A tale of three pandemics: Shining a light on a hidden problem

An "epidemic" is an event in which a disease, infectious or non-infectious, is actively spreading within a population and designated area. The term "pandemic" is defined as "an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people".The global response to the COVID-19 pandemic has not been seen since the outbreak of Human Immunodeficiency Virus in the early eighties. But there is another unseen pandemic running alongside the current COVID-19 pandemic, which affects a vast number of people, crossing international boundaries and occurring in every single country world-wide. The pandemic of traumatic injuries. Traumatic injuries account for 11% of the current Global Burden of Disease, resulting in nearly 5 million deaths annually and is the third-leading cause of death worldwide. For every trauma-related death, it is estimated that up to 50 people sustain permanent or temporary disabilities. Furthermore, traumatic injuries occur at disproportionately higher rates in low-and middle-income countries, with approximately 90% of injuries and more than 90% of global deaths from injury occurring these countries.Injuries are increasing worldwide, crossing international boundaries and affecting a large number of people, in the same manner Human Immunodeficiency Virus did in the 1980's and COVID-19 is today. The tremendous global effort to tackle the COVID-19 and Human Immunodeficiency Virus pandemics has occurred whilst ignoring the comparable pandemic of injury. Without change and future engagement with policy makers and in-ternational donors this disparity is likely to continue.(c) 2021 Published by Elsevier Ltd on behalf of Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.

Determining Clinical Priorities Using a Clinical Practice Guideline Deconstruction Tool: COVID-19 in Austere Operational Environments.

The Joint Trauma System (JTS) publishes Clinical Practice Guidelines (CPGs) used by military and civilian healthcare providers worldwide. With the expansion of CPG development in recent years, there was a need to collate, sort, and deconflict existing and new guidance using systematic methodology both within and across CPGs. This need became readily apparent at the start of the COVID-19 pandemic when guidelines were rapidly developed and fielded in deployed environments. To meet the needs of deploying units requesting immediate and concise guidance for managing COVID-19, JTS developed the CPG entitled Management of Covid-19 in Austere Operational Environments. By applying a deconstruction process to organize clinical recommendations across multiple categories, JTS was able to present clear clinical recommendations across "role of care" and "scope of practice." The use of a deconstruction process supported the rapid socialization of the CPG and may have improved clinical understanding among deployed medical teams.

Increasing hip fracture volume following repeated lockdowns: an Irish multicentre study of periods pre-Covid, during Covid lockdown and following vaccination.

BACKGROUND: Older age groups were identified as a high-risk cohort for Covid-19 and thus were a focus of lockdown measures enacted internationally. Resultant decreased social mobility and physical activity levels are associated with sarcopenia, which may lead to increased risk of hip fracture upon resuming social integration and physical activities after easing of lockdown restrictions. AIMS: Our aim was to compare the incidence of hip fractures during the period following vaccination with subsequent relaxation of restrictions, to those prior to and during the Covid pandemic. METHODS: A multicentre retrospective cohort study was performed consisting of all patients presenting with a "hip" fracture to 3 regional trauma units over the relevant time periods in 2019, 2020 and 2021. Tallaght, Galway and Waterford University Hospitals are large academic teaching hospitals with a combined mixed urban and rural catchment of over 1 million people. FINDINGS: Four-hundred-fourteen patients in total were included in the final analysis, with 133 eligible hip fractures observed proceeding to operative treatment across the study period in 2019, 132 in 2020 and 149 in 2021, representing a 12.88% increase. Demographic data revealed similar patient cohorts with respect to age and gender, fracture pattern and treatment. CONCLUSIONS: An increase in hip fracture volume was observed during the period post vaccination with subsequent relaxation of restrictions and increased social mobility, compared to those prior to and during the Covid pandemic. These findings have implications for hospital planning and orthopaedic resourcing as we navigate our way forward past the Covid-19 Pandemic.

Development of the quality of teen trauma acute care patient and parent-reported experience measure.

