Importance:Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective:To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants:This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures:People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures:Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results:Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance:The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.

BACKGROUND: Injury Severity Score (ISS) is a measurement of injury severity based on the Abbreviated Injury Scale. Because of the difficulty and expense of Abbreviated Injury Scale coding, there have been recent efforts in mapping ISS from administrative International Classification of Diseases (ICD) codes instead. Specifically, the open source and freely available International Classification of Diseases Programs for Injury Categorization (ICDPIC) in R (Foundation for Statistical Computing, Vienna, Austria) converts International Classification of Diseases, Ninth Revision, codes to ISS. This study aims to compare ICDPIC calculations versus manually derived Trauma Quality Improvement Program (TQIP) calculations for International Classification of Diseases, Tenth Revision (ICD-10), codes. Moderate concordance was chosen as the hypothetical relationship because of previous work by both Fleischman et al. (J Trauma Nurs. 2017;24(1):4-14) who found moderate to substantial concordance between ICDPIC and ISS and Di Bartolomeo et al. (Scand J Trauma Resusc EmergMed. 2010;18(1):17) who found none to slight concordance. Given these very different findings, we thought it reasonable to predict moderate concordance with the use of more detailed ICD-10 codes. METHODS: This was an observational cohort study of 1,040,728 encounters in the TQIP registry for the year 2018. International Classification of Diseases Programs for Injury Categorization in R was used to derive ISS from the ICD-10 codes in the registry. The resulting scores were compared with the manually derived ISS in TQIP. RESULTS: The median difference between ISS calculated by ICDPIC-2021 using ICD-10, Clinical Modification (ISS-ICDPIC), and manually derived ISS was -3 (95% confidence interval, -5 to 0), while the mean difference was -2.09 (95% confidence interval, -2.10 to -2.07). There was substantial concordance between ISS-ICDPIC and manually derived ISS (kappa = 0.66). The ISS-ICDPIC was a better predictor of mortality (area under the curve, 0.853 vs. 0.836) but a worse predictor of intensive care unit admission (area under the curve, 0.741 vs. 0.757) and hospital stay >= 10 days (AUC, 0.701 vs. 0.743). The ICDPIC has substantial concordance with TQIP for the firearm (kappa = 0.69), motor vehicle trauma (kappa = 0.71), and pedestrian (kappa = 0.73) injury mechanisms. CONCLUSION: When TQIP data are unavailable, ICDPIC remains a valid way to calculate ISS after transition to ICD-10 codes. The ISS-ICDPIC performs well in predicting a number of outcomes of interest but is best served as a predictor of mortality. (Copyright (c) 2022 Wolters Kluwer Health, Inc. All rights reserved.)

BACKGROUNDUnderrepresented minorities in medicine (URiMs) are disproportionally represented in surgery training programs. Rates of URiMs applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiMs disparities would persist into surgical critical care (SCC) fellowship applicants, matriculants, and graduates.METHODSWe performed a retrospective analysis of SCC applicants, matriculants, and graduates from 2005 to 2020 using the graduate medical education resident survey and analyzed applicant characteristics using the Surgical Critical Care and Acute Care Surgery Fellowship Application Service from 2018 to 2020. The data were stratified by race/ethnicity and sex. Indicator variables were created for Asian, Hispanic, White, and Black trainees. Yearly proportions for each race/ethnicity and sex categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and sex proportion as the dependent variables and year as the explanatory variable.RESULTSFrom 2005 to 2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p= 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p< 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p= 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased.CONCLUSIONDisparities in URiMs representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiMs in SCC training are warranted.LEVEL OF EVIDENCEPrognostic and Epidemiologic; level IV.

BACKGROUNDInjury severity score (ISS) is a measurement of injury severity based on the Abbreviated Injury Scale (AIS). Due to the difficulty and expense of AIS coding, there have been recent efforts in mapping ISS from administrative International Classification of Disease (ICD) codes instead. Specifically, the open source and freely-available International Classification of Diseases Programs for Injury Categorization in R (ICDPIC-R) converts ICD-9 codes to ISS. This study aims to compare ICDPIC calculations versus manually derived TQIP calculations for ICD-10 codes. Moderate concordance was chosen as the hypothetical relationship due to previous work by both Fleischman et al. who found moderate to substantial concordance between ICDPIC and ISS as well as DiBartolomeo et al. who found none to slight concordance. Given these very different findings, we thought it reasonable to predict moderate concordance with the use of more detailed ICD-10 codes.METHODSThis was an observational cohort study of 1,040,728 encounters in the Trauma Quality Improvement Program (TQIP) registry for the year 2018. ICDPIC-R was used to derive ISS from the ICD-10 codes in the registry. The resulting scores were compared to the manually-derived ISS in TQIP.RESULTSThe median difference between ISS derived from ICDPIC (ISS-ICDPIC) and manually-derived ISS (ISS-TQIP) was -3 [-5, 0] while the mean difference was -2.09 (-2.10, -2.07). There was substantial concordance between ISS-ICDPIC and ISS-TQIP (κ = 0.66). ISS-ICDPIC was a better predictor of mortality (AUC = 0.853 vs. 0.836) but a worse predictor of ICU admission (AUC = 0.741 vs. 0.757) and hospital stay ≥10 days (AUC = 0.701 vs. 0.743). ICDPIC has substantial concordance with TQIP for the firearm (κ = 0.69), motor vehicle trauma (κ = 0.71), and pedestrian (κ = 0.73) injury mechanisms.CONCLUSIONWhen TQIP data are unavailable, ICDPIC remains a valid way to calculate ISS after transition to ICD-10 codes. ISS-ICDPIC performs well in predicting a number of outcomes of interest but is best served as a predictor of mortality.LEVEL OF EVIDENCELevel III Prognostic and Epidemiologic.

