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Behind the Knife, the surgery

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and in bundle pricing. All

1:28

right, let's get back to the episode. Hello

1:30

and welcome to Behind the Knife. Today we

1:32

will host another episode of our new global

1:34

surgery series today with a special focus on

1:37

trauma care and emergency surgical care in remote

1:39

and resource limited settings. Traumatic

1:41

injury remains one of the largest burdens of disease

1:44

and causes of mortality at the international

1:46

level. WHO estimates that

1:48

over 4.4 million lives are lost

1:51

to traumatic injuries per year, accounting for

1:53

approximately 8% of all deaths. Typically

1:56

traumatic injuries are the top killer in children,

1:58

adolescents, and young adults compounding the pain. patient

2:00

years lost. Trauma is

2:02

ubiquitous. Accidents and injuries happen all over the

2:04

world, and thus differences in

2:06

trauma incidence and mortality is often a function

2:09

of health systems and infrastructure. Today,

2:12

we'll explore these concepts with a prominent leader in

2:14

both the field of trauma surgery and global health.

2:17

Specifically, we'll discuss the importance of systems-based interventions,

2:19

not only in the hospital setting, but also

2:21

in transit, in the field, and in the

2:23

community that the hospital serves. Additionally,

2:26

we will talk about the challenges and

2:28

successes of implementing these concepts in

2:30

resource-loaded settings across the world. I'm

2:33

John Williams, one of the Behind the Knife fellows, and

2:35

with me today, I have Dr. Anthony Charles. Dr.

2:38

Charles is a trauma surgeon at the University of

2:40

North Carolina, Chapel Hill. Additionally, he holds

2:43

professorships in the medical school and School of

2:45

Public Health at UNC, as

2:47

well as serving as the director of the Adult ECMO

2:49

Program, and the director of global

2:51

surgery at the UNC Institute of Global Health

2:53

and Infectious Diseases. He

2:55

also leads the Malawian Surgical Initiative,

2:58

designed to train and support local surgeons in the

3:00

country of Malawi, where he has

3:03

established a longstanding partnership with UNC.

3:07

Having been raised in Nigeria, Dr.

3:09

Charles completed medical school at the University

3:12

of Lagos, and subsequently underwent general surgery

3:14

residency training in London at

3:16

North Middlesex University Hospital, and then

3:18

subsequently at the Charles Drew University

3:20

in Los Angeles, California. Upon

3:23

completion of trauma and critical care fellowship at

3:26

the University of Michigan, he took a faculty position at

3:28

UNC, where he has remained since, and

3:30

has grown their global surgery presence to what it

3:32

is today. Dr. Charles, thank

3:34

you so much for joining us, we appreciate it. Well,

3:37

thanks very much for having me, and I'm happy to be here. Great.

3:41

Well, I guess first, I'd love to learn

3:43

more about you and your inspiration that brought

3:45

you to where you are today. Can you tell us

3:47

more a little bit about your personal journey that brought

3:50

you one into surgery in general, but also

3:52

into the global surgery space? Certainly.

3:55

So I have a very long and

3:58

unusual story. My father was a... as

4:00

a physician, my mother is a nurse, I've

4:03

got a whole load of doctors in

4:05

my family, my oldest sister is a

4:07

pediatrician and my younger

4:09

brother is in public health at the

4:11

United Nations. So I feel

4:13

like an underachiever really in

4:17

the healthcare space. But you know

4:19

with growing up in a medical family, you

4:21

know doing medicine was kind of sort of

4:23

imprinted in me from childhood. But

4:25

in medical school, I heard

4:27

a phrase from one of my professors that says,

4:30

a surgeon is an internist that has

4:32

completed their medical education. And

4:35

that kind of struck me as something rather

4:37

profound. I thought well as a

4:39

surgeon, really you have to be just

4:41

as good as an internist and then you can use your hands. And

4:44

I also have an attention span

4:46

of a grain of rice and surgery,

4:49

well about instant gratification. And

4:51

so I decided to do surgery. I

4:54

went on to do the fellowship of

4:56

the Royal College of Surgeons in Ireland

4:59

and in Edinburgh, my training in the

5:01

UK. And I

5:03

fell in love with a Nigerian American, I

5:05

moved to the United States, I

5:07

did my residency all over again in Los Angeles and

5:10

came over to Ann Arbor. I did

5:12

critical care. I'm

5:14

an accidental academic really because I thought I was going to

5:16

go into private practice when I was done. But I

5:18

said well let me try out academics

5:20

first if I don't like it, the private world

5:23

is still waiting. And I happened to

5:25

be at the right place at the right time by coming

5:27

to Carolina. At the

5:29

time I came here in 2006, the University of

5:32

North Carolina had been in Malawi

5:34

since 1989 with the HIV AIDS

5:36

crisis and they had a

5:38

collaboration there. And by 2007 with PEPFAR and

5:43

all the funding the Wednesday HIV,

5:45

HIV became a chronic disease and they noticed

5:47

that a lot of the HIV patients were

5:49

dying from trauma. And so

5:52

I was tasked to go to Malawi

5:54

and essentially just make an assessment and

5:56

see what we can do to help.

