Nabil Issa

Applying multimedia design principles enhances learning in medical education.

Medical Education 2011: 45: 818–826

Teaching for understanding in medical classrooms using multimedia design principles

Objectives  In line with a recent report entitled Effective Use of Educational Technology in Medical Education from the Association of American Medical Colleges Institute for Improving Medical Education (AAMC‐IME), this study examined whether revising a medical lecture based on evidence‐based principles of multimedia design would lead to improved long‐term transfer and retention in Year 3 medical students. A previous study yielded positive effects on an immediate retention test, but did not investigate long‐term effects.

Trauma system development in low- and middle-income countries: a review

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.

Aeromonas Pneumonia in a Trauma Patient Requiring Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Case Report and Literature Review

BACKGROUND Aeromonas species, particularly Aeromonas hydrophila, cause a wide spectrum of diseases in human being such as gastroenteritis; soft tissue infections including necrotizing fasciitis, meningitis, peritonitis, and bacteremia; but pneumonia and respiratory tract infections are uncommon. METHODS Case report and literature review. RESULTS A 30-year-old victim of a motor vehicle crash sustained pelvic fractures and splenic injury. Delayed splenic rupture caused sudden cardiorespiratory arrest. The patient was resuscitated but suffered septic shock and severe hypoxemia refractory to advanced mechanical ventilatory strategies. Aeromonas hydrophila was isolated as the causative pathogen of severe bilateral pneumonia. Venovenous extracorporeal membrane oxygenation (ECMO) was used temporarily. The patient recovered uneventfully. CONCLUSION This is the first case, to our knowledge, of the use of ECMO in a trauma patient with severe fulminant A. hydrophila pneumonia. Clinicians should be aware of the characteristics of this pathogen and associated clinical infections.

Abdominal compartment syndrome in trauma patients: New insights for predicting outcomes.

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:Pearsons 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.

Surgical subinternships: bridging the chiasm between medical school and residency: A position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education

BACKGROUND Surgery subinternship rotations are clinical rotations intended to provide senior medical students with experiential exposure and increased autonomy during the care of surgical patients in clinical settings. Due to the lack of guidelines from national surgical organizations, these rotations remain largely unstructured and unstandardized with wide variability in the goals and experiences they provide for medical students. METHODS Through synthesis of the literature and by applying an iterative process among members of the subcommittee for surgery subinternship and the curriculum committee of the Association for Surgical Education (ASE) consensus recommendations were established. RECOMMENDATIONS Five defined domains were identified as essential for establishing surgery subinternship rotations. These are: administrative structure, goals and objectives, curricular elements, instructional methods, and assessment tools. CONCLUSIONS These recommendations should serve as a blue print for establishing a structured, educationally sound, and rewarding clinical rotation for medical students. Applying these recommendations may also provide educators with opportunities for scholarships and academic advancement.

Development and evaluation of standardized narrative cases depicting the general surgery professionalism milestones.

Purpose Residency programs now are required to use educational milestones, which has led to the need for new methods of assessment. The literature suggests that narrative cases are a promising tool to track residents’ progress. This study demonstrates the process for developing and evaluating narrative cases representing the five levels of the professionalism milestones. Method In 2013, the authors identified 28 behaviors in the Accreditation Council for Graduate Medical Education general surgery professionalism milestones. They modified previously published narrative cases to fit these behaviors. To evaluate the quality of these cases, the authors developed a 28-item, five-point scale instrument, which 29 interdisciplinary faculty completed. The authors compared the faculty ratings by narrative case and specialty with the authors’ initial rankings of the cases by milestone level. They used t tests and analysis of variance to compare mean scores across specialties. Results The authors developed 10 narrative cases, 2 for each of the 5 milestone levels. Each case contained at least 20 of the 28 behaviors identified in the milestones. Mean faculty ratings matched the milestone levels. Reliability was good (G coefficient = 0.86, phi coefficient = 0.85), indicating consistency in raters’ ability to determine the proper milestone level for each case. Conclusions The authors demonstrate a process for using specialty-specific milestones to develop narrative cases that map to a spectrum of professionalism behaviors. This process can be applied to other competencies and specialties to facilitate faculty awareness of resident performance descriptors and provide a frame of reference for milestones assessment.

Role of non-operative management of spleen injury in patients with hemophilia: Report of two patients with review of literature

The non-operative management (NOM) of hemodynamically stable patients with splenic trauma is currently well accepted, yet non-operative therapy has rarely been attempted in coagulopathic patients. Two cases of successful NOM of splenic trauma in patients with hemophilia are presented with a review of the English medical literature.

The development and implementation of a layperson trauma first responder course in La Paz, Bolivia: a pilot study

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.