Trauma-Induced Coagulopathy: Prevalence and Association with Mortality Persist Twenty Years Later.

INTRODUCTION: A 2003 landmark study identified the prevalence of eTIC at 28% with a strong association with mortality of 8.9%. Over the last 20 years there have been significant advances in both the fundamental understanding of eTIC and therapeutic interventions. METHODS: A retrospective cohort study was performed from 2018-2022 on patients ≥18 using prospectively collected data from two level 1 trauma centers and compared to data from 2003. Demographics, laboratory data and clinical outcomes were obtained. RESULTS: There were 20,107 patients meeting criteria: 65% male, 85% blunt, mean age 54 ± 21 years, median injury severity score (ISS) 10 [10, 18]), 8% of patients were hypotensive on arrival, with an all-cause mortality 6.0%. The prevalence of eTIC remained high at 32% in patients with an abnormal PT and 10% with an abnormal PTT, for an overall combined prevalence of 33.4%. Coagulopathy had a major impact on mortality over all injury severity ranges, with the greatest impact with lower ISS. In a hybrid logistic regression/Classification and Regression Trees analysis, coagulopathy was independently associated with a 2.1-fold increased risk of mortality (95% CI 1.5-2.9); the predictive quality of the model was excellent (AUROC 0.932). CONCLUSION: The presence of eTIC conferred a higher risk of death across all disease severities and was independently associated with a greater risk of death. Biomarkers of coagulopathy associated with eTIC remain strongly predictive of poor outcome despite advances in trauma care.

Correction: Academic global surgical competencies: A modified Delphi consensus study.

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Qualitative Analysis of the Host-Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange.

BACKGROUND: As globalization of surgical training increases, growing evidence demonstrates a positive impact of global surgery experiences on trainees from high-income countries (HIC). However, few studies have assessed the impact of these largely unidirectional experiences from the perspectives of host surgical personnel from low- and middle-income countries (LMIC). This study aimed to assess the impact of unidirectional visitor involvement from the perspectives of host surgical personnel in Kijabe, Kenya. METHODS: Voluntary semi-structured interviews were conducted with 43 host surgical personnel at a tertiary referral hospital in Kijabe, Kenya. Qualitative analysis was used to identify salient and recurring themes related to host experiences with visiting surgical personnel. Perceived benefits and challenges of HIC involvement and host interest in bidirectional exchange were assessed. RESULTS: Benefits of visitor involvement included positive learning experiences (95.3%), capacity building (83.7%), exposure to diverse practices and perspectives (74.4%), improved work ethic (51.2%), shared workload (44.2%), access to resources (41.9%), visitor contributions to patient care (41.9%), and mentorship opportunities (37.2%). Challenges included short stays (86.0%), visitor adaptation and integration (83.7%), cultural differences (67.4%), visitors with problematic behaviors (53.5%), learner saturation (34.9%), language barriers (32.6%), and perceived power imbalances between HIC and LMIC personnel (27.9%). Nearly half of host participants expressed concerns about the lack of balanced exchange between HIC and LMIC programs (48.8%). Almost all (96.9%) host trainees expressed interest in a bidirectional exchange program. CONCLUSION: As the field of global surgery continues to evolve, further assessment and representation of host perspectives is necessary to identify and address challenges and promote equitable, mutually beneficial partnerships between surgical programs in HIC and LMIC.

Implementing the Trauma Evaluation and Management (TEAM) Course in Kenya.