6:00

And the hospital where we work at, it's in

6:02

Lilongwe Malawi, it's a 100,000 bed hospital and

6:05

at the time they had only one surgeon and he was 84.

6:09

And it became a button to care to me that

6:11

this is not viable, no, no, no, is it sustainable.

6:14

And the first efforts that we, when I came

6:16

back and I spoke to my chair is let

6:19

us see how we can essentially set up

6:21

a surgical residency program for Malawi and

6:23

so they can stay in the country.

6:25

Historically, a lot of their physicians had

6:28

been sent abroad and they

6:30

never came back. In fact, there were more

6:32

Malawian physicians in Scotland than there were in

6:34

Malawi. And so

6:36

we felt well, if we can support

6:38

them in country, train surgeons in general

6:40

surgery and orthopedics, which is really where

6:42

the bulk of the trauma burden is,

6:45

then we can do something that is

6:47

sustainable, that can sort of change and

6:49

move the needle when it comes to

6:51

global surgery. And so that's how I

6:53

got involved. It's

6:56

great. Yeah. And I

6:58

think it's, you know, kind of highlights a fascinating

7:00

theme that you and a lot of other global

7:02

surgery experts have touched on, which is, you know,

7:04

personnel is such a big part of

7:07

the equation and a lot of times there's

7:09

the best initiatives are the ones that grow

7:11

personnel. Well, thanks again for taking the time

7:14

to chat with us. It's been well

7:16

described on the large scale that trauma

7:18

is a massive burden, especially in these resource

7:20

limited or low and middle income countries. Could

7:23

you tell us more about some

7:25

of your experiences on the ground when you were there

7:27

in Malawi and what might have brought

7:30

those issues to light in a really meaningful way

7:32

to you? And were there any specific

7:35

events or cases when you were there other

7:37

than just seeing the sheer

7:40

size of the hospital and

7:42

few amount of surgeons to serve that hospital? Certainly.

7:45

So in the long way, I mean,

7:47

Malawi is a poor country, it's mostly

7:50

rural, but we're in the city and

7:53

every day you had about

7:55

15, 20

7:57

patients been brought in with a primary reason

7:59

for been shown to the surgical services, they've

8:02

been trauma. With one surgeon,

8:04

clearly for those that need an operative intervention,

8:06

it's really a matter of timing.

8:08

If you show up at the right time and the

8:10

surgeon was free, you get a surgery. If you don't,

8:12

you have to wait. And so the mortality was actually

8:15

relatively high. That's

8:17

one thing. Second thing that I noticed really was

8:19

that because a gallon

8:21

of gas cost around 10 and

8:23

11 dollars, the way

8:26

public transportation was set up was

8:29

there really was none whereby people either

8:31

walked, got on a bike or

8:34

stood behind a flatbed truck

8:36

to move from point A to point B. And

8:38

you can imagine where the roads are not very

8:40

good. You jump over a pothole, people essentially careened

8:43

off the flatbed truck and mass casualty

8:45

was a real problem. And

8:49

thirdly was the fact that trauma is an equal

8:51

opportunity disease. It doesn't matter who you are, what

8:53

your social standing is, it can happen to any

8:55

one of us. And

8:57

I can remember there was an American

8:59

couple that came to Comuso Central Hospital,

9:01

there were tourists, and they were involved in

9:04

a motor vehicle crash. The wife

9:06

was presented to us an extremist. She

9:08

had ruptured her spleen, she was

9:10

hypotensive and tachycardic. And I just got

9:12

a phone call being a surgeon on the ground saying

9:15

that there's an American here and just to stress

9:17

can you help. And it occurred

9:19

to me that one, if

9:21

I wasn't around, they would have been a half of them to

9:23

get the surgeon and do it in a timely manner. And

9:26

secondly, she was a death toll. Luckily,

9:29

she was taken to the operating room. I

9:31

would do a spleen actually and she did okay. But

9:34

all the other what I call the accoutrements

9:36

of trauma like CT scan

9:38

and getting a plane film and

9:41

making sure the blood bank had enough

9:43

blood and all that was really absent.