OBJECTIVE: Patient-Reported Experience Measures (PREMs) provide valuable patient feedback on quality of care and have been associated with clinical outcomes. We aimed to test the reliability of a modified adult trauma care PREM instrument delivered to adolescents admitted to hospital for traumatic injuries, and their parents. Modifications included addition of questions reflecting teen-focused constructs on education supports, social network maintenance and family accommodation. RESULTS: Forty adolescent patients and 40 parents participated. Test-retest reliability was assessed using Cohen's kappa, weighted kappa, and percent agreement between responses. Directionality of changed responses was noted. Most of the study ran during the COVID-19 pandemic. We established good reliability of questions related to in-hospital and post-discharge communication, clinical and ancillary care and family accommodation. We identified poorer reliability among constructs reflecting experiences that varied from the norm during the pandemic, which included "maintenance of social networks", "education supports", "scheduling clinical follow-ups" and "post-discharge supports". Parents, but not patients, demonstrated more directionality of change of responses by responding with more negative in-hospital and more positive post-discharge experiences over time between the test and retest periods, suggesting risk of recall bias. Situational factors due to the COVID-19 pandemic and potential risks of recall bias may have limited the reliability of some parts of the survey.

Planning the Trauma Hospital Network Expansion to Increase Access in Rural Communities

Trauma care services are a vital part of all healthcare-based networks as timely accessibility is important for citizens. Trauma care access is even more relevant when unexpected events such as the COVID-19 pandemic overload the capacity of hospitals. Research literature has highlighted that access to trauma care is not equal for all populations, especially when comparing rural and urban groups. In this research we present a decision-making model for the expansion of a trauma hospital network by considering the demand for services of rural communities. The decision-making model provides recommendations in terms of where to place additional aeromedical facilities and where to locate additional trauma hospitals. A case study is presented for the state of Texas, where a sensitivity analysis was conducted to consider changes in demand, cost, and the total number of facilities allowed in the network. The results show that the location of new facilities is sensitive to the expected service demand and the maximum number of facilities allowed in the network. © 2022 IISE Annual Conference and Expo 2022. All rights reserved.

Empowering catastrophic far-forward self-care: Nobody should die alone without trying

LAY SUMMARY Traumatic injury is the most common cause of death among young people. Most victims of trauma die alone before medical response is possible. Typical causes of death are not overly complex to fix if access to standard hospital interventions is feasible. Dying victims are often connected to smartphone-supporting informatic communication technologies, which make available a worldwide network of experts who can potentially reassure and remotely diagnose victims and provide life-saving advice. TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) researchers have focused on empowering point-of-care providers to perform outside their scope and deliver life-saving interventions. With the recognition that coronavirus disease 2019 (COVID-19) has profoundly isolated many people, solutions to respect COVID-19 isolation policies have stimulated the TMUSMI group to appreciate the potential for informatic technologies' effect on the ability to care for oneself in cases of catastrophic injury. Most traumatic death occurs pre-hospital, before a victim ever encounters a health care provider, whether in military or in civilian settings. Many of these deaths have been accepted as unpreventable, especially when severe injuries occur to isolated victims, with no possibility of rescuers responding. A double paradox is that dying individuals often have anatomically simple wounds with complex physiology. These individuals are physically dying alone while virtually connected via smartphone to a potential worldwide network of life-saving mentors - many of whom have the comprehensive library of human resuscitative science at their virtual fingertips. If a seriously injured victim is not immediately incapacitated, then many techniques to empower point-of-care self-resuscitation exist, including both remotely telementored and video-modelled diagnostic, resuscitative, and interventional procedures. This article discusses a small but evolving database and proposes developmental pathways to attempt to ensure that no conscious, dying victim ever dies alone without at least trying to save themselves or receiving comforting words through virtual expert help.

Development of virtual reality content for learning Japan Prehospital Trauma Evaluation and Care initial assessment procedures.

