Trauma education and care in the jungle of Ecuador, where there is no advanced trauma life support.

BACKGROUND: The advanced trauma life support course is not available or affordable to rural areas in low-income countries. A trauma continuing education course was created to educate physicians of rural hospitals in the jungles of Ecuador.
METHODS: A basic trauma care course was designed based on local resources and location of injury, including rudimentary health posts in the jungle, rural hospitals, and definitive referral centers. Course effectiveness was evaluated by a comparison of test scores before and after the course. A multiple choice questionnaire was given. Comparison to previous test scores was also performed. Paired Student's t test was used for statistical analysis. An objective structured clinical examination (OSCE), based on the course design, was administered.
RESULTS: Twenty-six rural physicians participated in the course. Mean test scores significantly improved from pretest to post-test (72% to 79%; p = 0.032). Knowledge deficiencies in prehospital care, extremity injury care, and patient evaluation adjuncts significantly improved from 23% to 87%, 23% to 100%, and 31% to 100%, respectively. Test results after the course showed improvements in all major categories tested. Twelve of the 26 participants were repeat test takers from a course provided 2 years earlier. These participants showed improved pretest scores compared with their highest previous test score (76.8% versus 68.5%; p = 0.0496). Compared with first-time test takers, these participants showed improved pretest (76.8% versus 68.4%) as well as post-test (81% versus 76%) scores. Twenty-five of the 26 physicians participated in the OSCE, with a pass rate of 76%. The OSCE identified various strengths and deficiencies based on patient location and available resources. In rudimentary health posts, management was adequate for hemorrhage control (65%), immobilization (77%), and early transfer to rural hospitals (92%). Prehospital communication was inadequate (53%). Rural hospital management was adequate for primary evaluation (60%) and resuscitation (74%) but poor in secondary patient evaluation (53%), adjuncts (25%), and transfer to definitive referral centers (11%). OSCE scores differed from multiple choice questionnaire test results. DISCUSSION: Where there is no advanced trauma life support, a tailored trauma course and evaluation can be effective in educating local providers. A well-designed competency evaluation (multiple choice questionnaire and OSCE) is helpful in identifying deficient local aspects of trauma care. The course design and evaluation methods may serve as a model for continuing trauma care education in developing countries.