9:45

And so it kind of so

9:48

puts in focus just the complexity of

9:51

already building a

9:53

surgical ecosystem that can treat trauma.

9:56

Because if you can do that, you

9:58

can treat every other disease. disease

10:00

process. And Bryce, if you have

10:02

a healthcare system that is built

10:04

on the basis of delivering surgical

10:06

care, trauma being a major aspect of

10:08

that, you can deliver all care. And

10:11

that's the way I've sort of looked at it

10:13

and thought about it. The

10:15

other thing that was also very obvious, particularly

10:18

in the field of global health, is this

10:20

disproportionate emphasis on infectious

10:22

diseases. And

10:24

a lot of people kind of look at PEPFAR, the

10:27

HIV-AIDS as one of the most altruistic things

10:29

that the American government has ever done, which

10:31

is good, it just grew. But

10:34

the truth of the matter is

10:36

infectious diseases are looked upon

10:38

as national security issues and

10:41

not healthcare issues. Therefore, if a

10:43

patient has got HIV and Malawi, it's better for

10:45

me to treat HIV and Malawi so

10:47

that it doesn't come to Chapel Hill. If

10:51

a person gets in a car crash in Malawi, well,

10:53

guess what? They got a car crash in Malawi, everybody's

10:55

Chapel Hill is fine. So

10:57

we need to start to look at

10:59

trauma as something that can affect anybody

11:02

or stories in the country so

11:04

that we can start to talk about the

11:06

real financing of trauma in order to really

11:08

make a huge difference. Absolutely. I

11:11

think that concept of communicable

11:14

versus non-communicable disease is interesting,

11:16

whereas the roots of global

11:19

health initiatives have been towards phenylchol

11:21

diseases, as you said. I

11:24

think that surgery and

11:26

also trauma surgery is kind of a hard

11:29

sell to the stakeholders that might

11:31

provide the financial or expertise backgrounds

11:33

to build initiatives in low and

11:35

middle income countries where surgery is

11:38

an expensive thing to provide to somebody. And

11:41

like you said, what's

11:45

the internal benefit for

11:47

the group providing that

11:49

care? Yeah, the other thing I want

11:51

to also notice of course is that trauma

11:54

victims are usually those between the ages

11:56

of 15 and 45 and these are

11:59

people who are the best. prime of

12:01

their productive lives. In

12:03

Sub-Saharan Africa, the average age is

12:06

less than 18. Life

12:09

expectancy is roughly between 55 and

12:12

60. So if the

12:14

most productive members of your society are

12:16

being struck down by trauma, then

12:18

certainly it's going to affect the economic health

12:20

of the country. It's going to

12:23

affect not just individuals, both families and

12:25

the extended family is going to affect

12:27

agriculture, but to be where subsistence farming

12:29

is the mainstay. And the sequelae and

12:31

the downstream effects of trauma is just

12:33

tremendous. Absolutely.

12:36

You mentioned something a little bit earlier

12:38

about this concept of, you

12:41

know, I think the pattern of trauma

12:43

disease and trauma care is so highly

12:45

influenced by the infrastructure of the general

12:47

area outside of the healthcare systems itself.

12:50

Folks sitting on the back of flatbed

12:52

trucks to get their work

12:54

every day, lack of

12:56

public transportation, lack of reliable

13:00

pedestrian paths versus roads and things like

13:02

that. Have you either

13:05

been part of or have kind of seen

13:07

success in initiatives that are

13:10

centered around kind of pre-hospital trauma

13:12

care, whether that be prevention or

13:15

triage and getting these

13:17

patients to a center where they can get the care they

13:19

need? Yes. So interestingly,

13:21

you know, sort of the key, I

13:24

think we all know this, the key

13:26

to trauma is prevention and primary prevention

13:28

strategies are particularly difficult

13:30

in trauma because really you're asking for

13:33

a change in behavior. Right?

