The Role of Trainees and Ethics in Global Surgery
Explore how medical trainees can get involved in global surgery through research, conferences, and international electives. Learn about ethical considerations like sustainability, equal partnerships, and locally driven solutions in this evolving field. Transcript Hello and welcome back to Surgery 101, the podcast brought to you with the help of the Department of Surgery at the University of Alberta. I’m Jonathan White coming to you direct and live from the Royal Alexander Hospital in Edmonton, Alberta. This week is the third and last in a series of episodes all about global surgery brought to us by visiting surgical education elective student Betty Ibrahu from George Washington University. In this episode she will be looking at how you can get more involved with the field of global surgery. She will be considering what opportunities are out there for medical students, what opportunities are out there for residents in surgery and what are some of the key ethical concerns you may come across in the field and how do you address those. So, let’s get ready to talk about how we can get you involved in global surgery here on Surgery 101. Hi, my name is Betty and I am a third year medical student at The George Washington University in Washington, D.C. This is the third episode in a three-part series on global surgery. Today we will discuss how medical students can get involved in global surgery and some ethical considerations in the field. By the end of this podcast, you should be able to identify global surgery opportunities for medical students, discuss key ethical concerns of global surgery, discuss strategies to mitigate those ethical concerns. In the past two episodes, we have explored global surgery, a field working to improve health outcomes for all in need for surgical and anesthesia care. We have discussed the widespread need for increased access to surgery. We’ve explored the global surgery 2030 goals and the importance of developing a data driven national surgery, obstetric and anesthesia plan to meet these goals. That being said, how a trainee can participate in this field is the next important topic to address. Studies have found that trainees, medical students in particular have a strong and growing interest in global health and global surgery. As global surgery continues to grow, it follows that student participation in research, conferences, and experiential learning, like international trips, internships, things like that will continue to grow. Now, global surgery, despite being a relatively small field still, has four avenues that I have identified for medical student participation. First is the Global Surgery Student Alliance, initially established in the United States with the recent establishment of the first Canadian chapters, the GSSA is an international student-run global surgery working group. The organization was established under the premise that students are a valuable resource for the advancement of global surgery. Through their website, you can find a collection of important journal articles to read, an opportunity database for students and researchers, a list of active chapters with contact information, and more. There is also a toolkit for establishing a chapter at your school or planning a global surgery event. The second way to get involved is through research. Global surgery is an academic field with new research constantly being published. How to find a PI? Well, you could start by identifying a country or topic you feel particularly strongly about. For me, for example, as a first-generation Ethiopian-Canadian, I could pick Ethiopia. Alternatively, you could pick a subtopic in global surgery you find interesting, like capacity building or orthopedics or medical education or health systems organization. Skim articles on this topic to strengthen your knowledge while also looking for commonly occurring authors. From there, you can normally find their emails either in the journal articles or through faculty information websites. Third way to get involved is through international electives. Most medical schools offer international electives through partner universities with, generally speaking, opportunities for funding. For those looking to travel abroad, this can be an excellent starting place. While the number of institutions with surgery-specific elective varies, students can also usually arrange their own trip through a PI or at the institution in their country of interest. The fourth and final way to get involved is through conferences. Conferences serve as a great way to network with other trainees, possible PIs, and future colleagues. Here’s a very short list of conferences about global surgery or with a large global surgery track. There’s the Annual Bethune Roundtable, hosted in Canada. There’s the McGill University Health Center Conference, again, annual and in Canada. There’s the Global Surgery Student Alliance Symposia, which is an annual conference in America and there’s the Incision Global Surgery