International outreach for pediatric surgical subspecialists.

International outreach for surgical subspecialists may take many forms. The first model is direct care of children by a pediatric surgical subspecialist, along with one or more nurses, in a facility in an underdeveloped area. On the first day or two of a one to two week stay the group will assess a large number of patients until the operating schedule for the duration of the visit is fully booked. The remainder of the time will be spent in surgery, perhaps assisted by a local surgeon, and they then leave the country with the local personnel providing follow-up. The team may bring sutures, instruments, and medications, and the amount of supplies that they bring with them may be a ratelimiting step. This type of outreach provides much needed care to the children who are treated. However, when the team leaves, help is over. Frequently in this model, the same core team will continue to visit the site on a regular basis. Funding may be from a variety of sources including religious institutions, ethnic community support groups, or through the philanthropy of the involved physicians and nurses themselves. One must ensure that the medical facility is able to support the anticipated surgical procedures and that adequate follow-up is available. In addition, if children are significantly malnourished or have loss of skin integrity then surgical healing may be compromised. The second level also involves a team going to a lessdeveloped country, but on a much grander scale. The team will be larger and include surgical and recovery room nurses, physical therapists, and enough equipment to sustain fully the work and more. Local personnel are fully involved, and funding is usually provided by an established philanthropic non-governmental organization. In addition to the clinical program, educational programs are also provided. This may involve direct teaching in the operating room and/or a series of lectures by the visitors. The next and final level of international medical outreach is exemplified by the Project HOPE program in which I was involved in Armenia following the devastating earthquake that occurred in December 1998. Project HOPE sponsored a team to provide immediate medical assistance, and arranged for transportation of 30 or more injured children to various centers around the United States for treatment. When the officials from Project HOPE looked into the possibilities of local followup, they found that pediatric rehabilitation was essentially non-existent in Armenia at that time. There were pediatric orthopedists but they concentrated primarily on trauma and congenital deformities. Project HOPE responded by developing a five-year program which provided a rotating team of health professionals who were in residence in Armenia, including a physiatrist, a nurse, a physical and an occupational therapist, and an orthotist, as well as administrative support staff including competent interpreters. They recruited Armenian medical personnel and made a five-year commitment to provide an E diorial