Objectives To develop and evaluate a simulation-based mastery learning (SBML) curriculum for cricothyrotomy using wet towels to suppress aerosolisation during a pandemic. Design Quasi-experimental, pre–post study. Setting Tertiary care, academic medical centre in Chicago. Participants Ear, nose and throat and general surgery residents, fellows and attendings. Intervention Cricothyroidotomy simulation-based mastery learning curriculum. Outcomes measure Pretest to posttest simulated cricothyrotomy skills checklist performance. Results 37 of 41 eligible surgeons participated in the curriculum. Median pretest score was 72.5 (IQR 55.0–80.0) and 100.0 (IQR 98.8–100.0) for the posttest p<0.001. All participants scored at or above a minimum passing standard (93% checklist items correct) at posttest. Conclusions Using SBML is effective to quickly train clinicians to competently perform simulated cricothyrotomy during a pandemic.

BACKGROUND: As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation. METHODS: Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05. RESULTS: A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission. CONCLUSION: Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control. Copyright (c) 2021 Wolters Kluwer Health, Inc. All rights reserved.

BACKGROUND:Cricothyrotomy is associated with significant aerosolization that increases the potential risk of infection among healthcare providers. It is important to identify simple yet effective methods to suppress aerosolization and improve the safety of healthcare providers.METHODS:5 ear, nose and throat and general surgeons used a locally developed hybrid cricothyrotomy simulator with a porcine trachea to test three draping methods to suppress aerosolization during the procedure: an X-ray cassette drape, dry operating room (OR) towels and wet OR towels. The three methods were judged based on three categories: effectiveness of suppression, availability in all healthcare systems and ease of handling.RESULTS:All five surgeons performed the procedure independently using each of the three suppression methods. The wet OR towel drape was found to be an effective method to suppress aerosolization, and it did not hinder the surgeons from performing the procedure accurately. This finding was confirmed by using an atomized fluorescein dye injection into the porcine trachea, representing aerosolized material while performing the procedure.CONCLUSIONS:We present a novel intervention using wet towels to suppress aerosolization during cricothyrotomy. Wet towels are cheap and readily available within any healthcare setting regardless of the financial resources available.

Clinicians faced with acute emergencies must act together as an effective, coordinated team to provide high-quality care to individual or multiple patients. Educators who train clinicians to provide emergent care need to address specific clinical algorithms, teamwork, and communication skills. In this chapter, we discuss established national life support curricula as exemplars of the challenges faced in training healthcare professionals to a high standard when targeting thousands of learners. We discuss the recent American Heart Association resuscitation education best practice report (Cheng et al, Circulation. 138:e82–122, 2018) and how mastery learning (ML) should be a key feature in a well-designed resuscitation program. We also review our experience with ML Advanced Cardiac Life Support to demonstrate the applicability of ML to resuscitation programs.

Background: Simulation-based education can augment residents' skills and knowledge. We assessed the effectiveness of a simulation-based course for surgery interns designed to improve their comfort, knowledge, and ability tomanage common surgical critical care (SCC) conditions. Materials and methods: For 2 y, all first year residents (n = 31) in general surgery, urology, interventional radiology, and the integrated plastics, vascular, and cardiothoracic surgery training programs at our institution participated in a simulation-based course emphasizing evidence-based management of SCC conditions. Precourse and postcourse surveys and multiple-choice tests, as well as summative simulation tests, assessed interns' comfort, knowledge, and ability to manage SCC conditions. Changes in these measures were assessed with Wilcoxon matched-pairs signed rank tests. Factors associated with summative performance were determined by linear regression. Results: The course consisted of four simulation-based teaching sessions in year 1 and six in year 2. The course taught seven of the 18 core SCC conditions in the Surgical Council on Resident Education general surgery curriculum in year 1 and 10 in year 2. Interns' self-reported comfort, knowledge, and ability to manage each condition taught in the course increased (P < 0.02). Their knowledge of each condition, as assessed by written tests, also increased (P < 0.02). Their summative simulation test performance correlated with the number of course sessions attended (P < 0.03) and status as general surgery residents (P < 0.01). Conclusions: A simulation-based SCC training course for surgery interns that emphasizes evidence-based management of SCC conditions improves interns' comfort, knowledge, and ability to manage these conditions. (C) 2020 Elsevier Inc. All rights reserved.

