Non-doctors as trauma surgeons? A controlled study of trauma training for non-graduate surgeons in rural Cambodia.

INTRODUCTION: Due to the accelerating global epidemic of trauma, efficient and sustainable models of trauma care that fit low-resource settings must be developed. In most low-income countries, the burden of surgical trauma is managed by non-doctors at local district hospitals.
OBJECTIVE: This study examined whether it is possible to establish primary trauma surgical services of acceptable quality at rural district hospitals by systematically training local, non-graduate, care providers.
METHODS: Seven district hospitals in the most landmine-infested provinces of Northwestern Cambodia were selected for the study. The hospitals were referral points in an established prehospital trauma system. During a four-year training period, 21 surgical care providers underwent five courses (150 minutes total) focusing on surgical skills training. In-hospital trauma deaths and post-operative infections were used as quality-of care indicators. Outcome indicators during the training period were compared against pre-intervention data.
RESULTS: Both the control and treatment populations had long prehospital transport times (three hours) and were severely injured (median Injury Severity Scale Score = 9). The in-hospital trauma fatality rate was low in both populations and not significantly affected by the intervention. The level of post-operative infections was reduced from 22.0% to 10.3% during the intervention (95% confidence interval for difference 2.8-20.2%). The trainees' self-rating of skills (Visual Analogue Scale) before and after the training indicated a significantly better coping capacity.
CONCLUSIONS: Where the rural hospital is an integral part of a prehospital trauma system, systematic training of non-doctors improves the quality of trauma surgery. Initial efforts to improve trauma management in low-income countries should focus on the district hospital.