Good morning, everybody, okay? So today, we're going to essentially talk about, well, basically, I work at Johns Hopkins University. I work with a group called the Global Alliance of Perioperative Professionals, which is a global health organization, and we're going to, let me see, how's your clicker work? Go to the other left one. Okay, okay, and we're going to talk about contrasting educational programs in low-resource areas of a high-income country versus low-resource areas of a low-income country. What are the differences, and what are the strategies? I have no disclosures to make within the past year. I'm also the founding president of the Institute of Global Perioperative Care, which is a 501c3 organization, and about three years ago, we did have some of our programs sponsored by Gradient Health. Let's see. All right, so objectives of today's, which one, when I hit this one, it just brings up that other thing. Interesting. Mm-hmm. That's odd. Click left. Yeah, the left clicker, that one. Got it, all right. That one. Okay. Let's take you back. Can you take it back one? Yeah, I got it. Okay. All right, so objectives will be to identify common barriers and contrasting barriers to low-resource location training in high-versus-high-income countries, recognize tools useful for education programs in resource-limited areas, and to compare short-term training versus multi-year certification programs, to review specific training programs, and to discuss changes needed for healthcare training in global health. There's really probably two main cores of the differences between a training program that you're developing in a high-income country versus low-income country where both may be low-resource areas of those countries. One of the big ones is related to simulation. I'm sure that I don't need to convince anyone here the value of simulation, that basically you can basically train with high-risk procedures, can be trained without risk to the patient, that procedures can be trained repeatedly, that seldom-needed critical care scenarios can be repetitively rehearsed, and that you can have a limited number of experts can connect with numerous learners to rehearse clinical scenarios. So we're gonna talk about that contrast, but the other contrasting area is also related to access to terminal, what I'll call terminal training. What do I mean by that? What I mean by that is if you have a person who wants to become a nurse, it doesn't make any sense to just have a two-week or a two-day or whatever nursing course. They need training in a nursing program. Someone wants to be an anesthesiologist or a critical care physician. Having just a, even if it's a month program, they're still not gonna be competent in terms of actually managing patient in that particular thing. And there are differences in terms of your ability to access those type of programs between these two different types of countries. So for training programs in high-income countries, you may not have a simulation program in your area, but that doesn't mean that you couldn't, it may be a couple-hour drive or something like that or even several-hour drive, but there is access to one in your country. Same thing for long-term terminal training programs. So even if you have a distance, you still don't have to deal with an international board or you don't have to deal with visas. And you don't have to deal, and you still have access to things that limit in terms of the infrastructure for limiting technology. You can overcome those by simply traveling to the other location, which is much more difficult if you're in a low-income country. We did a review of medical simulation for anesthesia in developing countries and low-income countries. And basically only found very few published articles related to anesthesia simulation. And it really is a representative of the absence of ability to connect to this type of technology for training, whether it's for anesthesia, critical care, or anything that's advanced medicine. There are barriers that prevent access to these if you're in a low-resource country. This is an example. This is a fancy simulation mannequin some of you may have seen. We have one of these at Hopkins. It's kind of freaky. The mannequin can cry. The mannequin talks to you. They have this new movie, Megan, that I just recently saw. Hopefully the mannequin can't attack you, but it can do a lot of other stuff that really actually isn't core to really what you need to do for the training program, but it creates a financial barrier that is difficult to overcome. Okay, so these aren't available in low-resource countries because of their expense, because of their high maintenance, because they're delicate. You can't even, sometimes you're in a, we actually brought some to Abuja, Nigeria for the All African Anesthesia Congress several years ago, and they're so finicky that even getting them to work in the environment can be challenging. In the first place, not to mention when you have a power surge, when you have, when they break down, when you're trying to maintain it. So there are just a lot of barriers to them, and yet sometimes they're not what you really need. This is an example of a very basic simulation system that costs $5,000 versus $100,000, and basically one of the things that this simulation mannequin system can do that the other one can't is actually breathing with realistic tidal volumes. That's the feature that you need. You need a feature where you can actually put a person on a synchronized mode of ventilation, and you can see how it interacts with the ventilator. Those are the features that you actually need. You don't actually need it to talk to you and cry and do all this other fancy stuff. And so the other barrier you have is just a lack of clinicians. So think about it. In Sierra Leone, you have like maybe two anesthesiologists in the whole country. One of them does critical care. One of them does operating room stuff. How, who's gonna, actually, believe it or not, they do have a training program, but how they do it, I don't even know. So that just doesn't leave you a lot of capacity for even having teachers at all. And then it increases the value of simulation, of course, but it makes it very challenging. This, using anesthesia as an avatar for other