Symposium, which is annual but international. Having discussed what global surgery is and how the work is being completed abroad, it would be remiss if we did not discuss the ethics of the field. This could be a whole series of episodes alone, but I thought it would be important to briefly address some key considerations. Western medical ethics are generally built on four key pillars, beneficence, non-maleficence, respective autonomy, and justice. These pillars should, but are not always applied to global health. A 2010 article in the World Journal of Surgery outlined seven sins of humanitarian medicine. They are, one, leaving a mess behind. Two, failing to match technology to local needs. Three, failures of non-governmental organizations to cooperate with each other. Four, having no follow-up plan. Five, allowing politics to trump service. Six, going to areas where help is not needed or wanted. Seven, doing the right thing for the wrong reason. While the list may seem short, it actually distills a complex conversation about power differentials between high and lower middle-income countries into seven brief points. It highlights the importance of locally driven solutions to locally identified problems, as well as sustainability. From a research perspective, it also touches on the plethora of studies conducted in developing countries to address the
Understanding Bariatric Surgery: Procedures, Outcomes, and Care
This podcast delves into the fundamentals of bariatric surgery, exploring four major procedures—gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch. Learn about patient considerations, surgical impacts, and the importance of postoperative care for long-term success. Transcript [00:00] Hello and welcome back once again to Surgery 101, the podcast series brought to you with the help of the Department of Surgery at the University of Alberta. This is Jonathan White broadcasting to you [00:20] live from the Royal Alexandra Hospital in Edmonton, Alberta. This week’s episode is number 3 in a series on bariatric surgery and obesity, brought to us by medical student Julie La, who is visiting on a surgical educational active from McMaster University. In this episode, Julie will be getting to the main topic, the bariatric surgery [00:40] itself she’ll be giving a brief overview of the four main procedures, the gastric band, the gastric bypass, the sleeve gastrectomy and the juillenal switch. So let’s get ready to get all the way up into bariatric surgery itself here on surgery 101. [01:00] Hi everyone, my name is Julie Law and I’m a third and final year medical agent. [01:20] Student at McMaster University in Hamilton, Ontario. This podcast was written and produced with guidance and support from Jenny Marshall, program assistant in digital education, and Dr. Jonathan White, general surgeon at the University of Alberta, creator of Surgery 101. The expert content reviewers were Dr. Alia Kanji, bariatric surgeon at the University of Alberta, and Dr. Renika Moti, [01:40] assistant clinical professor in the Department of Family Medicine at the University of Alberta, and medical lead for the Edmonton Adult Bariatric Clinic. The topic of today’s podcast is surgical options for the management of obesity. By the end of this episode, you should be able to describe various types of bariatric surgery, including the adjustable gastric band, [02:00] sleeve gastrectomy, row and wide gastric bypass, and the duodenal switch. Let’s start by reviewing the NIH [02:20] guidelines for bariatric surgery. 1. Age 18 to 64 2. BMI greater than 40 or BMI greater than 35 with comorbidities such as type 2 diabetes, cardiovascular heart disease, severe obstructive sleep apnea, or GERD. 3. Some contraindications include current [02:40] substance dependency, recent major cancer, untreated psychiatric illness, diseases that would make you ineligible for any surgery, if you are pregnant, have cirrhosis, or chronic pancreatitis. Most bariatric surgery is performed by general surgeons with subspecialty training in minimally invasive surgery and bariatrics. [03:00] Bariatric surgery has been evolving since the 1950s. Many groups around the world recognized obesity as a medical issue and began to try various ways to reduce the size of the stomach, the concept of restrictive surgery, rearrange the intestines to facilitate malabsorption, and then eventually a combination of both. As we learn more about [03:20] how and why bariatric surgery works, we are learning that there are a number of gut hormones that are involved in augmenting weight loss in these procedures. These procedures, while initially done open, are now almost exclusively performed laparoscopically. In Canada, bariatric surgery is covered by our Public Health Plan, which is decided upon provincially. [03:40] With that, there is variation in procedures that are covered. In Ontario, where I’m from, the Ministry of Health funds three types of bariatric surgery, all of which are done laparoscopically. The Roux-en-Y gastric bypass, the vertical sleeve