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Improving medical skills and training doctors in austere environments

Image credit: Abdulhakim Zaggut

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Muhammad M Rahman
Muhammad M Rahman Feb 13, 2021
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Medicine around the world is very consistent in terms of theory, practice, and training. A doctor will be able to practice all over the world given that they can speak the language in the given country. This explains why many brave doctors from all around the world can travel to third-world countries or war zones with various charities. The major difference here is the environment itself in what could be described as austere. There are a number of factors to consider when practicing medicine in austere environments:

- Power cuts: hospitals will have generators but in war zones, emergency operations may have to be performed without power or in makeshift surgery tents
- Equipment: advanced machines like MRI scanners may not be available; alternative methods or workarounds may be required
- Materials: if there is a sudden influx of casualties due to a bomb blast, vital materials could run out; so, what are the most viable alternatives?
- Hygiene: the environment may not allow for high standards of cleanliness, sterile equipment may be lacking
- Workload: when there are a large numbers of casualties, the priority will be to perform life-saving procedures and ignore aesthetic aspects of surgery due to time constraints

A recent article by a surgeon with experience of war surgeries suggests that the surgeons can be trained using unconventional equipment and simulators to improve their ability to treat a patient in a war zone . Examples include using cheap plaster molds to make jaw models for teaching as well as using sheep heads to demonstrate craniotomy. The best training simulators are very expensive so what alternative training models or techniques can you suggest that would help doctors operating in austere environments? It is worth considering the availability and cost of the simulators? How about teaching methods? Do you have any ideas regarding effective teaching or training methods in the absence of computers or any other high-end technology?

[1]1. Zaggut AW et al. Training Non-Specialists for Craniomaxillofacial Trauma in a Warzone Setting. September 2020, Journal of Dentistry Open Access. DOI: 10.31487/j.JDOA.2020.02.06

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General comments

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Shubhankar Kulkarni
Shubhankar Kulkarni8 months ago
There can be training programs for the doctors. During a crisis, along with the experienced doctors (experienced in providing medical care in austere environments), other doctors can accompany them as their associates. The experienced doctors can take charge of the patient while the fresh doctors can study the situation (absorb it - prepare themselves mentally for such situations), take notes on what alternative options need to be utilized in case of more demand and lack of expensive high-end diagnostic technology, and also assist the experienced doctors in providing medical care. This will no doubt increase the cost of employing more number of doctors (along with their transport, food, and shelter) but we will have a batch of experienced doctors and could more properly manage a similar situation in the future. Also, the doctors will have real-life experience, which is better than simulations.
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Povilas S
Povilas S8 months ago
Shubhankar Kulkarni Exactly what I was thinking - training in advance in actual austere environments. The non-experienced doctors could come when the situation is not an emergency, when it's rather steady and manageable, but the conditions are nevertheless harsh. I bet such circumstances are a status quo in many developing countries. Then the experienced ones would have more time and less stress which is a much better situation for teaching as well as for the patients who need the full attention of the experienced doctors in emergency times. Emergencies could be simulated so that the next time when the real one happens the newly trained doctors would be already familiar with the environment, the equipment available, and how things are done there and had undergone the training for extreme situations.
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Muhammad M Rahman
Muhammad M Rahman8 months ago
Both great comments however, it is not very difficult to simulate the austere environment in the sense that doctors can be taken to such environments for training or a mock environment to be built. The problem is that in Libya (the article that I referenced in the first post) the level of violence makes surgery unpredictable. As mentioned in the article, there can be a sudden surge in casualties and the doctors will have to save as many of them as possible and then consider secondary surgeries of the face/head. The purpose of the training was to perform fast and effective correction to the craniomaxillofacial area that will massively improve the quality of life for that patient so this could be a broken jaw or shredded lip. These types of surgery can be performed in under 30 minutes if the doctor is trained properly and prepared to use unorthodox tools. Bearing in mind that the patient may never return for follow up appointments, it is important to help the patients as best as possible to improve their everyday life. The other problem with large scale casualties is when you are surrounded with gunfire and explosions, it is perfectly understandable that doctors will be frightened for their own lives. This cannot be trained or simulated unless the trainees believe that their lives are under threat. Another angle to consider is that when there are sudden terror attacks in seemingly peaceful areas, it is unlikely that the doctors would be trained for such circumstances in which case, fast and effective surgical techniques can be of use to help the patient outcome so such courses should be made available in any environment.
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Shubhankar Kulkarni
Shubhankar Kulkarni8 months ago
Muhammad M Rahman All great points. The violent zones are the extreme austere environments, I think. Probably, the most unpredictable. It may take prolonged training and simulating which is very hard. A simple psychological notion that this is "just training" relieves much pressure and takes the environment far away from the actual violent zone. Traning, in such cases, can only be done in the actual zones. Therefore, the option of assistant (trainee) doctors is better in such cases. Of course, not all doctors would want to risk their lives and serve in violent zones. Therefore, another option is to employ military medical personnel. They have the managerial discipline and a sense (even though they might lack experience) of wars and mental war preparedness. They might be more capable to handle the situation.

For other austere environments like an epidemic outbreak, natural calamities, etc. a simulation training program can be used.
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