Encouraging innovation and investigation

The report from our last travel grant is as follows:

My name is Mohamed Shoaeir, an ST7 ICM registrar in the Southeast Scotland region. I was granted the 2023 Travel Prize Grant from SICS, which I used to gain more experience in Cardiac ICM and Extracorporeal Membrane Oxygenation (ECMO). I traveled to Cairo, Egypt, for three weeks of ECMO training in a dedicated ECMO unit. In the following sections, I will explain why I chose Cairo and the benefits I gained from this educational journey. I will also discuss the differences in cardiac ICM practice between Egypt and Scotland.

The application announcement for the travel grant prize typically comes out around April/May, with decisions granted by October. To ensure a successful application, it is important to provide clear evidence that this educational journey will benefit your career progression in intensive care medicine and SICS members by sharing experiences and applying new practices. The prize grant can be used to travel outside your training region or even outside the UK, as I did.

ECMO is an expanding subspecialty in intensive care medicine, and we can expect to see more ECMO centers established in the UK in the coming years. Different countries have varying approaches to establishing ECMO services, and it is interesting to learn how financially demanding services like ECMO are provided in low- and middle-income countries.

Intensive care medicine training in the UK is higher specialty training that begins after completing core training in specialties like emergency medicine, anesthesia, and acute medicine. There are three stages of training. In stage one, we rotate through general ICM, and other specialties not covered during core training. For example, if you come from an anesthesia background, you will receive one year of training in general medicine, and vice versa.

In stage two, the focus is mainly on rotation through intensive care subspecialties, including three months each in neuro, cardiac, and pediatric intensive care medicine. The remainder of stage two is spent in general ICM with more independent management responsibilities. Completing the Faculty of Intensive Care Medicine exam is essential during this stage.

Stage three involves one year of training aimed at preparing trainees to become consultants. This includes involvement in management and leadership activities such as arranging departmental and regional teaching, risk management, and contributing to departmental meetings. There is also a period of acting up as a consultant with indirect or distant supervision, providing experience in managing critical care units from a consultant perspective. During ST7 of ICM training, trainees can be granted up to four weeks (varies by deanery) to expand their experience in an area of interest not covered in their training region.

In Egypt, intensive care training differs as it can start without core training in other specialties. There are two routes: the academic route and the fellowship route. The academic pathway involves joining a university hospital with rotations between clinical and academic sessions over three to five years, culminating in a Master’s in intensive care medicine.

The fellowship program is a five-year program with rotations between teaching and district hospitals. Trainees must pass a two-part fellowship exam. Both pathways include up to two years training in general medicine and cardiology. Unlike in the UK, where most intensivists have an anesthesia background, in Egypt, most have a background in general medicine and cardiology.

I chose to gain more knowledge in ECMO because I had limited exposure to those groups of patients, and it is a subspecialty of interest to me as a future consultant. My main aim is to achieve ELSO (Extracorporeal Life Support Organization) accreditation to be certified to practice ECMO.

I chose Egypt to understand how they set up the service despite financial challenges. Additionally, I am already registered with the Egyptian Medical Syndicate, having completed my university and foundation training there.

ECMO is a developing medical service in Egypt, with the largest center at Cairo University Hospital (Kasr-Al-Aini). The unit has eight beds dedicated to VV and VA ECMO and is funded by the health system with significant contributions from charity organizations.

The referral pathway is like the UK, where an MDT decides ECMO suitability. In the UK, most respiratory failure patients are connected to ECMO before transfer to an ECMO center, whereas in Egypt, all patients are transferred to the ECMO center for reassessment before starting ECMO.

Interestingly, a large percentage of VA ECMO patients in Egypt come from toxicology centers, with good outcomes for cases like calcium channel blocker and aluminum phosphide toxicity. There is also an early mobilization team that assesses and guide patients’ mobilization while connected to ECMO circuits.

I joined the registrar Rota and worked under supervision initially, focusing on safety and daily checklists. During the first week, I learned to assess ECMO patients clinically and perform routine circuit checks. I also attended MDT meetings to discuss referrals and patient retrieval. Weekly simulation sessions on emergency management of circuit failure were also part of the training. I scrubbed in with the cannulation team and had the opportunity to insert ECMO cannulas under direct supervision. I kept a logbook to record my hours, patients reviewed, simulation sessions, and procedures.

The ECMO team was friendly and supportive, and the unit, overlooking the Nile River, offered fascinating views from the doctors’ room. There was also a 24-hour hot meal service in the hospital’s restaurant.

The application process for a clinical attachment is straightforward, taking up to six weeks for approval. Required documents included proof of ID, medical school qualification, approval from the specialty register, and medical council registration.

ELSO accreditation involves four steps. The first two steps are attending an ECMO course with simulation lab and cannulation practice, which I completed at Cairo University. A significant portion of the course involved simulation and emergency scenario practice. I secured approval for the clinical attachment from the training program director while attending the course. This approval was provided to my educational supervisor in Southeast Scotland, allowing me to take three weeks off the Rota. This clinical attachment counts towards the clinical hours required for ELSO step three. Step four is an online exam, which I hope to complete by the end of this year.

The travel grant prize is an excellent opportunity for intensive care trainees to broaden their experience in areas of interest not covered during their training. I am very pleased with the progress I have made in cardiac and ECMO experience and look forward to building on this progress. I am happy to offer guidance and support to trainees interested in undertaking a similar journey.