specialties, this is a World Federation of Society of Anesthesiologists map showing you the red is zero to one practitioner per 100,000. And there are some countries where they literally don't have the one per the entire country when you're talking about millions. So the pandemic created even more challenges to these programs, even in terms of having a in-person simulation program like what you saw us doing in Sierra Leone in the last slide. The pandemic made travel shutdowns, social distancing problems, all sorts of things difficult, yet governments were purchasing ventilators. And there was all this big ventilator push to get ventilators everywhere, even places that didn't have oxygen were getting ventilators. And yet the clinicians were left without critical care or ventilation skills. The country of Sierra Leone had an interesting approach to this is that above the level of the Ministry of Health, a level at the level of the president of Sierra Leone created a Sierra Leone Presidential Initiative for Technology and Healthcare where they actually purchased ventilators that were designed specifically to meet the needs of low resource countries. And they requested our group to rapidly do a training program in April of 2020. Believe it or not, they said, can you start next week? We said, no, we can't. But we actually did start two weeks from then. We worked very hard to do that. And we were able to initiate the training in two weeks. Fortunately, we did have some funding from the manufacturer of the ventilators that they had purchased that helped us to actually execute this. And then for every Saturday and every Sunday of April, May, and June, and some of July, we were there for eight to nine hours per day on conference calls with the location in Sierra Leone. And so how we were able to accomplish this is because we had already been in the country. We already knew. In fact, we had helped them to acquire the simulation equipment that they had. We had people who had been employed with us before in Sierra Leone. We knew the physicians. And we also had the right equipment and everything. So we were positioned well for setting this up. And this is another view of the simulation mannequin system that we had. And you see that the lung is separate from the mannequin, but you can actually connect them to. And then the computer actually connects by way of a Bluetooth connection so that you can actually get additional information as to how the simulation is going from that, okay? And the mannequin is capable of both oral and nasal simulation. It's got some little things that break intentionally, but you can just put it back if they're going to damage the teeth. And then you can tell whether they get esophageal intubation or not. And then the ventilation part, you set the tidal volume, you set the rate, you set the pattern that you want the patient to ventilate at. But you see it's quite a bit more basic and simple than a crying dummy, but does the job for what we want it to do, okay? So basically, the first step when you're doing this type of work is to do a needs assessment. Well, guess what? If you got two weeks, you're not going to be able to do a needs assessment. But fortunately, our needs assessment was done conceptually by the previous work that we had done in the country. And this is Dr. Gist, who is actually in one of the projects with us. And he was part of that effort where we were doing previous work. So we already had an idea as to what the knowledge base and the number of people with the ability to run a ventilator and all that kind of stuff, how many ICUs, all the information we already had in terms of the needs assessment. And so we started the next phase, which is the planning phase for the actual intervention. So we just started rehearsing with some of the same equipment in hallways, in empty operating rooms, wherever we could, and at Johns Hopkins to be ready for this particular intervention. And this is us with that same ventilator. The ventilator in the background is a ventilator that they were trained on. And it's a basic ventilator. It can run off a oxygen concentrator. It doesn't actually need compressed air or oxygen. It can run off a oxygen concentrator. And it has about a 14-hour battery backup so to overcome the problem of frequent power outages. So what did we do? We created a tele-education-directed medical simulation program. So it wasn't totally tele-education or telemedicine. It wasn't total just medical simulation. It was connecting those two worlds together by using confederates that were basically physicians and nurses and other non-medical people who we already had a relationship with on the ground in Sierra Leone to help us to simulate the different scenarios we wanted to happen in Sierra Leone. And using a software where we could literally control the vital signs, the blood pressure, heart rate, O2 saturation, rhythm, all of that we can control in real time from Johns Hopkins. And this is just a picture of our setup. You can see on the laptop on the left. That's what we're looking at with the camera. And we can actually have our guy manipulate the camera angle just as needed. And on the right, we are controlling those vital signs. We're controlling the PVCs, the heart rate, the rhythm, the O2 sat because it's taking a little bit of time for this patient to be intubated. And because they were already starting off with a low sat, you can see that we have them running at a low sat. And then the longer they take, the saturation will get lower, actually, because we're controlling that. This is an anesthesiologist, a critical care physician. It's Easter Sunday. Doctors in Baltimore are kicking off a six-hour Zoom chat with nurses in the West African nation of Sierra Leone. A country of eight million has 13 ventilators and two anesthesiologists. One is recovering from a stroke. The other is in quarantine. Anesthesiologists are supposed to handle or supervise the intubation of critically ill patients. But Sierra Leone saw its health care system crumble after years of civil war. Another option has emerged in this pandemic, video training with physicians across the world. Although it might be a rushed environment and the patient is decompensating, you always want to make sure that you have everything