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Muhrbeck M, Osman Z, von Schreeb J, Wladis A, Andersson P. Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study. BMC Emerg Med 2021; 21:94. [PMID: 34380419 PMCID: PMC8359038 DOI: 10.1186/s12873-021-00488-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/30/2021] [Indexed: 11/14/2022] Open
Abstract
Background In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings. Methods A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC’s hospitals in Peshawar, 2009–2012 and Goma, 2012–2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC). Results A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74–0.78) than for KTS (0.53, 95% CI 0.50–0.56) and RTS (0.51, 95% CI 0.48–0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79–0.88) than for KTS (0.71, 95% CI 0.65–0.76) and RTS (0.70, 95% CI 0.63–0.76) for all patients, but not for patients with complete data. Conclusion RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00488-2.
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Affiliation(s)
- Måns Muhrbeck
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden.
| | - Zaher Osman
- International Committee of the Red Cross, Geneva, Switzerland
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Wladis
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
| | - Peter Andersson
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,International Medical Programme, Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
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Using the Red Cross wound classification to predict treatment needs in children with conflict-related limb injuries: a retrospective database study. World J Emerg Surg 2020; 15:52. [PMID: 32948211 PMCID: PMC7501687 DOI: 10.1186/s13017-020-00333-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/06/2020] [Indexed: 11/25/2022] Open
Abstract
Background The International Committee of the Red Cross (ICRC) implemented the Red Cross wound classification (RCWC) to quickly assess the severity of a wound in conflict settings. A subdivision into wound grades derived from the RCWC consists of grades 1, 2, and 3, and represents low, major, and massive energy transfer, respectively, to the injured tissue. The aim of this observational study is to assess whether the Red Cross wound grade of a pediatric patient’s wound correlates with patient outcomes. Methods All pediatric patients (age < 15 years) treated in an ICRC hospital between 1988 and 2014 for conflict-related penetrating extremity injuries were retroactively included. Correlations were assessed between wound grades and number of surgeries, blood transfusions, days hospitalized, and mortality. Stratification analyses were performed to evaluate potential effect modifiers. Results The study included 2463 pediatric patients. Pediatric patients with a higher wound grade received significantly more surgeries (grade 1 median 2; grade 3 median 3), more blood transfusions (grades 1 and 3 received 33.9 and 72.2 units per 100 patients, respectively), and were hospitalized longer (grade 1 median 15; grade 3 median 40 days). Mortality rates did not significantly differ. Stratification analyses did not reveal effect modifiers for the association between wound grades and patient outcomes. Conclusion The Red Cross wound grade of a pediatric patient’s extremity wound correlates independently with treatment needs. This simple wound grading system could support clinical decision-making and should be integrated into the clinical assessment of weapon-wounded pediatric patients in conflict settings.
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Trends in Demographics and Surgical Treatment of Weapon-Related Limb Injuries Over Two Decades in a Resource-Scarce Setting. World J Surg 2020; 43:2681-2688. [PMID: 31407093 DOI: 10.1007/s00268-019-05110-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. METHODS Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. RESULTS Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. CONCLUSION In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.
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Haverkamp FJC, van Gennip L, Muhrbeck M, Veen H, Wladis A, Tan ECTH. Global surgery for paediatric casualties in armed conflict. World J Emerg Surg 2019; 14:55. [PMID: 31827594 PMCID: PMC6902420 DOI: 10.1186/s13017-019-0275-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/31/2019] [Indexed: 11/10/2022] Open
Abstract
Background Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones. Methods Characteristics of children (age < 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years). Results Of the patients listed in the database, 15% (5843/38,088) were aged < 15 years. The median age was 10 years (IQR 6–12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1–3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates. Conclusions Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts.
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Affiliation(s)
- Frederike J C Haverkamp
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid, 9101, 618 Nijmegen, the Netherlands
| | - Lisanne van Gennip
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid, 9101, 618 Nijmegen, the Netherlands
| | - Måns Muhrbeck
- 2Department of Surgery, Linköping University, Norrköping, Sweden.,3Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden.,4Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
| | - Harald Veen
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid, 9101, 618 Nijmegen, the Netherlands.,2Department of Surgery, Linköping University, Norrköping, Sweden.,3Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden.,4Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
| | - Andreas Wladis
- 3Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden.,4Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
| | - Edward C T H Tan
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid, 9101, 618 Nijmegen, the Netherlands
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Bäckström F, Bäckström D, Sadi L, Andersson P, Wladis A. Surgical Needs at the End of the Battle of Mosul: Results from Mosul General Hospital. World J Surg 2019; 44:673-679. [PMID: 31676974 DOI: 10.1007/s00268-019-05250-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of the study was to analyze the surgical needs of patients seeking emergency care at the Mosul General Hospital in the final phase of the battle of Mosul in northern Iraq between an international military coalition and rebel forces. During the conflict, the International Red Committee of the Red Cross (ICRC) supported the hospital with staff and resources. Ceasefire in the conflict was declared at the end of July 2017. METHODS Routinely collected hospital data from the ICRC-supported Mosul General Hospital from June 6, 2017, to October 1, 2017 were collected and analyzed retrospectively. All patients with weapon-related injuries as well as all patients with other types of injuries or acute surgical illness were included. RESULTS Some 265 patients were admitted during the study period. Non-weapon-related conditions were more common than weapon-related (55.1%). The most common non-weapon-related condition was appendicitis followed by hernia and soft tissue wounds. Blast/fragment was the most frequent weapon-related injury mechanism followed by gunshot. The most commonly injured body regions were chest and abdomen. Children accounted for 35.3% of all weapon-related injuries. Patients presented at the hospital with weapon-related injuries more than 2 months after the official declaration of ceasefire. A majority of the non-weapon-related, as well as the weapon-related conditions, needed surgery (88.1% and 87.6%, respectively). Few postoperative complications were reported. CONCLUSIONS The number of children affected by the fighting seems to be higher in this cohort compared to previous reports. Even several months after the fighting officially ceased, patients with weapon-related injuries were presenting. Everyday illnesses or non-weapon-related injuries dominated. This finding underlines the importance of providing victims of conflicts with surgery for life-threatening conditions, whether weapon related or not.
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Affiliation(s)
- Fredrik Bäckström
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
- Centre for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden.
| | - Denise Bäckström
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Lin Sadi
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Peter Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Surgery, Vrinnevi Hospital, 603 79, Norrköping, Sweden
- International Medical Program, Centre for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
| | - Andreas Wladis
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Centre for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
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Tounsi LL, Daebes HL, Gerdin Wärnberg M, Nerlander M, Jaweed M, Mamozai BA, Nasim M, Drevin G, Trelles M, von Schreeb J. Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan. World J Surg 2019; 43:2123-2130. [PMID: 31065777 DOI: 10.1007/s00268-019-05015-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. MATERIALS AND METHODS This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. RESULTS Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). CONCLUSION Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
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Affiliation(s)
- Linnea Latifa Tounsi
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Hadjer Latif Daebes
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | | | - Maximilian Nerlander
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Momer Jaweed
- Kunduz Trauma Centre, Médecins Sans Frontières, Kunduz, Afghanistan
| | | | - Masood Nasim
- Kabul Medical Coordination, Médecins Sans Frontières, Kabul, Afghanistan
| | - Gustaf Drevin
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Miguel Trelles
- Medical Department - Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden.
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