Aim: The Japan Prehospital Trauma Evaluation and Care (JPTEC) is a standardized educational program for prehospital trauma care in Japan. The initial assessment in the JPTEC course comprises a training segment that includes a 30-min session. Given the limited face-to-face training due to the coronavirus disease 2019, virtual reality (VR) content has become an alternative. However, creating VR content typically requires the assistance of expert technicians. We aimed to create VR content for the initial assessment segment of the JPTEC and verify its educational effectiveness. Methods: We created VR content for learning the initial assessment of the JPTEC using our easy-to-use VR content creation system. The participants played the VR content for 15 min. The number of times they "cleared" (i.e., made a correct decision and completed the initial assessment) was recorded every 5 min. Then, a JPTEC-certified instructor tested their practical skills through face-to-face simulation. Results: The authors had no specialized skills and created the VR content in 2 days. Fourteen students used the material. They cleared the scenario 3 (3-4) times in the first 5 min in 15 min, 5 (4-5) times in the second 5 min, and 5 (5-5) times in the third 5 min (P < 0.05). All participants passed the practical evaluation. Conclusion: A shorter VR training developed using our easy-to-use VR content creation system can replace the 30-min JPTEC session on the initial assessment. This system allows for the free and easy creation of VR content.

"I didn't sign up for this": Four English language arts teachers' perceptions, implementations, and reflections of trauma care in the midst of COVID-19

The prevalence of trauma and the pervasive nature of students' exposure has only been compounded by the trauma of COVID-19 and racial violence of 2020 This study is a qualitative comparative case study of four English language arts (ELA) teachers' perceptions, implementations, and reflections of trauma-informed care in the midst of a pandemic. Data was collected through observations, interviews, and artifacts collected over the course of four months and analyzed through Thematic Inquiry (ITI) (Morgan & Nica, 2020). Teachers in this study all noted varying levels of confidence in supporting students with trauma prior to COVID-19 and all expressed concerns at their preparation and ability to support students with a return to face-toface instruction. Findings suggest that teachers' perceptions of trauma are shaped by their professional knowledge, their personal experiences with trauma, and their classroom experiences. The teachers in the study leaned on each of these knowledge bases when addressing a challenging experience or discussing trauma-informed care. This study also confirmed the struggle most teachers have finding and maintaining boundaries, something that became increasingly difficult for the teachers in this study during COVID-19. Lastly, this study found that teacher/team relationships offered crucial support. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Observational Study of Hand Hygiene Compliance at a Trauma Hospital in Iraqi Kurdistan

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference in compliance rates between units in resource-limited trauma hospitals is largely unknown. We aimed to assess hand hygiene compliance rates among healthcare workers at a trauma hospital in Iraqi Kurdistan and compare the levels of compliance between the emergency room (ER), the intensive care unit (ICU), and the acute care ward (ACW). We carried out overt observations in 2018 using the validated World Health Organization ‘five moments for hand hygiene’ observational tool. We observed a total of 622 hand hygiene opportunities performed by 149 healthcare workers. Hand hygiene compliance was defined as handwashing with soap and water or the use of alcohol-based hand rub, in accordance with the ‘five moments for hand hygiene’ concept. Overall, the hand hygiene compliance rate was found to be 6.8% (95% confidence interval 5.0–9.1). Compliance was significantly lower in the ER (1.0%), compared with the ICU (8.1%) (p = 0.0012), and the ACW (11.1%) (p < 0.0001). In all three units, the availability of alcohol-based hand rub and handwashing sinks was insufficient in relation to the number of patient beds. We conclude that the overall level of hand hygiene compliance was low, with the lowest level of compliance in the ER. Our findings call for improved resource allocation and strengthened hand hygiene routines. These relatively simple measures could potentially lower the incidence of healthcare-associated infections and improve the mortality and morbidity of patients in already overburdened healthcare systems.

Virtual fracture clinic reduces patient X-ray volume for common wrist and ankle fractures.

