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Baird MD, Madha ES, Arnaouti M, Cahill GL, Hewa Kodikarage SN, Harris RE, Murphy TP, Bartel MC, Rich EL, Pathirana YG, Kim E, Bain PA, Alswaiti GT, Ratnayake AS, Worlton TJ, Joseph MN. Global assessment of military and civilian trauma systems integration: a scoping review. Int J Surg 2024; 110:3617-3632. [PMID: 38935828 PMCID: PMC11175771 DOI: 10.1097/js9.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators. METHODS A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers. RESULTS Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%). CONCLUSION Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.
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Affiliation(s)
- Michael D. Baird
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Emad S. Madha
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Matthew Arnaouti
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Royal National Orthopaedic Hospital, Stanmore, Middlesex
| | - Gabrielle L. Cahill
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Sadeesh N. Hewa Kodikarage
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | | | - Timothy P. Murphy
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Megan C. Bartel
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Elizabeth L. Rich
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Yasar G. Pathirana
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | - Eungjae Kim
- School of Medicine, Uniformed Services University
| | - Paul A. Bain
- Countway Library, Harvard Medical School, Boston
| | | | | | - Tamara J. Worlton
- Department of General Surgery, Walter Reed National Military Medical Center
- Department of Surgery, Uniformed Services University, Bethesda
| | - Michelle N. Joseph
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Surgery, Uniformed Services University, Bethesda
- Clinical Trials Unit, University of Warwick, Warwickshire, UK
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Benzar I, Levytskyi A, Khrapach V, Unukovych D. Warzone pediatric trauma care: Lessons from civilian medical staff in Kyiv. World J Surg 2024; 48:540-546. [PMID: 38319195 DOI: 10.1002/wjs.12091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/06/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION The article discusses the challenges faced by civilian healthcare providers in Kyiv, Ukraine, during the conflict in treating pediatric trauma resulting from war-related incidents. METHODS The authors share their experiences and insights from managing a series of 12 pediatric patients admitted to the Ohmatdyt children's hospital between February 25 and April 1, 2022. During this period, the hospital was under constant threat due to the military conflict. RESULTS The patients, ranging in age from 3 months to 17 years, suffered injuries from various causes, including vehicle shootings, explosions, and other traumatic events. The interventions and timely management are discussed, and two detailed clinical cases are presented to illustrate the complexities of treating pediatric trauma in a warzone. CONCLUSION In summary, the article sheds light on the unique challenges faced by healthcare providers in a warzone when treating pediatric trauma. It underscores the importance of timely intervention, effective triage, and the utilization of advanced medical techniques to improve patient outcomes in such challenging circumstances.
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Affiliation(s)
- Iryna Benzar
- Department of Pediatric Surgery, Bogomolets National Medical University, Kyiv, Ukraine
| | - Anatolii Levytskyi
- Department of Pediatric Surgery, Bogomolets National Medical University, Kyiv, Ukraine
| | - Vasyl Khrapach
- Department of Plastic Surgery, Bogomolets National Medical University, Kyiv, Ukraine
| | - Dmytro Unukovych
- Department of Plastic Surgery, Bogomolets National Medical University, Kyiv, Ukraine
- Department of Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
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Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness. Eur J Trauma Emerg Surg 2022; 49:1217-1225. [PMID: 35524778 DOI: 10.1007/s00068-022-01983-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/16/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness. METHODS This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries. RESULTS PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI. CONCLUSION Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.
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Developing a National Trauma Research Action Plan (NTRAP): Results from the Pediatric Research Gap Delphi Survey. J Trauma Acute Care Surg 2022; 93:360-366. [PMID: 35293373 DOI: 10.1097/ta.0000000000003610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND In 2016, the National Academies of Sciences, Engineering, and Medicine trauma report recommended a National Trauma Research Action Plan (NTRAP) to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." With a contract from the Department of Defense, the Coalition for National Trauma Research (CNTR) created 11 expert panels to address this recommendation, with the goal of developing a comprehensive research agenda, spanning the continuum of trauma and burn care. This report outlines the work of the group focused on pediatric trauma. METHODS Experts in pediatric trauma clinical care and research were recruited to identify gaps in current clinical pediatric trauma research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Using successive surveys, participants were asked to rank the priority of each research question on a 9-point Likert scale categorized to represent priority. Consensus was defined as >60% agreement within the priority category. Priority questions were coded based on a dictionary of 118 NTRAP taxonomy concepts in nine categories to support comparative analysis across all panels. RESULTS 37 subject matter experts generated 625 questions. 493 questions (79%) reached consensus on priority level. Of those reaching consensus, 159 (32%) were High, 325 (66%) Medium and 9 (2%) Low priority. The highest priority research questions related to surgical interventions for traumatic brain injury (ICP monitoring and craniotomy); second highest priority was hemorrhagic shock. The prehospital setting was the highest priority phase of care. CONCLUSIONS This diverse panel of experts determined that most significant pediatric trauma research gaps were in traumatic brain injur, hemorrhagic shock, and the prehospital phase of care. These research domains should be top priorities for funding agencies. LEVEL OF EVIDENCE IV.