BACKGROUND: Trauma training provides crucial knowledge and skills for health-care providers in low- and middle-income countries (LMICs). Although such training has been adapted for physicians and emergency personnel in LMICs, few courses have been offered for medical students. The Trauma Evaluation and Management (TEAM) course, developed by the American College of Surgeons, provides a valuable framework for providing this content to medical students in an LMIC-context. MATERIALS AND METHODS: We implemented the TEAM course at a single medical school in rural Kenya, for final-year medical students, utilizing the multimodal instruction and reference materials provided by the American College of Surgeons. We administered precourse and postcourse assessments, adapted the content for particular low-resource considerations, expanded the course to 2 d, and utilized a multidisciplinary and multinational group of surgical expert instructors. RESULTS: The entire final-year medical school class participated, and all completed pretesting and posttesting (100%, n = 61). Posttesting revealed significant improvement (P < 0.001), demonstrating successful knowledge acquisition, with the greatest improvements among the poorest performing decile on the pretest (P < 0.05). On narrative course feedback (100% completion, n = 61), participants appreciated instructors' interactive teaching style and the course's practical demonstrations, while requesting more time allotment for trauma training. CONCLUSIONS: We describe the feasibility of implementing TEAM training for final-year medical students in Kenya and demonstrate the course's effectiveness in this context as shown by knowledge acquisition. We plan for additional study to assess interval knowledge and skill retention. With refinement based on these results, we plan to repeat and expand trauma-education initiatives for medical students in LMICs.

Perception of medical professionalism among the surgical community in the University of Nairobi: a mixed method study.

BACKGROUND: Professionalism defines the relationship between colleagues, patients and the society as a whole. Furthermore, being a social construct, professionalism is sophisticated to be regarded simply as a single concept across different cultural contexts. This study sought to explore how professionalism is conceptualized by the clinicians, students and patients in a teaching hospital in Kenya. METHODS: A sequential mixed methods study was conducted among clinicians, students and patients at Kenyatta National Hospital on the surgical wards from March 1(st)-December 31(st), 2014. The first phase of the study involved focus group discussions (FGDs) of between 10-12 persons and individual in-depth interviews of senior faculty and patients. Grounded theory method was used for collecting perceptions of participants on professionalism. These views were then coded using Atlas 5.2, allowing the development of a questionnaire that provided the survey tool for the second phase of the study. For the questionnaire, response options utilized a 4-point Likert scale with a range from "strongly agree" to "strongly disagree". Factor analysis was used to analyse the responses to the survey. Internal reliability was determined by Cronbach's α. RESULTS: Sixteen FGDs and 18 in-depth interviews were held with 204 clinicians, students and patients. A further 188 participants completed the questionnaire. Respect was the most frequently mentioned or picked component of professionalism during the interview and survey respectively, with 74.5 % of participants reporting "strongly agree". Factor analysis showed that 3 factors accounted for the majority of the variance in the items analysed; respect in practice, excellence in service and concern for the patient. The Cronbach's α for this analysis was 0.927. CONCLUSION: The study cohort predominantly conceptualizes professionalism as relating to respect between colleagues and toward patients. Respect, being a cultural norm, should form part of the core curriculum of professionalism in order to be relevant for the Kenyan context.

Early trauma induced coagulopathy (ETIC): prevalence across the injury spectrum.

INTRODUCTION: Newer studies have hypothesised about a coagulopathy that occurs early after trauma, early trauma induced coagulopathy, ETIC, and is defined by an elevated admission prothrombin time (PT). Also, referred to by some authors as acute traumatic coagulopathy, it has been most often studied in cohorts of severely injured or hypotensive patients. However, we wanted to prospectively investigate ETIC in a large all-comers cohort to confirm its prevalence across the entire spectrum of injury, to evaluate its risk pattern and to determine a possible relationship to reduced survival. METHODS: We conducted a prospective cohort study at a Level I trauma centre from July 15, 2008 to November 15, 2009. Demographics, injury mechanism, time from injury and to hospital arrival, fluid and blood administration and vital signs were collected at hospital arrival and to the time of first blood sample collection for all patients admitted for 24h or longer. Our primary outcome was the incidence of mortality by the 28th hospital day, referred to as 28 day in-hospital mortality. RESULTS: 701 patients were included in the final study cohort. There was 75.3% male, 25.7% penetrating, with a mean age of 39 years. The overall mortality was 7.3%. ETIC occurred in 114 patients (16.3%) and was found to be independently associated with death (odds of death (per 0.10s increase in PT): 1.10, p=0.001). ETIC patients, as a group, were more severely injured, had more hypotension and head injury and used more crystalloid and blood products than non-ETIC patients. However, even mildly injured patients, who had an ISS<16, normal RTS score, and no fluid resuscitation, had an ETIC prevalence of 11.7% (11/94). CONCLUSIONS: ETIC is an early, primary post-injury coagulopathy that occurs in 16.3% of admitted trauma patients. It is associated with an increase in mortality, even when controlling for crystalloids, vital signs, injury severity and head injury. It can also be found in approximately 11% of mildly injured patients (patients without physiological derangement or blood product administration). Therefore, further elucidation of ETIC is strategic to impacting trauma patient outcome.

