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Introduction

On 3rd December 2016, a team from the UK journeyed to Khartoum, Sudan by invitation of the Sudanese Plastic Surgery department. The team comprises of Mr. David Bell and Mr Wee Lam, two consultant hand and plastic surgeons from Liverpool and Edinburgh, UK, respectively, and accompanied by Janet Hunter, a senior occupational therapist from Liverpool. Initial invitations were sent by Associate Professor Abdelsamie Abdalla Mohamed, and subsequent arrangements were made by Mohammed Abdelrahman, who is presently a fellow in Glasgow. Mohammed Abdelrahman travelled with us to Sudan for the purpose of facilitating the trip.

Day 1

The team landed at different times. Mohammed Abdelrahman, David and Janet arrived late on 3rd December night while Wee Lam arrived lunchtime 4th December. We were taken to our hotel which was extremely comfortable and also located near the airport. VIP immigration arrangements had been made to facilitate a smoother transit into the country. VISAs had been pre-arranged via emails of our photocopied passports which made things a lot easier.

On Sunday afternoon, we were taken on a cruise of the river Nile by our gracious tour guides, Mohamed Abdelrahman, Alhadi and Walid Fadlalla. who accompanied us for the whole trip and took great care of us.

Sunset overlooking the beginning of the River Nile in Khartoum, Sudan

On Sunday night, we were invited to a lavish dinner with Dr. Osama Murtada Ahmed, Chair of Training Board and Abdelsamie Abdallah Mohamed, Head of Examination. We received a briefing for our activities the next day; David and Wee Lam were external examiners for five plastic surgery candidates and Janet would be conducting a physiotherapy workshop for about 100 physiotherapists.

Day 2

The exam report has previously been submitted separately. Janet would be preparing a separate report for her experience in teaching physiotherapy in Sudan.

Janet Hunter teaching hand physiotherapy and the making of hand splints

In the evening, we were taken to another lavish dinner with Dr. Osama Murtada Ahmed and Professor Yagi, among others and also several registrars. We received generous gifts and were presented with a plaque on behalf of the Sudan Medical Specialization Board for our efforts as external examiners.

Day 3 and 4

The proper teaching starts! We were taken to the lecture theatre at 830 AM and was delighted to find a poster on the wall with the theme: ‘Functional Hand Reconstruction’. The various organisations involved were listed on the poster including BSSH, BFIRST and the Sudanese Plastic Surgery Association.

We counted about 100 people in attendance although we were aware that not everyone could stay the whole meeting due to work commitments. About 90% were Orthopaedic Surgeons of various grades and 10% were Plastic Surgeons. This ratio was expected as our Hand Symposium forms part of the Pre-Programme for the annual National Orthopaedic Conference. We were informed that previous BSSH trips were the other way round, i.e., the audience were mainly Plastic Surgeons rather than Orthopaedic Surgeons.

The contents of the lectures previously requested by the Sudanese group are the Mangled Hand, the Congenital Hand and Nerve Injuries. The Teaching programme were split into 4 parts: (1) The Mangled Hand; (2) The Paediatric Hand; (3) The Deformed Hand and (4) The Paralysed Hand. Day covered topics 1 and 2 while Day 2 covered topics 3 and 4. Each session consists of a series of lectures from the surgeons David Bell and Wee Lam, followed by a therapy talk by Janet. Each candidate received a certificate of attendance and also filled in a feedback form.

Feedback

The feedback was overwhelmingly positive in terms of contents (interesting, understandable or clarity). Overall satisfaction was also excellent. However, there were several comments about the need for the course to be more practical, workshop-based or even cadaveric-based. There were a few comments that the talks were too Plastic-focused, which was unsurprising from an Orthopaedic audience. We wondered if the audience knew beforehand that the lectures were going to be delivered by Plastic Surgeons. Certainly we felt that if the audience were a majority of Plastic Surgeons, we could perhaps go deeper into specific techniques and discussions, but there were times where the contents seemed to be too much for the Orthopaedic group, for example, when talking about microsurgery or peripheral nerve surgery.

Reflections

Overall, we thoroughly enjoyed our first trip to Khartoum and were extremely touched by the warmth, generosity and hospitality of our hosts. Everyone we met went out of their way to make us feel welcome, from the moment we were picked up to the last minute before departure. The arrangement for VIP lounges, VISA application, excellent accommodation and meals were more than what we can ask for.

We were slightly concerned whether the topics we delivered were suitable for the orthopaedic-majority audience but were informed (and reassured) that the contents were relevant. Hand surgery is undertaken by a wide body of surgeons in Sudan, including orthopaedic and plastic and even general surgeons. This means that not only fractures, but also tendon repairs, nerve repairs and even congenital hand surgeries may be undertaken by anyone who have been referred these cases. The lectures would serve to highlight a few general principles of managing these cases but more importantly, to stress the importance of referring them on to a more specialist hand unit for optimal management, and for future ortho-plastic collaboration.