gastrectomy, and the duodenal switch. In Alberta, the duodenal switch is not yet performed, but the adjustable gastric bandage. [04:00] is. Now to review the steps in anatomy of bariatric surgery. These can be tricky to follow. Honestly, reading them in textbooks repeatedly was even difficult to follow. I hope that I’ve simplified things and the slides that we provided will be a helpful tool. This might be a section that needs a few listens. [04:20] The first procedure I’ll discuss is the adjustable gastric band. The gastric band was initially approved by the FDA in 2000. Since then, hundreds of thousands of these bands were placed around the world. The principle behind this procedure is the placement of a foreign body, the adjustable gastric band around the proximal [04:40] stomach. This is then connected via tubing to a port that sits on the fascia below the skin. The port can then be accessed to inflate the band with saline or deflate the band removing saline. The adjustment is to allow for more or less restriction. The band was initially a very attractive weight loss procedure as it is minimally invasive, adjustable, and [05:00] completely reversible. Unfortunately with it were many complications that led to a large number of these bands being removed. Next the components of the Roux-en-Y gastric bypass. This procedure includes the pouch, [05:20] which is a small segment of the stomach that is stapled off. It acts as the new gastric reservoir with a much smaller volume. This will help decrease overall intake and increase the sense of satiety or fullness. Next is the bypass part, where a distal portion of the small intestine, the jejunum, is divided and then attached to the gastric pressure. [05:40] pouch. This is called a gastrostomach to jejunum jejunostomy. This is the new pathway that food will travel and it’s called the Roo Lim. Recall the physiology of obesity. One simple way to look at it is energy in versus energy out. Using a distal portion of the small intestine will [06:00] result in bypassing a large absorptial surface, decreasing the amount of energy in. Okay, now about 100 to 150 cm downstream from this new connection, the proximal aspect of the jejunum from your division is connected to a downstream part of your small intestine. Remember, this connection goes [06:20] from the bottom part of your stomach, the distal stomach, from where the pouch was stapled off, all the way down to the proximal jejunum. But as you might notice, there’s an important area stuck between the stomach and the jejunum, the duodenum.
Exploring the Essentials of Anesthesiology
This episode introduces the basics of anesthesia, including its history, types, and the role of anesthesiologists. It explains how anesthesia works to make surgeries pain-free and safe using different techniques and medicines. Transcript [00:00] Hello and welcome back to Surgery 101. The podcast series brought to you with the help of the Department of Surgery at the University of Alberta and our partners at Covidien. I’m Jonathan White. [00:20] broadcasting to you from the Royal Alexandra Hospital in Edmonton, Alberta. It’s been a beautiful summer here and our summer students have been very busy making videos for Surgery 101. You may have seen a few of them already including Lego Can Meds and Lego eRAS. So more of those videos are coming out in the fall but for now we thought [00:40] we’d start an audio series, which we’ve been looking forward to for quite a while now. It’s a series of episodes focusing on anesthesia, because a lot of our listeners have gotten touched to say, well, we like what you’re doing in surgery, but is there any chance of making a podcast to cover the basics of anaesthesiology? So over the next few weeks, we’ll be introducing the topic, looking at [01:00] what anaesthesiology is and what anaesthesiologists do. We’ll be looking at how you assess a patient prior to anaesthesia and we’ll be looking at how you induce general anaesthesia during an operation. We’ll also look at local and regional anaesthetic and also consider how they manage post-operative pain. The first step of SODE in the series is brought [01:20] to us by Danica Kindretuk from the University of Saskatchewan. Danica was one of the very first students who did a Surgery 101 education elective with us. You may recall a couple of excellent episodes she did recently on cataract surgery and in this first episode of Anesthesia 101 she’ll be introducing the topic for us. She’ll be [01:40] looking at some of the history of anesthesia and looking at the scope of practice of an anesthesiologist. She’ll be defining local, regional and general anesthesia and then she’ll be talking about what is balanced anesthesia as well. So let’s let Danica get us started here as we consider anesthesiology on [02:00] surgery 101. [02:20] My name is Danica Kindrachuk. So far on Surgery 101, the team has covered a myriad of interesting topics, ranging from the bowels to the brain, along with some career guidance, health innovation, and patient [02:40] stories. Up until now, however, we’ve yet to cover the surgical journey from the other side of the drape. That’s right, today we’ll be talking about the role of anesthesia. The objectives of this podcast are to 1. Understand some history of anesthesia and [03:00] understand its importance. 