On the first afternoon of a three-day training session in Kampala, Uganda, Whitney Fu hung back. Nineteen Ugandan surgery residents, along with two Yale residents and Kevin Pei, MD, assistant professor of surgery, were clustered around two cadavers. Fu, a medical student, didn’t want to take up precious space.
“What are you doing back there?” asked one of the Ugandan residents as he motioned her over.
“Dr. Pei was directing people to feel this one structure and the resident said, ‘Get your hand in and feel it,’” Fu said. “This was an awesome example of generosity of spirit—we want everyone to learn and gain.”
That gesture made clear that, in this workshop, education was a two-way street. “We go over there, and we learn as much from them as we hoped they get from what we’re offering,” said Fu, who’s on track to graduate in 2019. Before the team left New Haven, she prepared educational material and PowerPoint presentations, and drafted a trauma management pocket guide. “We are united under this goal of education and patient care.”
Pei, Fu, and the two surgery residents were in Mulago Hospital in February for a week-long trip that included two full days of travel in addition to the three-day workshop that covered operative dissection and use of ultrasound in a trauma setting. Their team was the latest from Yale to travel to Kampala since 2006, when the Department of Medicine and the medical faculty at Makarere University launched their collaboration on clinical care and training. Over the years Yale faculty, residents, and students in pediatric surgery, endocrine surgery, emergency medicine, and obstetrics and gynecology have gone to Uganda for clinical rotations and research projects. Pei first brought a team to Uganda in 2017 and returned this year. Both times, he has offered training in trauma surgery.
“This is purely educational,” Pei said. “We’re trying to focus on capacity building.”
Pei’s path to Mulago Hospital started with a colleague at Yale. Doruk Ozgediz, MD, assistant professor of surgery (pediatrics), and of pediatrics, has had a long-standing relationship with Mulago Hospital, having spent a year there earlier in his career. An informal needs assessment led him to conclude that residents there needed more trauma education. The curriculum was determined in consultation with Ugandan faculty. “We were trying to support what they wanted and needed, as opposed to having an agenda of our own,” Pei said.
After discussions with their Ugandan counterparts, the Yale team scaled back the course from the four-day session offered last year to just three days—the 19 Ugandan trainees comprised a third of the trauma section’s work force, a main source of care providers. “There, the residents are the manpower,” Pei said. “If they’re not on the wards, patients aren’t taken care of.” But the Ugandan residents were not totally relieved of their duties—one arrived for the 9 a.m. class after spending the night on call.
The Yale team arrived in Kampala with 100 pounds of surgical supplies in five duffle bags and spent the evening before the first class organizing scalpels, forceps, hemostats, and retractors spread out over beds and desks in a room in their guest house. Still jet lagged, the team started at 9 a.m. the next morning with didactic sessions on initial management and resuscitation of trauma patients.
“Then we transitioned to inter-operative management, how to approach different types of injury,” said Michael DeWane, MD, a fourth-year surgical resident. “Penetrating abdominal injury has one protocol versus blunt abdominal injury. That’s like the difference between getting stabbed in the belly versus being hit by a car.”
The other component of the course was ultrasound, a substitute for X-rays or CT scans that are not always available to Ugandan trauma surgeons. “We have a lot of experience with that and sharing our skill set with them allows them to get more utilization out of a resource that they have there,” DeWane said.
The entire team wrestled with the difficulties of working with limited resources. They had brought their own surgical tools because none could be spared from the operating rooms in Mulago. And, they observed how careful their Ugandan colleagues were to tie off their sutures with as little waste as possible. For the Yale team it was a lesson in resource-limited medicine.
“We are coming from a place of essentially unlimited, infinite resources, so in a sense we are not prepared to be in that setting,” said Matt Fleming, MD, a third-year surgical resident.
“It has been an eye-opening experience,” Pei said. “What they can do with what they have is astounding to me. Given the same situations with what they have, we would be paralyzed.”
Pei hopes to continue offering the course and would like to add a clinical rotation at Mulago for students and residents. He also plans to make the curriculum available online. “I don’t want us to be a group that pops in for a week and then leaves, not to be seen for a year,” Pei said. “I want us to be engaged.”
For Pei, one of the highlights of the trip was a social gathering at the end of the course.
“It got beyond the PowerPoints and the surveys and the cadavers and brought it to a personal level,” Pei said. “We talk about resilience and grit, and I see it there. When resources are limited, people rise to the occasion and do the best they can. This trip gave me a lot of hope.”
Namugga Martha Monica, MD, a general surgeon in the accidents and emergency department of Mulago, said the residents hope that the class continues so that others may benefit from it. “As one of their immediate supervisors, I have noted an improvement in the way the students that received the training are managing patients while rotating through the trauma unit compared to before the training,” she said.