13:35

And so that is always very

13:37

difficult to do as a

13:39

surgeon, right? That is not our area

13:41

of expertise. All right? You

13:44

know, secondary and tertiary prevention is where we

13:46

focus our efforts. And one

13:48

of the biggest things is, okay, the

13:50

trauma has happened. How are you

13:52

going to get a patient from the site of

13:54

injury to where they can get

13:57

definitive care? So we worked with

13:59

the World Bank. The World Bank

14:01

has an initiative whereby they tried

14:03

to essentially start a pre-hospital service

14:06

and also try to upgrade

14:09

all of the what I'll call the tertiary care facilities

14:11

in the country such that if

14:15

a motor vehicle crash occurs,

14:18

an ambulance can be called that

14:20

is stationed all across the highway and then

14:22

the patient can be brought either to the

14:24

closest hospital or hospital for definitive care. Just

14:28

like everything else, the amount of money

14:30

they thought they were going to need to do it

14:32

and the amount of money that was actually available, there

14:34

was a huge gap. So

14:37

it ultimately wasn't very successful

14:39

but what it did do was

14:41

essentially bring trauma to

14:44

the attention of the Ministry of Health

14:46

and there were some resources brought into

14:49

the essentially enhancing the

14:51

trauma bay, making sure resources were

14:53

available, making sure cervical cars

14:55

were available. The second thing

14:57

that we've also done is

14:59

the fact that the majority of trauma victims are brought in by

15:02

the police and so

15:04

having an initiative that actually trains

15:06

the police in basic life support,

15:09

basic trauma care was

15:11

what we believe was going to be helpful. Now

15:14

showing whether or not it's helpful has been

15:16

challenging because we can tell you the data

15:18

and the amount of trauma is significant. The

15:21

third thing we actually have a unique

15:23

advantage in Malawi that we have set

15:25

up is that every death,

15:29

whether it's happened in the field or

15:31

at the site of injury or before

15:33

hospital has to be brought to the hospital

15:36

to be declared and certified and so

15:38

we know the just

15:40

the shared number of trauma related

15:42

deaths that are happening because all

15:44

the bodies have to

15:46

come through the casualty departments. And

15:49

so we have a fair idea of trauma but we

15:51

also know based on that that trauma

15:53

mortality has gone down given the increase

15:55

in personnel and it showed up

15:57

to the hospital. Robins

16:00

altered Free hospital. That's what we shouldn't

16:02

have altered in hospital debts by increase.

16:04

Not so I tried occasion top us.

16:07

Now I just the operating on Isis

16:09

blow banking. And. So forth. Very

16:13

interesting. yeah I remember being in turn

16:16

myself in net a take a lot

16:18

of our trauma surgeons really. Hammer.

16:20

Home. This concept of it's kind of like the

16:22

three. Spikes. Of trauma deaths

16:24

every year the first bike is before they

16:27

ever. You. Know right on the scene

16:29

before they ever see Care Provider. The. Second

16:31

is an enemy or assesses here period in it.

16:33

The third is. And. Some point down

16:35

the road when. He. Really made it

16:37

through that initial presentation. but there. And.

16:39

The I see you so. I guess

16:41

my next question is about in hospital trauma

16:43

care. Is kind of in a segway

16:46

to that. Consider. A

16:48

in hospital travel care in. Places.

16:50

Like my alley. You. Think

16:52

that this should look. Identical

16:54

or similar to in hostile trauma

16:57

care in. The United

16:59

States and the Western World Year

17:01

we have well established advanced Olisipio

17:03

training. We have. Trauma. Center

17:05

distinctions that are. Provided. By

17:07

governing bodies of our profession or are

17:10

there some aspects of this systematic approach

17:12

of in hostile trauma care that need

17:14

to be tailored to these areas. Was.

17:17

About that that's a great question. Adding that suit

17:19

two ways to from his or answer your question

17:21

of the first the Aussies as human physiology of

17:24

the same. Regardless away your. Rights.

17:26

And several years on with Hypothalamic Salty. Malawi's

17:28

on. Absolutely shocking. The I states is one

17:30

of the same and if you do not

17:32

seats either in a timely manner the results

17:34

are going to be the same. right?

17:36

And so on the one hand, there's a

17:38

basic. Necessary. Requirements

17:40

in other to manage trauma. Anywhere

17:43

in the world that has to be

17:45

available. So access drive a flurry to

17:48

access to. To. You know,

17:50

intravenous cannolis, access to timely

17:52

blood. Okay and access

17:54

to basic storm I can't as

17:56

of knowledge. And access or to

17:59

solder free. I. I think those are the basic

18:01

things. Now, do I need to CT scan everybody in Malawi?

