INTRODUCTION

Global academic partnerships in surgery are expanding worldwide.^1-6 Students from the United States report their international clinical experiences, but little has been written about international students’ experience in US trauma programs. Given the current US policies restricting international students from practicing direct clinical care,⁷ an observership rotation introducing trauma systems (TS) to international students was initiated as an alternative. These kinds of experiences are useful to help medical students to model their professional profile and narrow their specialization choices,⁸ with a probable increment in research productivity in the field that was stimulated by experience.⁹ Acute care surgery (ACS) models in US Departments of Surgery are implemented at major Latin America academic institutions and fellowships. Medical students participate clinically at the few programs that exist, and have an opportunity to attend national and Latin American society conferences. However, medical education internationally needs development to prepare for the TS development necessary within the ACS divisions. The US trauma programs within ACS models follow systems elements to organize a multidisciplinary care of the injured. As surgical systems in Latin America become a focus of domestic academic faculty, little formal education on surgical systems structure in trauma exists for the next generation of academic surgeons in the region. As American students, residents, trainees, and faculty have participated in international exchanges in Latin America, systems education in US trauma programs provides a valuable construct for experience in TS different from current domestic opportunities. This is an important academic endeavor as the Latin American burden in injury and trauma continues because of systems underdevelopment at national levels.

MATERIALS AND METHODS

A nonclinical TS observational rotation was granted to an international senior medical student from the Universidad de la Sabana, Chia, Colombia. It occurred at a trauma center with Level One American College of Surgeons designation. Before the rotation began, the student applied to the Office of Global Health and the ACS Division. The host university hospital and the visiting international student and medical school required Health Insurance Portability and Accountability Act (HIPPA)¹⁰ and the Federal Emergency Medical Treatment and Labor Act (EMTALA)¹¹ certification completion. The student secured an opportunity in the United States under a B1 tourist visa permit for a total 30-day experience in multidisciplinary trauma program and systems elements recommended by the American College of Surgeons Committee on Trauma (ACSCOT).^12,13 The observational benefits were retrospectively evaluated for a 30-day experience.

RESULTS

Trauma morning report was held daily for the student’s 30-day experience. In the observation of ACSCOT, the international student learned unique principles in trauma patients’ and programs’ prehospital, hospital, and discharge activities including clinical and surgical care, physical therapy, occupational therapy, social services, financial/insurance applications, performance improvement, trauma registry, and injury prevention. Advanced Trauma Life Support (ATLS)-based primary and secondary survey, imaging, trauma bay, and operative indications were observed for 113 activations. The student participated in performance improvement teams’ prehospital and interhospital processes in mortality conference-based loop closure and clinical practice guideline development for Massive Transfusion Protocol and solid organ injury management. The Department of Surgery’s Surgical Morbidity and Mortality conference and grand rounds also provided subspecialty educational context. Education led by attending surgeons for surgery clerkship students, surgical residents, ACS fellows, and other members of the multidisciplinary team covered selected topics in spine injury, pelvic fracture, penetrating neck injury, head injury, gunshot wounds, and anatomical landmarks. The international student was integrated into a team of students, residents, fellows, faculty, social workers, physical therapists, advanced nurse practitioners, performance improvement coordinator, and nurse trauma manager. The experience led to better conceptualization of interprofessional and multidisciplinary US trauma programs and systems.

DISCUSSION

In a review of the development of TS in the low-middle-income country (LMIC), varying organization of emergency medical services (EMS) and TS was found.¹⁴ The diversity in these results is based on the cultural and socioeconomic differences between the countries, also showing that economic stress is the main barrier to implement high-income country models of EMS and TS in the LMIC.¹⁴ The education and certificated trauma and emergency medicine training is a repetitive component of the EMS improvement strategies proposed in the LMIC.¹⁴ Studies of EMS trauma students’ “hand-off” experiences in the care of injured within trauma programs, where medical students rotated with emergency medical technicians, resulted in an improvement of the student’s confidence and patient care skills.¹⁵ Clinical observational experience comprising of trauma resuscitation; surgical procedures; ACS consult evaluations; intensive care unit; and ward in company with general surgery residents, ACS fellows, and in-house surgical attending physicians stimulated the students who participate in these experiences to pursue general surgery residency.⁸ Students who participate in a trauma research program were found to exhibit an incremental increase in the interest to enter the surgical field, while also improving research productivity.⁹

International medical student exchange programs in clinical practice have shown to improve medical students’ history-taking and physical exam skills.^16-18 However, they are predominantly in a transnational North-to-South direction.¹⁷ It is critical at this time that the United States reverse this predominance and balance a South-to-North transnational experience in education within US practice of multidisciplinary systems-based trauma care, i.e., not readily available in other reported international student experiences.¹⁹ The components of surgical burden in the LMIC²⁰ include surgical systems under development, and if international medical schools and students from LMICs are offered opportunities to participate in systems rotations concluded to be beneficial, both may play an important developmental role in policy emphasis to accelerate the improvement and development of such programs for domestic EMS and TS processes.^12,13 This is very timely as more formal educational structure and medical student opportunity in surgery and injury are needed to meet 2030 Lancet Commission of Global Surgery goals.²⁰

CONCLUSION

Nonclinical trauma morning report and rotation served as a nonclinical observational education in multidisciplinary trauma program and systems for international students. The experience in the United States provides a new perspective on systems-based care in trauma, i.e., not readily available for all international students. A simple approach to trauma program and systems education is introduced.

CLINICAL SIGNIFICANCE

The educational alternative exposed is a pathway that can be used by the medical students from LMIC to broaden their clinical perspective, ACS model knowledge, and do so all in the context of TS-based understanding. The students who opt for this kind of experience may choose a specialization in surgery, increase systems research capacity, and develop emergency medical and TS in Latin America.