Adrenocorticotropic hormone and cortisol response to corticotropin releasing hormone in the critically ill-a novel assessment of the hypothalamic-pituitary-adrenal axis.

BACKGROUND: The pathophysiology of adrenal insufficiency, common in surgical intensive care units, has not been fully elucidated. METHODS: Patients at risk (age > 55 years, in the surgical intensive care unit >1 week, baseline cortisol < 20 µg/dL) were enrolled. After measuring cortisol and adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH) was administered. ACTH and cortisol were measured over 120 minutes. Short and long cosyntropin stimulation tests determined adrenal function. Area under the curve (AUC) and mixed linear models were used to compare cortisol and ACTH responses. Patients were grouped according to survival and response to stimulation testing. Chi-square and t tests were performed, and P values < .05 were considered statistically significant. RESULTS: Six of 25 patients responded poorly to cosyntropin, and 5 died compared with 3 after a normal response (P < .01). ACTH (AUC) and ACTH peak were increased in nonsurvivors after CRH administration. Cortisol peak and AUC were not different. CONCLUSIONS: ACTH responsiveness was increased in nonsurvivors and may predict mortality.

Alcohol-related injury visits: do we know the true prevalence in U.S. trauma centres?

INTRODUCTION: Alcohol consumption is a significant risk factor for injuries. Further, level I trauma centres are mandated to screen and provide a brief intervention for identified problem drinkers. However, a valid population-based estimate of the magnitude of the problem is unknown. Therefore, the goal of this study is to evaluate the extent to which the present literature provides a valid estimate of the prevalence of alcohol-related visits to U.S. trauma centres. METHODS: A Medline search for all articles from 1966 to 2007 that might provide prevalence estimates of alcohol-related visits to U.S. trauma centres yielded 836 articles in English language journals. This review included only papers whose main or secondary goal was to estimate the prevalence of positive blood alcohol concentration (BAC) or acute intoxication. Both a crude aggregate estimate and sample size adjusted estimate were calculated from the included papers and the coverage and comparability of methods were evaluated. RESULTS: Of the 15 studies that met inclusion criteria, incidence estimates of alcohol-related visits ranged from 26.2% to 62.5% and yielded an aggregate, weighted estimate of 32.5%. Target population, capture rate, and threshold for a positive screening result varied considerably across studies. No study provided a comprehensive estimate, i.e., of all trauma patients hospitalised, treated and released, or who died. CONCLUSIONS: Although the incidence of alcohol-related visits to U.S. trauma centres appears very high perhaps higher than any other medical setting, the validity of our aggregate estimate is threatened by crucial methodological considerations. The lack of a methodologically valid prevalence estimate hinders efforts to devise appropriate policies for trauma centres and across medical settings.

Intensive medical student involvement in short-term surgical trips provides safe and effective patient care: a case review.

BACKGROUND: The hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience. FINDINGS: Over three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%). Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained. DISCUSSION: This demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.

Pathophysiology of early trauma-induced coagulopathy: emerging evidence for hemodilution and coagulation factor depletion.