18:03

Absolutely not. I think with good clinical exam

18:06

and timely access to things I've previously listed,

18:08

I think you can move the needle. That's

18:11

one thing. The advantage we have

18:13

in the United States is we have plenty

18:15

of personnel, not just surgeons, right? So your

18:17

trauma shows up because of the emergency department,

18:19

the ED folks who evaluate you, your trauma

18:21

surgeon comes along. You have critical

18:24

care and intensivists. You have plenty of

18:26

nurses. You have non-commissioned physicians. Well

18:28

on the other hand, in Malawi, we

18:31

give away to weeks to

18:33

have enough surgeons to

18:36

be able to provide adequate trauma

18:38

care. We'll wait a lifetime,

18:40

right? That will happen. And so

18:43

the emphasis is really on training

18:46

physicians and non-physician clinicians

18:48

alike to be

18:50

able to provide trauma care and

18:53

child surgery care, not just at the

18:55

central tertiary referral centers, but also in

18:57

the district hospitals. And also

18:59

understanding and giving them the notion of who

19:01

do I refer, who do I hold on

19:03

to, and what are my capacities and capabilities.

19:07

And so to answer your question

19:09

directly, I do not think that you would need all

19:11

the bells and whistles that we have in the United

19:13

States to change the move the needle, but I

19:15

think there's a basic minimum set that you

19:17

need. You need people, you

19:20

need the patients to arrive in a

19:22

timely manner in the right place, right? You

19:24

need all the other resources that

19:26

a hospital should bring to bear,

19:30

water, electricity, supplies,

19:32

disposables, blood. And given the fact that

19:34

the mortality is high right now, it

19:37

does not going to take a lot to actually

19:39

bring the mortality down. Now, we may never get

19:41

it to that of the United States, but we

19:43

certainly can bring it close. Absolutely.

19:48

So the basic supplies and also the people that

19:50

know how to use them sounds like. Correct.

19:53

Okay. Without the ones like

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So, yeah, I think it's interesting when you mention... It

20:57

is. I

20:59

think in the United States, there needs to be trauma

21:01

surgeon present to take care of a trauma patient. Yeah.

21:03

But I think that's, like you mentioned, it's unrealistic in

21:06

a lot of places of the world. What

21:08

does that outreach look like in your

21:11

experience with the Malawian Surgical Initiative to

21:14

spread the knowledge and the basic

21:16

amount of training to physician

21:19

and non-physician providers that are not

21:21

surgeons and have no intention

21:23

to be a primary surgeon, but really to

21:26

provide this care to people? Certainly.

21:29

So, we've been very lucky that we've worked

21:31

closely with the medical school.

21:33

And so, we have a pipeline of physicians

21:35

that are going to be joining a residency

21:37

program. And then there's

21:40

also something called a clinical officer surgical

21:42

training. It's called the COSP program where

21:45

essentially the equivalent of PAs and

21:47

NPs can be trained

21:49

in surgery. And they're the

21:51

ones that are going to be located in what are

21:53

called the community hospitals or the district hospitals And

21:56

essentially teaching them something called not the

21:58

equivalent of the ETA. The in a

22:00

slight scobey internationals all of our support. Education:

22:03

Busy summer. Course. And

22:06

we've done that. I. Think

22:08

it's been moderately successful.

22:10

I think one of the things

22:13

we forget his when you have

22:15

our healthcare system. That. Has

22:17

more non clinician providers.

22:20

Then conditions. There. Has

22:23

to be oversights. He.

22:25

right? So. For.

22:27

Instance you will never let appear move your appendix.

22:30

Yeah, he received Michigan or a bus. Never gonna

22:32

happen zone going to happen in our lifetime. Okay,

22:35

And. So. If. That isn't acceptable

22:37

to you than what is should also

22:39

be similar ya acceptable to our colleagues on

22:41

our part of in Africa But the

22:43

reality is. Sometimes. If

22:45

the As we do trained and. There's.

22:48

Someone who is available should they

22:51

get in trouble. In

22:53

of their guy I. The. No.

22:55

Place. In emphasis on not wanting some providers.

22:58

Would. Work and so is really about

23:00

of extinction oversight to everything they do.

23:03

I. Know that's me once get similar

23:05

results. We have looted this specifically in

23:07

Pediatric surgery in trauma. Very.

23:09

Well trained, Non to

23:11

some physicians can provide. Similar.

23:14

Cat. With. Similar results.

23:17

right? But understand where you draw the

23:19

line in terms of complexity. Your I'd is

23:21

really surgical judgments. That. Is hard

23:23

to train someone erectus, I need any

23:25

that a bit of oversight as what

23:27

we've done that but is really the

23:29

keys. Repeated training. And it's release

23:32

of Constance trainees are we train them

23:34

now that with the the go up

23:36

there for two years yes bring them

23:38

back in and films were fresh avenues

23:40

for going refreshes and that's where the

23:42

difficulty sense convince him to come back.