Background: Morbidity and mortality conferences (MMCs) promote patient safety, spur quality improvement (QI) projects, and enhance interprofessional cooperation. The use of MMCs to address the Accreditation Council for Graduate Medical Education's (ACGME's) six core competencies and specialty-specific milestones for surgical critical care (SCC) fellows has yet to be explored. Methods: We developed a monthly, interprofessional, case-based MMC program managed by SCC fellows. We assessed participants' experiences through post-conference surveys and semi-structured interviews. Results: After nine conferences, 95.1% of participants (n = 143) agree or strongly agree that the MMC improved their knowledge and clinical assessment skills. The MMC spurred two QI projects, increased interprofessional cooperation, and addressed all six ACGME core competencies and 16 specialty-specific milestones. Conclusions: Interprofessional, case-based MMCs are an effective educational tool for SCC fellowship programs. They promote patient safety, QI, and interprofessional cooperation, and address ACGME core competencies and specialty-specific milestones for SCC fellows. (C) 2019 Elsevier Inc. All rights reserved.

PROBLEM:Thirteen measurable Entrustable Professional Activities (EPAs) have been proposed by the Association of American Medical Colleges as a means to operationalize medical school graduates' patient care qualifications. Mastery learning is an effective method for boosting clinical skills, but its applicability to the EPAs remains to be studied. The authors designed this study to evaluate a mastery learning intervention to teach and assess components of 3 of the 13 EPAs in a 4th-year capstone course.INTERVENTION:The course featured mastery learning principles and addressed three EPA-based skills: (a) obtain informed consent, (b) develop a differential diagnosis and write admission orders, and (c) write discharge prescriptions. All students underwent a baseline skills assessment, received feedback, engaged in deliberate practice with actionable feedback, and completed a similar skills-based posttest assessment. Students continued with practice and testing until the minimum passing standards (MPSs) were reached for each posttest.CONTEXT:All medical students at a single medical school (Northwestern University, Feinberg School of Medicine) who matriculated in 2012 and graduated with the class of 2016 participated in a required transition to residency course immediately prior to graduation.OUTCOME:There were 134 students eligible to participate, and 130 (97.0%) completed all curricular requirements and assessments. All 130 medical students who completed the course met or exceeded the MPS for each of the three EPA-based clinical skills. Reliability coefficients for outcome data were uniformly high. Measures for each of the three clinical skills showed statistically significant improvement.LESSONS LEARNED:The capstone course was an effective approach to teach and assess components of three EPA-based clinical skills to mastery learning standards in a 4th-year capstone course. We learned that this approach for implementation is feasible and results in significant improvement in components of EPA skill performance. Next steps will include developing assessments incorporating the mastery model into components of additional EPAs, identifying the best location within the curriculum to insert this content, and expanding the number of assessments as part of a larger assessment system.

Introduction: Exposure to pain management curriculum in medical school is currently variable. This paper reports on formal prescribing education, self-perceived prescribing readiness, and prescribing practices among incoming surgical residents before and after a pain management training session. Methods: Pre-residency survey of thirty surgical interns at a single urban medical center, followed by a repeat survey after an educational session on prescription writing and opioid abuse. Results: Thirty-three percent of respondents had formal education on prescription writing in medical school. Median subjective preparedness to write an opioid prescription was 1.5 (range 1-10) on a 1-10 Likert scale. Ranges of morphine milligram equivalents (MME) prescribed varied from 420-2700 MME for 8 mock surgical scenarios. Post-training, median subjective preparedness increased to 3.5 (range 1-6) and prescription accuracy (the inclusion of a medication, dose, frequency, and duration) improved from 75% to 97% (p < 0.001). Overall, 90% of interns found the training session useful. Conclusion: Most surgical interns were not trained in prescribing narcotics in medical school. Improved pain management curriculum is necessary to assure safe and consistent opioid prescriptions. (C) 2017 Elsevier Inc. All rights reserved.

A 3-day simulation-based capstone course was developed and pilot tested for a cohort of graduating medical students to assess their readiness for residency. The intervention taught and assessed individual performance on specific components of the 13 core entrustable professional activities (EPAs) that all medical school graduates should perform independently. Two 6-station clinical skills examinations (CSE) were developed to assess performance before and after a simulation-based educational intervention. Graduating medical students could not reliably perform selected EPAs at baseline. However, a focused 3-day simulation-based capstone experience produced significant improvement in core clinical skills.