BACKGROUND: Trauma patients present with a coagulopathy, termed early trauma-induced coagulopathy (ETIC), that is associated with increased mortality. This study investigated hemostatic changes responsible for ETIC. METHODS: Case-control study of trauma patients with and without ETIC, defined as prolonged prothrombin time (PT), was performed from prospective cohort of consecutive trauma patients who presented to Level I trauma center. Univariate and multivariate analyses were performed. RESULTS: The case-control study group (n = 91) was 80% male, with mean age of 37 years, 17% penetrating trauma and 7% mortality rate. Patients with ETIC demonstrated decreased common and extrinsic pathway factor activities (factors V and VII) and decreased inhibition of the coagulation cascade (antithrombin and protein C activities) when compared with the matched control patients without ETIC. Both cohorts had evidence of increased thrombin and fibrin generation (prothrombin fragment 1.2 levels, thrombin-antithrombin complexes, and soluble fibrin monomer), increased fibrinolysis (d-dimer levels), and increased inhibition of fibrinolysis (plasminogen activator inhibitor-1 activity) above normal reference values. Patients with versus without ETIC had increased mortality and received increased amount of blood products. CONCLUSION: ETIC following injury is associated with decreased factor activities without significant differences in thrombin and fibrin generation, suggesting that despite these perturbations in the coagulation cascade, patients displayed a balanced hemostatic response to injury. The lower factor activities are likely secondary to increased hemodilution and coagulation factor depletion. Thus, decreasing the amount of crystalloid infused in the early phases following trauma and administration of coagulation factors may prevent the development.

Evaluation of fundamental critical care course in Kenya: knowledge, attitude, and practice.

BACKGROUND: Critical care training for medical personnel is crucial for the survival of the highest acuity patients. The Fundamental Critical Care Course (FCCS), a critical care course developed by the Society of Critical Care Medicine, permits course adaption and, thus, has potential for global dissemination. The FCCS course was provided in two Kenyan hospitals after minimal adaption. Participant knowledge and confidence gain as well as FCCS applicability to an African context were evaluated. METHODS: Questionnaires and a multiple-choice test were administered to assess knowledge, attitude, and self-reported confidence or self-efficacy. For applicability, the pre-course questionnaire assessed participant expectations and existing levels of confidence/knowledge in the care of the critically ill patient. Post-course, the participant evaluated the overall quality of the course, lectures, and skill stations along with context applicability questions. RESULTS: There were 100 participants, 45 doctors, 45 nurses, and 10 clinical officers. There was a 22.7% gain in the mean test score (P < 0.0001) after the course, with 98% of participants showing improvement. Confidence to perform new skills post-course, or self-efficacy, was demonstrated by a median of 4 or greater on a Likert scale of 5 (most confident) in 10 of 12 clinical scenarios and in 11 of 14 new procedures. There was a consistency between areas reported as needed expertise, and participant evaluation of similar lecture and skill station's quality and appropriateness. The most common areas reported were mechanical ventilation, patient monitoring, and their related procedures. CONCLUSIONS: The FCCS course met participant's expectations and was reported as applicable for the Kenyan context with minimal adaption. Post-course, knowledge improved and confidence increased for implementation of new skills in clinical care situations. We confirmed the effectiveness and relevancy of the FCCS course for other resource-constrained health care settings.

Evaluation of trauma and critical care training courses on the knowledge and confidence of participants in Kenya and Zambia.