23:44

As. Be challenging. I.

23:47

See. A bridge between paradigms

23:49

and undies. You know, establishing the

23:52

standards of trauma training for these

23:54

providers. Where did that

23:56

process look like to make that training

23:58

program was their trial and. Where Where

24:00

Where There are times? Where. It. Did

24:02

he realize that? You need to do

24:04

this differently or we need to do this at a higher

24:07

frequency. You're. Eighteen or

24:09

heard. It while. Trial and error

24:11

will will will, we will be bought or wider.

24:13

It's in terms of. You

24:15

just have to see whether or not you're

24:17

getting through to folks in see well Ah

24:20

the understand what you're doing and India. So.

24:22

So. All. The bells and

24:24

whistles in have some a splint at all at

24:26

the will have to in a deal as and

24:29

and the United States is is not available. But

24:31

you could improvise. Or. Write a

24:33

sequel. Is a Sikh all a anywhere right? He doesn't

24:36

have to be the beautiful see cause we use here

24:38

that are the ones that are simple. And

24:40

cheaper that can achieve similar

24:43

things. Are really easy. Trying

24:45

to gauge the baseline knowledge

24:47

of the tree nice is

24:50

most challenging. And right. And

24:52

some people are gonna get it right away and they going

24:54

to excel and into the another. Got it and other people

24:56

just go take their time and gonna have to do it

24:58

again and again and again. And understanding

25:00

that not everybody's kind of oscillates

25:02

now the same pace as really

25:05

that. The biggest challenge and awesome

25:07

on number two. It.

25:09

Is sometimes they language barriers mean other

25:11

than they are, because even though Malawi's

25:13

a former British colony in this is?

25:16

In as the language of business, not

25:18

everybody speaks English and so it's he

25:20

those things we we lost in translation

25:22

and so that that's another challenge. But

25:24

more importantly we have to test. You.

25:27

Know and do scenarios with our trainees to make

25:29

sure they get it. And that's the

25:31

only way to do it's. Definitely.

25:35

It's can be at the age old

25:37

train showers, bed rings true regardless of

25:39

than medical setting. Mayor Ed is. What?

25:41

Every learners different and hands you know

25:44

there's no cookie cutter. One size fits

25:46

all train for him. As right

25:48

as on people will just never be good and

25:50

I just have to recognize the lead. I'm not

25:52

mad. maybe list of the best bet is thing

25:54

for them and that's okay. Absolutely.

25:57

Absolutely. Old. Ten zooming

25:59

out. I know we talked a lot about

26:01

personal training in. Establishing. The

26:03

basic resources required for trying to care.

26:06

Now. That been involved with didn't allow research

26:08

on a ship for some time weren't big

26:10

T challenges that you see that remain today

26:12

versus the one that you feel like. We've.

26:16

Me: a lot of ground on. For.

26:18

The ongoing improvement A Trauma care. In

26:20

that setting, So. That

26:23

the greatest challenge to global

26:25

surgery. Attaining to trauma

26:27

is pub in the loophole

26:29

Ministries of Health. Understand.

26:33

The. Importance of providing and

26:35

supporting and finance and. Surgical.

26:38

Can former care and the

26:41

impact of. Doing that

26:43

on the overall national economy and

26:45

gdp. The. And until

26:47

they understand that they are

26:49

more likely to just assume

26:51

that either trauma somebody else

26:53

problem. And. We don't even

26:56

would only to spend money on it

26:58

or you will only response to our

27:00

donors and most of the don't dissolve

27:02

infectious diseases ah. Supported. Dot

27:05

or projects. And. As Malibu

27:07

Grid greatest challenge I'm in our in our

27:09

our I spent some allowing the acknowledge and

27:11

recognize the impacts of having a surgical training

27:14

program. They acknowledge the

27:16

in by two blue immortality. Ah,

27:19

But. I yet to funded. And.

27:22

So so at some point in time, It.

27:25

May no longer become sustainable because they have

27:27

to have a pot in his adding

27:29

the key to any successful duel program. Is

27:32

have a your local partners buying a hobby

27:34

a local part to set the agenda. And.

27:36

In I experience. That. Has

27:38

been the greatest challenge, you know not. I didn't

27:41

want to set the agenda where they don't want

27:43

to pay for it's. Ads.

27:45

Nelson Financing Global Surgery.

27:48

Or. Has mostly been slammed saw bake.

27:50

even the Nih doesn't have enough grants.

