title: "A short trauma course for physicians in a resource-limited setting: Is low-cost simulation effective?".
abstract: BACKGROUND
  Morbidity and mortality from intentional and unintentional injury accounts for a high burden of disease in low- and middle-income countries. In addition to prevention measures, interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality. A trauma curriculum tailored to low-resource settings was implemented in Managua, Nicaragua utilising traditional didactic methods and novel low-cost simulation methods. Knowledge gain in attending and senior residents was subsequently assessed by using pre- and post-written tests, and by scoring pre- and post-simulation scenarios.
  
  
  METHODS
  A 5-day trauma course was designed for Nicaraguan attending and senior resident physicians who practice at six hospitals in Managua, Nicaragua. On days 1 and 5, participants underwent pre- and post-training evaluations consisting of a 26-question written exam and 2 simulation cases. The written exam questions and simulations were randomly assigned so that no questions or cases were repeated. The Wilcoxon signed-rank test was used to compare pre- and post-training differences in the written exam, and the percentage of critical actions completed in simulations. Time to critical actions was also analyzed using descriptive statistics.
  
  
  RESULTS
  A total of 33 participants attended the course, including 18 (55%) attending and 15 (45%) resident physicians, with a 97% completion rate. After the course, overall written examination scores improved 26.3% with positive mean increase of 15.4% (p<0.001). Overall, simulation scores based on the number of critical actions completed improved by 91.4% with a positive mean increase of 33.67 (p<0.001). The time to critical action for completion of the primary survey and cervical spine immobilisation was reduced by 55.9% and 46.6% respectively.
  
  
  CONCLUSIONS
  A considerable improvement in participants' knowledge of trauma concepts was demonstrated by statistically significant differences in both pre- and post-course written assessments and simulation exercises. The participants showed greatest improvement in trauma simulation scenarios, in which they learned, and subsequently demonstrated, a standardised approach to assessing and managing trauma patients. Low-cost simulation can be a valuable and effective education tool in low- and middle-income countries.
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States. Electronic address: Kimberly.pringle@gmail.com.
authors.forename: K
authors.initials: K
authors.lastname: Pringle
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: J M
authors.initials: JM
authors.lastname: Mackey
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: P
authors.initials: P
authors.lastname: Modi
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: H
authors.initials: H
authors.lastname: Janeway
authors.affiliation: School of Medicine, Universidad Autónoma de Nicaragua, Managua, De donde fue ENEL Central 3KM al Sur, Recinto Universitario "Ruben Dario", Managua, Nicaragua.
authors.forename: T
authors.initials: T
authors.lastname: Romero
authors.affiliation: School of Medicine, Universidad Autónoma de Nicaragua, Managua, De donde fue ENEL Central 3KM al Sur, Recinto Universitario "Ruben Dario", Managua, Nicaragua.
authors.forename: F
authors.initials: F
authors.lastname: Meynard
authors.affiliation: School of Medicine, Universidad Autónoma de Nicaragua, Managua, De donde fue ENEL Central 3KM al Sur, Recinto Universitario "Ruben Dario", Managua, Nicaragua.
authors.forename: H
authors.initials: H
authors.lastname: Perez
authors.affiliation: Department of Emergency Medicine, Antonio Lenin Fonseca Hospital, Frente a las Brisas, Managua, Nicaragua.
authors.forename: R
authors.initials: R
authors.lastname: Herrera
authors.affiliation: Department of Emergency Medicine, Dr. Roberto Calderón Teaching Hospital, Costado Oeste Mercado Roberto Huembes, Managua, Nicaragua.
authors.forename: M
authors.initials: M
authors.lastname: Bendana
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: A
authors.initials: A
authors.lastname: Labora
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: J
authors.initials: J
authors.lastname: Ruskis
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: J
authors.initials: J
authors.lastname: Foggle
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: R
authors.initials: R
authors.lastname: Partridge
authors.affiliation: Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903, United States.
authors.forename: A C
authors.initials: AC
authors.lastname: Levine
mesh_terms: D002983:Clinical Competence / Q000191:economics / Q000592:standards*; D003362:Cost-Benefit Analysis; D004502:Education, Medical, Continuing / Q000191:economics / Q000592:standards*; D004635:Emergency Medicine / Q000191:economics / Q000193:education*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D009527:Nicaragua / Q000453:epidemiology; D010820:Physicians; D015397:Program Evaluation; D014947:Wounds and Injuries / Q000628:therapy*
keywords: Global emergency medicine; Medical education; Nicaragua; Simulation; Trauma