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Civilian-Military Collaboration before and during COVID-19 Pandemic—A Systematic Review and a Pilot Survey among Practitioners. SUSTAINABILITY 2022. [DOI: 10.3390/su14020624] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Due to the similarity in skills and assets, Civilian-Military collaboration has emerged as one of the most reliable partnerships during the disaster and public health emergency management to address all necessary elements of surge capacity, i.e., staff, stuff, structure (space), and systems. This study aimed to evaluate this collaboration before and during the coronavirus 2019 pandemic. The outcomes of the systematic review revealed several published reports on successful civilian-military collaboration and proposed a need for further improvement. One hundred sixty-six individuals from 19 countries responded to nine questions, included in an online survey with the possibility to leave comments if necessary. The questionnaire referred to elements such as command and control, safety, communication, assessment, triage, treatment, and transport, as the crucial components of emergency management. The comprehensive examination of the survey results together with registered comments revealed a possible improvement in collaboration particularly on the strategic levels, i.e., meetings at the command-and-control level, safety, communication, and networking issues. While logistic collaboration seemed to be unchanged, the practical parts of the collaboration, i.e., clinical and non-clinical operational partnership (Triage and Treatment), mutual education, training, and operational understanding of each organization remained unchanged. In conclusion, although the current pandemic may have facilitated a more intense collaboration between civilian and military healthcare organizations, it lacks practical partnership and operative engagement, representing two crucial elements necessary for harmony and compatibility of both systems. Such collaboration may require a political will and perhaps a mutual civilian-military authority.
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Nijman RG, Bressan S, Brandenberger J, Kaur D, Keitel K, Maconochie IK, Oostenbrink R, Parri N, Shavit I, Teksam O, Velasco R, van de Voorde P, Da Dalt L, Guchtenaere AD, Hadjipanayis AA, Ross Russell R, Del Torso S, Bognar Z, Titomanlio L. Update on the Coordinated Efforts of Looking After the Health Care Needs of Children and Young People Fleeing the Conflict Zone of Ukraine Presenting to European Emergency Departments-A Joint Statement of the European Society for Emergency Paediatrics and the European Academy of Paediatrics. Front Pediatr 2022; 10:897803. [PMID: 35558376 PMCID: PMC9090499 DOI: 10.3389/fped.2022.897803] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/31/2022] [Indexed: 01/04/2023] Open
Abstract
This joint statement by the European Society for Emergency Paediatrics and European Academy of Paediatrics aims to highlight recommendations for dealing with refugee children and young people fleeing the Ukrainian war when presenting to emergency departments (EDs) across Europe. Children and young people might present, sometimes unaccompanied, with either ongoing complex health needs or illnesses, mental health issues, and injuries related to the war itself and the flight from it. Obstacles to providing urgent and emergency care include lack of clinical guidelines, language barriers, and lack of insight in previous medical history. Children with complex health needs are at high risk for complications and their continued access to specialist healthcare should be prioritized in resettlements programs. Ukraine has one of the lowest vaccination coverages in the Europe, and outbreaks of cholera, measles, diphtheria, poliomyelitis, and COVID-19 should be anticipated. In Ukraine, rates of multidrug resistant tuberculosis are high, making screening for this important. Urgent and emergency care facilities should also prepare for dealing with children with war-related injuries and mental health issues. Ukrainian refugee children and young people should be included in local educational systems and social activities at the earliest opportunity.
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Affiliation(s)
- Ruud G Nijman
- Division of Medicine, Department of Paediatric Emergency Medicine, St. Mary's Hospital - Imperial College NHS Healthcare Trust, London, United Kingdom.,Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom.,Centre for Paediatrics and Child Health, Imperial College, London, United Kingdom
| | - Silvia Bressan
- Division of Paediatric Emergency Medicine, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Julia Brandenberger
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, ON, Canada.,Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Division of Paediatric Emergency Medicine, Department of Paediatrics, University Hospital of Bern, Bern, Switzerland
| | - Davi Kaur
- European Society for Emergency Medicine, Antwerp, Belgium
| | - Kristina Keitel
- Division of Paediatric Emergency Medicine, Department of Paediatrics, University Hospital of Bern, Bern, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Ian K Maconochie
- Division of Medicine, Department of Paediatric Emergency Medicine, St. Mary's Hospital - Imperial College NHS Healthcare Trust, London, United Kingdom.,Centre for Paediatrics and Child Health, Imperial College, London, United Kingdom
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC - Sophia, Rotterdam, Netherlands
| | - Niccolo Parri
- Emergency Department & Trauma Center, Ospedale Paediatrico Meyer Firenze, Florence, Italy
| | - Itai Shavit
- Paediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Ozlem Teksam
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Hacettepe University School of Medicine, Ankara, Turkey
| | - Roberto Velasco
- Paediatric Emergency Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | - Liviana Da Dalt
- Division of Paediatric Emergency Medicine, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | | | | | - Robert Ross Russell
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Zsolt Bognar
- Department of Paediatric Emergency Medicine, Heim Pal National Paediatric Institute, Budapest, Hungary
| | - Luigi Titomanlio
- Paediatric Emergency Department, Hopital Universitaire Robert-Debre, Paris, France.,Université Paris Cité, INSERM UMR 1141, DHU Protect, Paris, France
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