27:53

To. Have to syria to his of bills urge

27:55

as an entity to force people to change the

27:57

pod I'm on the ground. Allow the.

28:00

And in comes from so anthropic

28:02

organizations industry has helped Johnson Johnson

28:04

as gonna agree partner with us

28:07

and doing this. And so

28:09

try and see project for his

28:11

you know. We need

28:13

a much more sustainable funding

28:15

structure. Either. Were philanthropy on I and.

28:18

All. The ministry of health on on on our

28:20

part of sent to make it work work.

28:24

And. Who shouldn't either ones? They're

28:27

advocating for that, right? You know? a

28:29

killer gets. It. Seems like it's

28:31

a little bit challenging for somebody to come to

28:33

the United States and than. Preside.

28:36

Bread that ministry of Health that in Malawi

28:38

and say i know what's riot you said

28:40

agree with me. What? Does that advocacy

28:42

cyber quake as a soft spot shots out?

28:44

So one of the things he lively about

28:47

while been grappling with is what is the

28:49

will of the Wh? Oh. There's

28:51

a lot had organization has a Los we on

28:53

the ministry of health and and in each country. I

28:55

was the World War, where the hell did I organization

28:58

when it comes to surgical care? And

29:00

from okay. In. Reality Debate

29:02

or as it would have much of a large

29:04

budgets and the office of Google search or this

29:06

or who the smallest spotted would you go everywhere

29:09

One person that of right now and so so

29:11

so it's challenging is up. There. Debater

29:13

is also there's almost like it also needs

29:15

aid from individual countries to function. And.

29:17

Save money that are coming of age or that bisley little

29:19

that can happen on the rap. But.

29:22

I think. What Should happen? Release

29:24

A. We can make a financial. If we

29:26

can make a financial. I didn't. Bomb.

29:28

Why it is important. For.

29:32

A country that is so desperately

29:34

need of healthcare resources or finance

29:36

all the money to for healthcare.

29:39

To. To protect it's own people, If

29:41

the way to even if they're gonna come out

29:43

of poverty. So. How did he?

29:45

you having a cost benefit analysis? Trauma

29:48

case important? Big. Enough financial

29:50

arguments are just to the minister of

29:52

help others, Minister of Finance. And

29:54

the has to com that's that's what I believe is the

29:56

next step and that's a little can help them with. You

29:59

know if we can share? Where. I do For thousand

30:01

people are dying from drama every day. right?

30:03

And H Elites have you ever that hundreds

30:06

of men. Rise. And the

30:08

ball have a wife and three children.

30:10

On average, that is a significant amount

30:12

of loss. right? Of it's

30:14

medium for the country. At if

30:16

you're gonna come out of poverty, people to

30:18

work. And if trauma have a

30:20

placebo, the what if don't die from trauma

30:22

See how a satchel fema. That. That's

30:25

it right You tell you can local walk on

30:27

the farms and so so that has the we

30:29

have to make of financial I didn't so that

30:31

it is. You. Know incontrovertible that

30:33

if you invest in Sharma, we

30:35

all read solid investment is is

30:37

is is worth it. And

30:39

that was has to happen and that that's what. that's

30:41

where we need so spend our time on. A

30:44

surges when I experts in that but was so big and.

30:46

Partner. With experts to help us convinced that

30:48

the governor that the governments of the parties are

30:51

working with suit to make that argument. Very.

30:54

Interesting in this concept of tragic

30:56

injuries or health burden, but they

30:59

are in economic burden maybe even

31:01

more so to act. In.

31:03

These countries final question

31:05

is is or. folks.

31:07

Like myself, trainees, students,

31:09

young, early career surgeons,

31:12

Who. Are interested in and inspired

31:14

and eat words of wisdom for.

31:17

Getting. Involved in global surgery work. Suddenly.

31:20

I will say the first thing you have to

31:22

do is. No yourself.

31:25

And that that is, ask yourself what

31:27

is my motivation. Or. Bilbo

31:29

Surgery or be will health as a whole.

31:32

And in all kinds of the so

31:35

categorize that the are types of trainees

31:37

or surgeons. Or. Ones into the global

31:39

said surge of the at their. Their

31:42

mercenaries, they missionaries, and their

31:44

misfits. And you have to ask

31:46

yourself, which one are you. Okay, At

31:49

was that is clear your mind

31:51

arise. Because. I'm very busy.

31:53

Go to a loves over developing countries. You see all

31:55

kinds of people that sort of other just there to

31:57

find themselves. Sample. Other to find us.