Context: Abdominal compartment syndrome (ACS) is associated with high morbidity and mortality among trauma patients. Several clinical and laboratory findings have been suggested as markers for ACS, and these may point to different types of ACS and complications. Aims: This study aims to identify the strength of association of clinical and laboratory variables with specific adverse outcomes in trauma patients with ACS. Settings and Design: A 5-year retrospective chart review was conducted at three Level I Trauma Centers in the City of Chicago, IL, USA. Subjects and Methods:A complete set of demographic, pre-, intra- and post-operative variables were collected from 28 patient charts. Statistical Analysis:Pearson's correlation coefficient was used to determine the strength of association between 29 studied variables and eight end outcomes. Results: Thirty-day mortality was associated strongly with the finding of an initial intra-abdominal pressure >20 mmHg and moderately with blunt injury mechanism. A lactic acid >5 mmol/L on admission was moderately associated with increased blood transfusion requirements and with acute renal failure during the hospitalization. Developing ACS within 48 h of admission was moderately associated with increased length of stay in the Intensive Care Unit (ICU), more ventilator days, and longer hospital stay. Initial operative intervention lasting more than 2 h was moderately associated with risk of developing multi-organ failure. Hemoglobin level <10 g/dL on admission, ongoing mechanical ventilation, and ICU stay >7 days were moderately associated with a disposition to long-term support facility. Conclusions: Clinical and lab variables can predict specific adverse outcomes in trauma patients with ACS. These findings may be used to guide patient management, improve resource utilization, and build capacity within trauma centers.

BACKGROUND:Ninety percent of nearly five million annual global injury deaths occur in low- and middle-income countries (LMICs), where prehospital care systems are frequently rudimentary or nonexistent. The World Health Organization considers layperson first-responders as essential for emergency medical services in low-resource settings lacking more formalized systems. This study sought to develop and implement a layperson trauma first responder course (TFRC) in Bolivia.MATERIALS AND METHODS:In March and April 2013 nine sessions of the eight-hour TFRC were held in La Paz, Bolivia. The course charged a nominal fee, and was led by an American surgeon and medical student. The TFRC built upon existing models with local stakeholder input, and included both didactic and practical components. Participants completed a baseline survey, and pre and posttests. The primary outcome was test performance, with secondary outcomes including demographic sub-group test score analyses and exam question validation. Data were assessed using nonparametric and psychometric methods RESULTS: One hundred fifty-nine individuals met study inclusion criteria. Participant median age was 28 (IQR 24, 36), 49.1% were male, 59.1% worked in a medical field, most had secondary (35.2%) or university (56.0%) level educations, and 67.3% had prior first aid training. Median test scores improved after course completion (48% vs. 76%, p <0.001), along with skill confidence (4 vs. 4.5, p <0.001). Most questions had appropriate item difficulty indices, point bi-serial correlation coefficients, and positive Pretest Posttest Difference Indices. Cronbach alpha coefficients for pre and posttest scores were 0.72 and 0.78, respectively.CONCLUSIONS:This study presents data from the first offering of an original TFRC for laypeople in Bolivia. Increased participant knowledge and skill confidence after course completion, and acceptable overall psychometric test properties, indicate this model is valid and effective. Future aims include TFRC revision, and enrollment of more layperson first responders to increase population-level impacts.

Hospital-acquired infections, sepsis, and critically ill patients cost the healthcare system billions of dollars every year. Many factors contribute to these problems, and the remedies are multifactorial. Education is an important component in resolving many of the issues related to better combating the economic, social, and personal costs associated with surgical infections. The Surgical Infection Society (SIS) convened a symposium to begin a dialogue on how the SIS can facilitate a better understanding of how to educate the surgical infection professionals and trainees. The following report summarizes the presentations and commentary presented at the 2013 Annual Meeting.

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included "Strengthening Women's Leadership in Global Health", "Decolonizing Global Health Education", and "Capacity Building for Global Health Leadership Training". Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

BACKGROUND:Trauma systems in resource-rich countries have decreased mortality for trauma patients through centralizing resources and standardizing treatment. Rapid industrialization and urbanization have increased the demand for formalized emergency medical services and trauma services (EMS and TS) in low- and middle-income countries (LMICs). This systematic review examines initiatives to develop EMS and TS systems in LMICs to inform the development of comprehensive prehospital care systems in resource-poor settings.MATERIALS AND METHODS:EMS and TS system development publications were identified using MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts, and full texts in a hierarchical manner.RESULTS:A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS programs were identified. Common initiatives included the integration of existing EMS and TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model.CONCLUSIONS:There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems.

Although abdominal impalement injuries are less common than other types of penetrating trauma (eg, gunshot wounds), these injuries present providers with a unique set of challenges.