in your care, which includes IV access. The sickest patients require anesthesia as they go on the breathing machines. But most of Africa's 54 nations have fewer than one doctor who can provide it per 100,000 people. The continent faces the world's most extreme shortage, health experts say. Physicians used to board planes to help each other through times of crisis. But now almost everyone needs their experts at the same time and dozens of nations have closed their airports. With no other choice, doctors across the planet are linking up with their African counterparts in video calls. They sit six feet apart in hospital conference rooms demonstrating techniques on the human dummies with fake lungs. What you're doing as well is wearing a face shield. So again, this helps with guarding you from splashes. It's also going to help with protecting your mask. If you don't have anesthesia, you don't have critical care, said Dr. John Sampson, an anesthesiologist who led the class last weekend at the Johns Hopkins University School of Medicine. By the end of the week, they hope to have at least 15 more healthcare workers ready for the fight against the coronavirus in Sierra Leone. So bringing us back to this particular graph again, again, that's representative of all of the different specialties. So that gives you an idea as to why this thing was important because there weren't the number of physicians that we need to even do clinical work, much less do the training program. Yet, how do we do training programs in these environments? Well, like I said, if you're in a high-income country, you can always travel to the other area. But what if you're in a low-income country like Sierra Leone? This is a model of a program created by the foundation we work with and partner with called the Mama Pickin Foundation. Pickin is actually a Sierra Leone term for children. So it means mothers and children. And so for an obstetric residency training program. And you can see actually a 50% decrease in mortality just in the first year of starting the residency training program. We're not talking about waiting till you graduate residence, the first year of starting. The reason being is that when you start it, you have to bring in the faculty that are gonna from out of the country. So these programs often fail when the Westerners focus on Westerners and they wanna bring in Western faculty to do the training. Or when they want to bring the trainees to a Western environment to get the training. They need to train in their environment and you need to get people from other countries that have similar conditions but are at a higher level of advancement in terms of their medical systems. So we brought in Nigerians for this particular program for obstetrics. And so basically you can afford them at a more reasonable rate. They have better contact sensitivity in terms of the treatment and the equipment that are being used and the diseases that are being used. And on top of that, they are also in the same certifying system. So for West Africa, that's the West African College of Surgeons. For Southeast or Central Africa, that's the College of Surgeons of South and Central East Africa. So that all of those advantages make this more sustainable. And then you have to have the commitment. So programs that have been done by the World Bank where there's a one year renewable program, that's not a commitment to training a person to terminal training. You can't get trained as an anesthesiologist. I'm telling you, obstetrician are hardly anything in one year. It's a multi-year. You have to have a commitment to train long enough so that you can generate the faculty. And this is just another month by month look at the mortality impact. Now the next video is actually, so we looked at in terms of anesthesia, how would we develop an anesthesia training program given there's only two anesthesiologists in the country, one doing ICU, one doing anesthesia. How do we do this? And so this is just a proposal that we're working on. A match does not generate light or heat without intense energy to catalyze the reaction. But with energy, the flame is ignited and the energy coming from the match can easily be maintained. In Sierra Leone, war decades ago extinguished training programs and brought specialist numbers down to nearly zero. Starting over without faculty takes energy in the form of capital. As a result, there are few specialists for 8 million people leading to one of the highest maternal and infant mortality rates in the world. Minimal numbers of specialists are contrasted to the 20 per 100,000 recommended by the Lancet Global Commission. We want to infuse energy to change this. Johns Hopkins is leveraging 150 years of training and experience to collaborate and support government and community-based Mama Pecan Foundation to start programs that can be sustained by the government and interact positively with nurses of all types. Our collaborative team will bring in African regional experts for multidisciplinary training and care and then extend this care model to all rural provinces. Our objectives are to sustainably expand post-graduate training programs in anesthesia, obstetrics, and pediatrics, to establish the internationally recommended number of specialists, to provide an administrative and financial handoff to government for sustainability. We plan to monitor and evaluate using internationally recognized standards for maternal and infant health. Let's stop the cycle of poor health and death through the support of multidisciplinary training and teamwork development in Sierra Leone. All right, and in this case, the multidisciplinary is intended to mean including nursing. All right, so basically, the short-term programs like with the FCCS courses today can have an impact, definitely can have a positive impact, but the impact is best made in the context of existing long-term training because the key to the health system is to train them until they finish their training program and to train enough so that they can be their own faculty for continuing training, not to have perpetual dependence upon some sort of a Western program. All right, so thank you very much.

educational programs

simulation technology

low-income countries

tele-education

medical training

sustainability