32:00

And some people are there to get paid this

32:02

Sunday the time to extracts from the on the

32:04

Country. But. As a fourth group

32:07

who I call that academic medical centers which

32:09

I think do global surgery the best where

32:11

you wanna trade was trend these or we

32:13

do. Education is key. were coming from a

32:15

like academic an educational center by you. What

32:17

does he wrote Cynical care rarely do that.

32:20

I want to do research. As. We find

32:22

out and ask the tough questions and so I'll

32:24

tell people if you Really interesting little surgery. You

32:27

see department ought to be to yourself with an

32:29

academic medical sense to that are it does it's

32:32

and does it well. And. Where

32:34

the entire resources of that institution.

32:37

And the woman Bristle Dynasty can protect. You ain't when

32:39

you're on the ground. Or. You don't really

32:41

have to reinvent the wheel or the older beloved

32:43

which is t since I've done this. Try

32:46

to do this by yourself is hot and

32:48

ah in a try to do missions such

32:50

as expensive are not by show is worth

32:52

the return on investment. But. Having

32:54

a long term partnerships are way can

32:56

deliver care you can trained other the

32:58

the future generation of of surgeons in

33:00

that country. I can do research web

33:03

I asked him what puts them in

33:05

question since I find solutions I think

33:07

isolated up. All. Right?

33:09

So just wrap up or aka highway.

33:11

Some key points from are very conversation

33:13

first is that. Often total

33:16

first step. To. Improving trauma

33:18

care. In. A resource voted setting

33:20

is to increasing trained personnel. Both.

33:22

Are at that position level and the

33:24

not omniscient level so that. There's.

33:27

A lot of. Bandwidth. To provide the

33:29

trauma care that folks needed, some training and

33:31

issues are obviously very meaningful in the space

33:33

and. More. Sustainable in terms of

33:35

styles of it bodes initiatives that can be

33:38

made. Second, As you

33:40

can, build a trot a system that treats

33:42

trout patients well. It turns out that that

33:44

also. That. Kid translator treating all

33:46

the medical conditions well to it kind

33:48

of. Is the tie. The ride is

33:50

all ships in terms of health care of it and

33:52

of the in hostile setting. Other

33:54

key to improving trauma care. Is. That

33:57

it is a Maltese setting

33:59

initiative. So. Includes provision of

34:01

disease of safety measures. Pre.

34:03

Asshole Care Tree hugging and

34:05

and transporting patients appropriately. And.

34:07

Of course the in hospital care. With. Scared

34:09

as protocols to minutes Third patients for

34:12

Mac injuries. It. Takes

34:14

more than just surgeons to improve trauma care in

34:16

the global setting. Thus, Both.

34:18

Clinician and Nine. Clinician training is

34:20

critical and requires allows. Outreach.

34:23

And tailoring as train paradigms to

34:25

train folks aren't just surgeons. And

34:28

finally. The economic side of the

34:30

coin is possibly even more important in there

34:32

needs to be support from local governing bodies

34:35

to. Understand the importance of trauma

34:37

care and invest that trauma is a.

34:40

Medical. Burden. But it's also financial

34:42

burden on these countries, and their

34:44

financial burden is possibly the most

34:46

convincing argument in terms of it's.

34:48

Allowing. For economic. Incentive in

34:51

support improve trauma care systems were allied.

34:54

Their got a good at Charleston as allow The

34:56

great allows a great summary. I think you hit

34:58

the hit all the meals. On. All

35:00

the heads a specific. Nut. Or

35:03

bank you. Likes again add add charles.

35:05

I think all of us in our listeners

35:07

had. Learned. So much for your

35:09

perspective and your spirits on trauma care delivery

35:12

and Malawi and and on the global stage.

35:14

We. Absolutely. Appreciate your time and

35:16

your work. If you enjoyed

35:18

this episode, be sure to keep an eye

35:20

out for future behind a Nice Color Surgery

35:23

series of So it's if you're interested in

35:25

more topics or have suggestions in regards circle

35:27

the surgery content. Please feel free to contact

35:29

us at hello at behind a nice.org. I

35:32

conclude or episode we hope you're much more familiar

35:34

with how to Feel is growing so rapidly over the

35:36

years. And. The influence. That.

35:39

We can all have on a global scale in terms of

35:41

trauma surgery. Appreciate your listening

35:43

and until next time dominate the

35:45

day. He should

35:47

check out our website www.behind the Knife.or if

35:49

the more great content can also follow us

35:51

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35:53

has he has and I thought cast you

35:55

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35:57

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36:01

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36:04

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36:06

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