2. Describe anesthesia and its scope of practice. 3. Understand the differences between and uses of local, regional and general anesthesia. 4. [03:20] List four main goals of general anesthesia and five. Define the term balanced anesthesia and explain its rationale. When the dreadful steel was plunged [03:40] into the breast, cutting through veins, arteries, flesh, nerves. I needed no injunction not to restrain my cries. I began a scream that lasted unintermittently during the whole time of the incision and I almost marvel that it rings not in my ears still. [04:00] So excruciating was the agony. I then felt the knife racking against the breastbone, scraping it. This performed while I yet remained in utterly speechless torture.” That was a quote from an early 19th century woman named Fanny Burke. [04:20] who underwent a mastectomy. The only anesthetic she received was a bit of wine to calm her nerves. She also needed seven men to hold her down during the procedure. This is a good reminder that prior to the advent of anesthesia many patients would forgo life-saving surgery [04:40] due to pain. Anesthesia is described in the dictionary as a loss of sensation resulting from pharmacologic depression of nerve function or from neurologic dysfunction. The term is also used to describe the medical specialty of anesthesiology. [05:00] As with many things in history, there is some debate over who, where and when anesthesia was first used. In the year 1800, Sir Humphry Davy wrote a paper on nitrous oxide, commenting on its capability [05:20] to destroy physical pain and remarked its potential to be used in surgery. Though cocaine was likely used as a topical anesthetic by some ancient tribes in South America, it was first isolated by Albert Neiman in 1860 and its first recorded use was in 1880. [05:40] The first public use of anesthesia was in October of 1846 when William Morton used diethyl ether on a patient with a jaw tumor at Harvard Medical School. It was also used for the delivery of Queen Victoria’s child in 1853. [06:00] Over the years, numerous new agents have been discovered and created and anesthesia has gone from a somewhat risky enterprise to a very safe endeavor. In the year 1950, the death rate from anesthesia was 1 in 1500. In 1995, this was 1 in [06:20] 250,000. So then, who are anesthesiologists today? Anesthesia as a medical specialty encompasses a broad range of activities and includes operating room management, [06:40] preoperative assessment, routine day surgery, acute and chronic pain management, resuscitation, obstetrical anesthesia, pediatric anesthesia, clinical pharmacology, [07:00] patient safety experts. It is in a nutshell physiology and pharmacology live in action. Anesthesia can be broadly categorized into local [07:20] regional and general. Local anesthesia involves the numbing of a small part of the body. The patient remains conscious. It is mainly used for small procedures where the nerves innervating the area of treatment can be easily reached with [07:40] injections, drops or ointments. Common procedures performed with local anesthesia are cataract removal, dental procedures and some biopsies. Regional anesthesia is used for slightly larger procedures or for those located deeper in the body. It is a [08:00] bit of a variant on
Short Bowel Syndrome: Insights, Challenges, and Management Strategies
This podcast explores Short Bowel Syndrome (SBS), highlighting its causes, challenges, and management strategies. It covers medical and surgical options, nutrient absorption issues, complications, and treatment advancements to improve patient outcomes. Transcript [00:00] Hello and welcome back to Surgery 101. The podcast brought to you with the help of the Department of Surgery at the University of Alberta. By [00:20] My name is Jonathan White, coming to you from the Royal Alexandra Hospital here in Edmonton. In this week’s episode, we’ll be hearing from medical student Leanne Kim, who comes to us from McMaster University, and she’ll be considering the topic of short bile syndrome. Given the topic, we’re going to try to be brief. [00:40] you’ll be considering what the syndrome is, how we recognize it, how it works, what are the prognostic factors, and how we treat it. So let’s keep it short with Short Bile Syndrome here on Surgery 101. [01:00] Hello, my name is Leanne Kim and I’m a third year medical student at McMaster University. [01:20] Today we’ll be discussing short bowel syndrome. After listening to this podcast, listeners will be able to 1. define the term short bowel syndrome, SBS for short 2. recognize SBS in post-surgical patients 3. describe the pathophysiology of SBS [01:40] 4. List prognostic factors for SBS 5. Describe the basis and indications for medical and surgical therapy for