The Beating Blue Heart

More often than not, traumatic injuries result from preventable events that claim 5.8 million lives worldwide annually. These events can conceivably happen anywhere, but only by analyzing them within the greater context of a society’s economic structure can one begin to disentangle chance from circumstance. It is well established that trauma in low- and middle-income countries is a very different beast than trauma in high-income countries – both from etiologic and management standpoints. Even within high-income countries, trauma can vary significantly between rural and urban settings. Trauma responders must be adequately and appropriately prepared to deal with the injury burden which their patient populations face.

These truths drew us to Cuba.

With a population of just over 11 million, Cuba is a middle-income country often described as straddling the past and the present. Cubans often speak of their “corazón azul,” or blue heart, as the driving force behind their resilience against trying odds. Walking beneath the merciless Havana sun, you would be hard-pressed to identify who is Cuban and who is not because there is not one quintessential Cuban appearance. From the lightest of European ancestry to the darkest of African heritage, all are Cuban; they recognize their past without magnifying their differences. So, when it comes down to it, Cubans all have the same beating blue heart.

Our goal as physicians and physicians-in-training is to keep those hearts beating strongly. Cuba is well known for its robust primary care system, but how does it fare when it comes to specialty medicine, and in particular, trauma surgery? To what extent does its traditionally hierarchical surgical structure allow for equal participation of all members of the trauma response team? What types of injuries must its healthcare workers – from pre- to post-hospital care – be prepared to face?

In 2015, traumatic incidents represented the fifth highest cause of all-age mortality in Cuba, behind heart disease, malignant tumors, stroke, and flu/pneumonia (Anuario estadístico MINSAP, La Habana 2016). Accidental falls (2460/5421) comprised the overwhelming majority of total trauma fatalities, followed by motor vehicle accidents (908) and drowning (204). In 2012, Dr. Marc de Moya of Massachusetts General Hospital initiated annual trauma education and development programs at Hospital Calixto García. The percentage of all the hospital’s patients presenting with traumatic injuries has since increased from 8.9% (2010-11) to 10.3% (2014-15) with a compensatory decrease in trauma mortality from 11% to 6.4% in those respective years (Department of Medical Records, Hospital Universitario General Calixto García).

This May, I had the distinct privilege of joining a group of over twenty trauma surgeons, a radiologist, critical care nurses, and surgical fellows and residents from six countries across the Americas to host the 3^rd Annual International Trauma Symposium in Havana, Cuba with the Inaugural Emergency Surgery Nursing Workshop. With our fearless leader Dr. de Moya at the helm, we collaborated with Hospital Calixto García for a week-long symposium that shone brightest in its unwavering commitment to an exchange of ideas rather than pedagogy.

The symposium’s success – measured by attendance, eager participation, and effusive gratitude of over 300 surgeons, nurses, and surgical trainees from across the island – arose due to the following major actions and characteristics:

1. Inclusion: This year marked the first time that nurses participated in the conversation. It goes without saying that nurses are essential to the care of patients, trauma included, because of the invaluable work they do – side-by-side with surgeons – to render safe yet swift care. Participation of so many nurses from both Cuba and from the visiting team opened the conversation about re-evaluating the respective roles of nurses and surgeons in Hospital Calixto García, especially with regards to how best to empower each group and work in concert to maximize patient survival.
2. Variety: I am sure many of you have sat through conferences that were…less than stimulating. The key to holding the audience’s attention, in my opinion, is to keep participants on their toes. This symposium kicked off with a Nursing Workshop focused on small-group hands-on simulation sessions, followed by a Nursing Symposium for a larger group of over 200 nurses. Additionally, we tackled FAST ultrasound training, new advances in technical approaches in the OR, and a two-day Surgeons’ Symposium filled with a mix of debates, North vs. South [America] panel discussions, and research presentations from U.S. and Cuban surgical residents.
3. Desire to learn: The active involvement of the Director of Hospital Calixto García and the Chief of Surgery, with palpable candor and warmth of spirit not distant oversight, demonstrated how no one felt that he or she had all the answers. Case in point, a senior Cuban surgeon remarked that the healthy exchange of ideas during the symposium further underscored the importance of leaving behind the stereotypical surgeon’s ego in favor of humility.
4. Mutual respect: With different training, licenses, practice environments, surgical burden of disease, and access to resources, differences in opinion cannot be avoided. However, by challenging rather than disparaging these differences in opinion, symposium participants focused on the binding commonality between us all: the desire to save a life.

This symposium was just one piece of a larger prospective, phased longitudinal project to investigate how trauma education and trauma system development impact trauma-related mortality. Looking ahead, the aim is to promulgate trauma and critical care courses from the Panamerican Trauma Society to multiple institutions across Cuba. Additionally, the development of a formal web-based trauma registry, first at Hospital Calixto García with eventual expansion into a national trauma registry, will be used to benchmark trauma outcomes and provide a foundation for more formal quality and patient safety programs.

Joint efforts allow for progress, and progress permits the corazón azul to keep beating on.