Developing sustainable trauma care education in Egypt: sequential trauma education program, steps to success.

INTRODUCTION: As one of the leading causes of death and disability in the world, human trauma and injury disproportionately affects individuals in developing countries. To meet the need for improved trauma care in Egypt, the Sequential Trauma Emergency/Education ProgramS (STEPS) course was created through the collaborative effort of U.S. and Egyptian physicians. The objective of course development was to create a high-quality, modular, adaptable, and sustainable trauma care course that could be readily adopted by a lower- or middle-income country. METHODS: We describe the development, transition, and host nation sustainability of a trauma care training course between a high-income Western nation and a lower-middle-income Middle Eastern/Northern African country, including the number of physicians trained and the challenges to program development and sustainability. RESULTS: STEPS was developed at the University of Maryland, based in part on World Health Organization's Emergency and Trauma Care materials, and introduced to the Egyptian Ministry of Health and Population and Ain Shams University in May 2006. To date, 639 physicians from multiple specialties have taken the 4-day course through the Ministry of Health and Population or public/governmental universities. In 2008, the course transitioned completely to the leadership of Egyptian academic physicians. Multiple Egyptian medical schools and the Egyptian Emergency Medicine Board now require STEPS or its equivalent for physicians in training. CONCLUSIONS: Success of this collaborative educational program is demonstrated by the numbers of physicians trained, the adoption of STEPS by the Egyptian Emergency Medicine Board, and program continuance after transitioning to in-country leadership and trainers.

Ultrasound-guided peripheral intravenous access in the intensive care unit.

PURPOSE: Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician's ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters. MATERIALS AND METHODS: We performed a retrospective cohort review of our requests for ultrasound-guided PIV access in the intensive care unit between September 2007 and February 2008. RESULTS: Over a 6-month period, 77 requests for ultrasound-guided PIV access were made for 59 surgical, trauma, and cardiothoracic intensive care unit patients. Reasons for inability to obtain PIVs through standard means included edema (95%), obesity (42%), IV drug abuse history (8%), and emergency access (4%). Of the 148 PIV lines that were requested, 147 PIV catheters were successfully placed (99%). Of these, 105 PIV catheters were placed on the first attempt (71%). Complications of PIVs included IV infiltration (3.4%), inadvertent removal (2.7%), and phlebitis/cellulitis (0.7%). As a result of placing these PIV catheters, 40 central lines were discontinued and 34 central lines were avoided. The average number of line days at the time of central venous catheter removal was 11 ± 11 days. CONCLUSION(S): In intensive care unit patients who do not require central venous lines, ultrasound-guided PIV access can have a high placement success rate and can result in fewer central line days and/or less reliance on central venous catheters for access-only purposes.

Massive ventral hernias: role of tissue expansion in abdominal wall restoration following abdominal compartment syndrome.

Massive ventral hernias may result from a variety of clinical situations. One such clinical situation, a common problem in trauma patients, is abdominal compartment syndrome. Abdominal compartment syndrome frequently results in a massive abdominal defect when primary closure after surgical decompression is not possible. We offer a technique for repairing these massive ventral hernias by first expanding the lateral abdominal wall muscles, fasciae, and skin with tissue expanders and then closing the defect with elements of the "components separation" method. Additionally we present other clinical situations resulting in a massive ventral hernia that were repaired using this technique.