SBS What is Short Ball Syndrome and why do you need to know about it? Short Ball Syndrome is defined as the impairment and absorption of macronutrients and micronutrients [02:00] from a small bowel due to an adequate length and absorptive surface. Although SBS can result from congenital defects and surgeries in pediatric patients, today we would like to focus on post-surgical SBS in adult patients. Normal length of the small bowel is 6 meters for adults. Adult patients with a small bowel length of less than [02:20] centimeter due to surgical resection or bypass are at high risk for SBS. Intestinal failure where the patient remains dependent on parenteral nutrition is more likely when the small bowel length is less than 60 centimeters. In general, up to 50% of patients are able to be weaned off parenteral nutrition within five years of diagnosis. [02:40] as to gastrointestinal mucosa undergoes compensatory remodeling. Usually the remaining length of the small bowel can be found in the OR nuts. Patients with SBS are found to have low quality of life index, chronic fatigue associated with frequent defecation, dehydration, as well as frequent care for parent [03:00] nutrition pump can interfere with their sleep. Moreover, SVS is associated with increased mobility and high healthcare costs as well. With that in mind, let’s dive in. Let’s look at a case. You’re on neurogeneral surgery rotation and in the follow-up clinic you meet Charles. Charles is a 55-year-old patient [03:20] who is dependent on home parenteral nutrition two years after the small bowel resection from acute mesenteric ischemia. Since the resection, he has not been able to tolerate internal nutrition due to abdominal cramping, bloating, and persistent watery diarrhea. He has lost about 15 pounds. You notice on his chart that he was hospitalized a few weeks [03:40] ago were catheter-associated sepsis. As this has been greatly impacting his life, he’s here to discuss possible medical or surgical options for his parenteral nutrition dependence. What are common causes of SBS? The causes of SBS depend on the underlying condition that requires surgical resection. [04:00] In adults, most common causes are acute mesenteric ischemia, malignancy, and Crohn’s disease. In patients with Crohn’s disease, SBS may develop over a series of resection. In pediatric patients, most common causes of SBS are intestinal atresia, valvulus, and necrotizing intercalation. [04:20] clinical presentation. Postoperative ileus, which refers to a decrease in bowel motility following a major abdominal surgery, usually results within 24 hours after small bowel surgery. Usually, passing a gas or stool indicate the resolution of postoperative ileus. [04:40] Enterol feeding is initiated once the isleist resolves, though recently there was a cochlear review that enterol nutrition within the first 24 hours after lower gastrointestinal surgery is associated with shorter length of hospital stay. Once the enterol nutrition is initiated, patients at risk for SBS may experience symptoms such as non-proliferation [05:00] blood watery diarrhea with increased transit time, anorexia, vomiting, bloating, and abdominal cramping. All of these elements should be characterized further systematically on history. On physical exam, the patient may be cacti, tachycardic, and appear dehydrated from ongoing intestinal loss of fluid, electrolytes, and [05:20] It is important to do thorodomol and volume setus exams. In post-surgical patients with watery diarrhea, a few differential diagnoses should be ruled out before making the final diagnosis of SBS. If the patient is fibril, it is important to roll out intraabdominal sepsis with further investigation. [05:40] Infectious colitis should also be ruled out with stool studies to ensure that the patient receives appropriate treatment. Let’s look at the case again. Charles had an extensive small bowel resection from acute mesenteric ischemia two years ago and since then has not been able to tolerate enteral nutrition, eutopdominal cramping, bloating, and persistent water [06:00] area. What is the pathophysiology of compensatory modeling in post-surgical patients? In the post-resection phase, decrease in absorptive surface for macronutrients and micronutrients contribute to persistent osmotic diarrhea and bloating. In the following months, compensatory structural and [06:20] physiological adaptations take place to increase uptake of nutrients and fluid. For instance, the crypt, death, and villus height are increased and optimized to maximize the surface area that is in contact with the luminal content. The crypt cells undergo proliferation and differentiation to replenish the enterocytes and tereundocrine cells called the cells and [06:40] cells. Such hyperplasia of the mucosa is accompanied by the angiogenesis to ensure effective nutrient delivery via the hepatic portal system. Gross changes such as bowel lengthening and dilation also take place. Of interest, glucagon-like peptide 2, GLP2 for short, is an anti-rheumatoid hormone that