Plexus Service in Cambodia - Conception, Training and Establishment V Rajaratnam, Senior Consultant Hand Surgeon Khoo Teck Puat Hospital, Singapore W Lam, J K Yong, Keo V, J Gollogly
- 2. Introduction
- 3. Methodology – ADDIE Model Severe burn contractures Severe venomous injuries • Community-oriented curriculum • Needs analysis of surgeons • Personalised programme • Targeted training • Feedback and Practice • Assessment • Evaluation of the programme
- 4. Methods – 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
- 5. 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%
- 6. Designing the Curriculum TOPICS LEARNING PROCESS TIME Basic Science Hand Assessment Workshop 6 mths Deformity 1: Burn contractures Flap design workshop 1-2 yrs Deformity 2: Tendons Tendon workshop 6 mths 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 ✔
- 7. Learning needs analysis of surgeons 1. Identify surgeon 2. Assess skill level 3. Develop personalized training program 4. Show and Supervise 5. Assess independent practice
- 8. 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
- 9. Selected Workshops Microneural Workshop Nov 2013
- 10. Selected Nerve Transfers (CSC Reconstructive Strategy for 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) Useless Limb -> Assisting Limb
- 11. 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 ELBOW FLEXION: • Ulnar nerve fascicle to biceps branch (Oberlin) ELBOW EXTENSION: • Triceps branch to axillary nerve Weak Limb -> Useful Limb
- 12. 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
- 13. 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
- 16. Thank you This work is licensed under a Creative Commons Attribution 4.0 International License.
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 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.