The lectures also serve to demonstrate that if specialisation is achieved and cases concentrated in a few units, that much more can be achieved, for example, the possibility of replantation surgery or free flap surgery. This leads to the next important point:

Is it possible to create hand surgery specialist units in Sudan? We certainly felt that this was one of the most important thing achieved at the symposium: an awareness of the need for ortho-plastic collaboration and the need for ortho-plastic hand units. We changed our last talk and presented the ‘history’ of the BSSH and how Hand Surgery reached its prominence today in the UK through the setting up of the Hand Society and biannual meetings, and by focusing on three important elements: Instructional Courses, Dedicated Hand Fellowships and the BSSH Hand Diploma Examination.

At the end, we were encouraged when both Mohammed Abdelrahman (representing the Plastic group) and the general secretary of the Sudanese Orthopaedic Association, Dr Dr Sami Nougd Allah came on stage to emphasise the importance of ortho-plastic collaborations.

We were encouraged that Janet Hunter taught about 100 physiotherapists on the first day, and also integrated her lectures with ours on the second and third day. Hand therapy remains a need in Sudan and if hand surgery is to develop, now is a good time to incorporate the therapy component as one of the essential elements.

Recommendations

  1. We would propose future trips as BSSH/BFIRST collaborations. This ensures that the resources of both Plastic and Orthopaedic Hand surgeons are tapped from the UK. It would also foster a closer working relationship between the Sudanese Plastic Surgery Association (who would remain instrumental in organising future trips) with BAPRAS, in assisting their aim to raise the Plastic Surgery Sudanese examination to an Intercollegiate FRCS standard.
  2. The Sudanese Plastic Surgery examinations have shown us that the level of training in Sudan is at a very high level and that there are national standards to ensure sufficient quality in the trainees. The level of organization of the National Orthopaedic Conference by the Orthopaedic Association also showed unity in national training. This meant that any development of a hand surgery curriculum can be set at a national level. We would therefore recommend a national hand surgery programme, and for this reason, the birth of a Sudanese Hand Surgery Society is paramount.
  3. The Sudanese Hand Surgery Society (SHSS) can serve as the platform for true ortho-plastic collaborations with these channels:
    1. Annual SHSS National Hand Meetings
    2. Hand surgery Instructional courses, as part of the National Meetings
    3. Hand Fellowships (BSSH/BFIRST can facilitate this; initially in the UK and then locally in Sudan)
    4. A dedicated Hand Surgery examination (post Orthopaedic or Plastic training)
  4. In order to ensure the success of these plans, future BFIRST/BSSH visits should aim to be within the remits of the activities of the Sudanese Hand Surgery Society, i.e., to support the National meetings, to teach on the Instructional courses or to help facilitate the Hand examination. There were several feedbacks regarding workshops and cadaveric courses; again these should be run as part of the National Meetings or Instructional Courses.
  5. BFIRST/BSSH to support 6-week to 3-month hand fellowships in approved hand units within the UK for selected trainees or consultants. Once the specialist hand centres are set up in Sudan, these fellowships could be run locally. The selection criteria would be rigorous and only candidates who demonstrate a dedication to the setting up of the Sudanese Hand Surgery Society and potential for future impact on hand surgery in Sudan, should be selected. The timing of fellowships should coincide with BSSH meetings or Instructional Courses, and attendance at these events should be complimentary.
  6. It would obviously take time to set up such a society. In the meantime, future ‘hand meetings’ can take place under the auspices of more established and bigger societies, like the Plastic Surgery or Orthopaedic Surgery Associations. Our impression is that the Plastic Surgery Association is probably taking the lead in Sudan when it comes to hand surgery. Until such time as the establishment of the SHSS, the focus in Sudan should be on education, and on educating selected individuals with a special interest in hand surgery. As mentioned, these are the individuals who should be selected for fellowships in the UK and to attend events at the same time.
  7. Future trips should also be more clinically based and less lecture based. A week’s trip could consist of the following format:
    1. Day 1: Clinic for selection of patients
    2. Days 2-4: Surgeries
    3. Day 5: Lectures and Workshops
  8. Hand therapy must be an integral part of the SHSS. Future BFIRST/BSSH trips should incorporate therapy teaching to both therapists and surgeons. The British Association of Hand Therapy (BAHT) could also play a vital role in the development of a possible future SHTS.
  9. To facilitate the development of new services such as microsurgery, BSSH or BFIRST should consider limited donations, e.g., micro-instruments. We did not have the opportunity to visit the facilities so am unable to comment on what is available and what is not. Future operating
    trips would be able to determine what kind of services are available and what fund raising events are needed to raise money for specific equipment, like microscopes.

Conclusions

All in all, this was a very fulfilling and worthwhile trip that allowed us to glimpse a snapshot of the Plastic Surgery training in Sudan through the examination, and also the level of hand surgery through interactions with the local faculty. We are excited by the potential that is in Sudan. Apart from the existing national societies, both Plastic and Orthopaedic, the key to success in the future must surely lie with the passionate individuals like Mohammed Abdelrahman and other professors, who desire to see hand surgery raise to a high level nationally. BAPRAS and BSSH should continue to commit to help raise this standard, but within the remits of a future Sudanese Hand Surgery Society.

Report prepared by:
Wee Lam and David Bell