BACKGROUND: Trained health-care personnel are essential for improved outcomes for injured and critically ill patients. The highest injury-related mortality is seen in sub-Saharan Africa, where there is a paucity of skilled personnel. Therefore, the College of Surgeons of East, Central, and Southern Africa (COSECSA) along with Emory University provided an acute trauma care (ATC) and fundamental critical care support course (FCCS). This study evaluates the impact of American-derived courses on the knowledge and confidence of participants from resource-limited countries. METHODS: Courses were held in Lusaka, Zambia, and Nakuru, Kenya. Participants were COSECSA trainees and personnel from local institutions. The evaluation used a pre-/postcourse multiple-choice exam for knowledge acquisition and a pre-/postcourse questionnaire for confidence assessment. Confidence was measured using a 5-point Likert score, with 5 being the highest level of confidence. Confidence or self-reported efficacy is correlated with increased performance of new skills. RESULTS: There were 75 participants (median age = 31 years, 67% male). Three-quarters of the participants reported no prior specific training in either trauma or critical care. Knowledge increased from an average of 51 to 63.3% (p = 0.002) overall, with a 21.7% gain for those who scored in the lowest quartile. Confidence increased from pre- to postcourse on all measures tested: 22 clinical situations (10 trauma, 9 critical care, 3 either) and 15 procedures (p < 0.001 for all measures both individually and aggregated, Wilcoxon rank sum test). The strongest absolute increase in confidence, as well as the largest number of participants who reported any increase, were all in the procedures of cricothyroidotomy [median: pre = 3 (IQR: 2-3) to post = 5 (IQR: 4-5)], DPL [median: pre = 3 (IQR: 2-4) to post = 5 (IQR: 4-5)], and needle decompression [median: pre = 3 (IQR: 3-4) to post = 5 (IQR: 5-5)]. CONCLUSIONS: Participants from resource-limited countries benefit from ATC/FCCS courses as demonstrated by increased knowledge and confidence across all topics presented. However, the strongest increase in confidence was in performing life-saving procedures. Therefore, future courses should emphasize essential procedures, reduce didactics, and link knowledge acquisition to skill-based teaching.

The epidemiology of childhood injury in Maputo, Mozambique.

BACKGROUND: Injury remains a major cause of death and disability worldwide. AIMS: This study describes the characteristics of childhood injury at three hospitals in Maputo, Mozambique. METHODS: An observational, prospective convenience study was conducted in June and July 2007. We prospectively collected data on 335 children (0-14 years) who presented to three hospitals in Maputo during the study period. RESULTS: The prevalence of trauma-related complaints on presentation to the hospital in this study was 12%, with higher rates in boys (59%) and in those between the ages of 5-9 years (34.9%). Falls were the most common mechanism of injury (40.6%), followed by burns (19.1%) and road traffic injuries (RTI) (14.3%). The majority of falls occurred in the home (61.8%) and were unintentional. (94.1%) Burns were predominantly due to hot liquids (82.8%) and less frequently due to fire (17.2%). The majority of burns involved the patient alone (62.5%). The majority of RTIs were pedestrians struck by vehicles (81.2%). A substantial number of patients presented more than 24 h after injury (23.3%). Children from households living with a lower family income in general suffered trauma more often regardless of the mechanism. CONCLUSIONS: Childhood injury accounts for a substantial burden of disease in Maputo, Mozambique. This study highlights the fact that many of these injuries are consistent with the injury patterns seen in children in other low and middle income countries, and are amenable to prevention, access, and emergency care programs targeted at children and their families, schools, and the local and national community.

The Epidemiology of Traumatic Hemothorax in a Level I Trauma Center: Case for Early Video-assisted Thoracoscopic Surgery.

OBJECTIVE: Hemothorax is a common sequela of chest trauma. Complications after chest trauma include retained hemothorax and empyema requiring multiple interventions. We studied the epidemiology of hemothorax and its complications at a level I trauma center. METHODS: The trauma registry was reviewed from Jan 1995 toMay 2005.Allpatients ≥16 years of agewhowere admitted with hemothorax, an AIS chest score of ≥ 3, and did not receive an immediate thoracotomy were entered in the study cohort. The patient demographics, details of the injury event, treatments, hospital length of stay (LOS), complications and outcome were analyzed. RESULTS: The study cohort of 522 patients with a hemothorax were treated with 685 chest thoracostomy tubes. Overall, the median ISS was 18 and 62% were penetrating injuries. 109 patients (21%) had a retained hemothorax and required placement of ≥ 2 chest tubes with a median LOS of 15 days longer than patients with no retained hemothorax (p < 0.0001). The overall complication rate was 5% (26/522). Of these, 20 patients had empyema (3.8%), 8 patients required decortication, and 6 patients received streptokinase treatment. CONCLUSION: More than 1 out of every 5 patients undergoing intervention for trauma-induced hemothorax develops a complication. The development of retained hemothorax is associated with empyema in 15.6% of cases and a 2-week median increase in length of stay. Future research into interventions such as Video-assisted thoracoscopic surgery (VATS) on the day of admission to completely evacuate hemothorax is warranted to reduce complication rates, length of stay and cost.

Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients.

BACKGROUND: Recent data from military and civilian centers suggest that mortality is decreased in massive transfusion patients by increasing the transfusion ratio of plasma and platelet (PLT) products, and fibrinogen in relationship to red blood cell (RBC) products during damage control resuscitation and surgery. This study investigates the relationship of plasma:RBC, PLT:RBC, and cryoprecipitate:RBC transfusion ratios to mortality in massively transfused patients at a civilian Level 1 trauma center. STUDY DESIGN AND METHODS: Demographic, laboratory, transfusion, and outcome data were collected prospectively from February 1, 2007, to January 31, 2009, and retrospectively from February 1, 2005, to January 31, 2007, on all injured patients who underwent massive transfusion (defined as >or=10 RBC products within 24 hr). Mortality was analyzed in relation to the plasma:RBC, PLT:RBC, and cryoprecipitate:RBC transfusion ratios using both univariate and multivariate analyses. RESULTS: A total of 214 patients received massive transfusion secondary to traumatic injury. High versus low transfusion ratios were associated with improved 30-day survival: plasma:RBC 59% versus 44%, p = 0.03; PLT:RBC 63% versus 33%, p < 0.01; and cryoprecipitate:RBC 66% versus 41%, p < 0.01. By multivariable stepwise logistic regression analysis, increased plasma:RBC (p = 0.02) and PLT:RBC (p = 0.02), and decreased age (p = 0.02), ISS (p < 0.01) and total RBCs (p = 0.03) were statistically associated with improved 30-day survival. CONCLUSIONS: In the civilian setting, plasma, PLT, and cryoprecipitate products significantly increased 30-day survival in trauma patients. Future prospective randomized clinical trials are required to determine the optimal transfusion ratios.

Assessment of acute trauma care training in Kenya.

An Acute Trauma Care (ATC) course was adapted for resource-limited healthcare systems based on the American model of initial care for injured patients. The course was taught to interested medical personnel in Kenya. This study undertook a survey of the participants' healthcare facilities to maximize the applicability of ATC across healthcare settings. The ATC course was conducted three times in Kenya in 2006. A World Health Organization (WHO) Needs Assessment survey was administered to 128 participants. The data were analyzed qualitatively and quantitatively. Ninety-two per cent had a physician available in the emergency department and 63 per cent had a clinical officer. A total of 71.7 per cent reported having a designated trauma room. A total of 96.7 per cent reported running water, but access was uninterrupted more often in private hospitals as opposed to public facilities (92.5 vs 63.6%, P = 0.0005). Private and public employees equally had an oxygen cylinder (95.6 vs 98.5%, P > 0.05), oxygen concentrator (69.2 vs 54.2%, P = 0.12), and oxygen administration equipment (95.7 vs 91.4%, P > 0.05) at their facilities. However, private employees were more likely to report that "all" of their equipment was in working order (53 vs 7.9%, P < 0.0001). Private employees were also more likely to report that they had access to information on emergency procedures and equipment (64.4 vs 33.3%, P = 0.001) and that they had learned new procedures (54.8 vs 25.4%, P = 0.002). Despite a perception of public facility lack, this survey showed that public institutions and private institutions have similar basic equipment availability. Yet, problems with equipment malfunction, lack of repair, and availability of required information and training are far greater in the public sector. The content of the ATC course is valid for both private and public sector institutions, but refinements of the course should focus on varying facets of inexpensive and alternative equipment resources. Furthermore, the implementation of this course should create a setting that advocates, promotes, and investigates resources. The WHO survey can guide future research in understanding impediments to implementing essential trauma care courses for resource limited healthcare systems.