BACKGROUND: Virtual fracture clinics (VFC) have been widely adopted worldwide as part of the changes in healthcare delivery during the COVID-19 pandemic. They have been shown to be a safe and effective method of delivering trauma care for injuries which do not require immediate intervention or specialist management, whilst maintaining high levels of patient satisfaction. AIMS: Our aim was to evaluate whether VFCs reduce the volume of X-rays performed for common fractures of the wrist and ankle. METHODS: A retrospective cohort review was performed. The pre-VFC group consisted of 168 wrist and 108 ankle referrals from March to September 2019. The VFC group included 75 wrist and 68 ankle referrals, during the period March to September 2020. The total number of X-ray images, carried out within a 3-month period for each fracture was summated, with statistical analysis performed following fracture pattern classification. FINDINGS: A statistically significant decrease in mean X-rays was observed for isolated stable fracture patterns, such as non-displaced distal radius, - 0.976 (p = 0.00025), and Weber A ankle fractures, - 0.907 (p = 0.000013). A reduction was also observed for more complex fracture patterns such as dorsally displaced distal radius, - 0.701 (p = 0.129) and Weber B ankle fractures, - 0.786 (p = 0.235), though not achieving statistical significance. CONCLUSIONS: Virtual fracture clinics can reduce X-ray frequency for common stable wrist and ankle fractures, with resultant benefits for both patients and healthcare systems. These benefits may be sustained in patient care beyond the current COVID-19 pandemic.

A Rapid Ethnographic Assessment of the Impact of the COVID-19 Pandemic on Mental Health Services Delivery in an Acute Care Medical Emergency Department and Trauma Center.

A rapid ethnographic assessment of delivery of mental health services to patients at a Level I trauma center in a major metropolitan hospital undergoing a COVID-19 surge was conducted to assess the challenges involved in services delivery and to compare the experience of delivering services across time. Study participants were patients and providers who interacted with or otherwise were observed by three clinicians engaged in the delivery of care within the Emergency Department (ED) and Trauma Center at Harborview Medical Center from the COVID-19-related "surge" in April to the end of July 2020. Data were collected and analyzed in accordance with the Rapid Assessment Procedures-Informed Clinical Ethnography (RAPICE) protocol. Community and institutional efforts to control the spread of the coronavirus created several challenges to providing mental health services in an acute care setting during the April surge. Most of these challenges were successfully addressed by standardization of infection control protocols, but new challenges emerged including an increase in expenses for infection control and reduction in clinical revenues due to fewer patients, furloughs of mental health services providers and peer specialists in the ED, services not provided or delayed, increased stress due to fear of furloughs or increased workload of those not furloughed, and increases in patients seen with injuries due to risky behavior, violence, and substance use. These findings illustrate the rapidly shifting nature of the pandemic, its impacts on mental health services, and the mitigation efforts of communities and healthcare systems.

Impact of the COVID-19 outbreak on severe trauma trends and healthcare system reassessment in Lombardia, Italy: an analysis from the regional trauma registry.

BACKGROUNDS: The COVID-19 pandemic drastically strained the health systems worldwide, obligating the reassessment of how healthcare is delivered. In Lombardia, Italy, a Regional Emergency Committee (REC) was established and the regional health system reorganized, with only three hospitals designated as hubs for trauma care. The aim of this study was to evaluate the effects of this reorganization of regional care, comparing the distribution of patients before and during the COVID-19 outbreak and to describe changes in the epidemiology of severe trauma among the two periods. METHODS: A cohort study was conducted using retrospectively collected data from the Regional Trauma Registry of Lombardia (LTR). We compared the data of trauma patients admitted to three hub hospitals before the COVID-19 outbreak (September 1 to November 19, 2019) with those recorded during the pandemic (February 21 to May 10, 2020) in the same hospitals. Demographic data, level of pre-hospital care (Advanced Life Support-ALS, Basic Life Support-BLS), type of transportation, mechanism of injury (MOI), abbreviated injury score (AIS, 1998 version), injury severity score (ISS), revised trauma score (RTS), and ICU admission and survival outcome of all the patients admitted to the three trauma centers designed as hubs, were reviewed. Screening for COVID-19 was performed with nasopharyngeal swabs, chest ultrasound, and/or computed tomography. RESULTS: During the COVID-19 pandemic, trauma patients admitted to the hubs increased (46.4% vs 28.3%, p < 0.001) with an increase in pre-hospital time (71.8 vs 61.3 min, p < 0.01), while observed in hospital mortality was unaffected. TRISS, ISS, AIS, and ICU admission were similar in both periods. During the COVID-19 outbreak, we observed substantial changes in MOI of severe trauma patients admitted to three hubs, with increases of unintentional (31.9% vs 18.5%, p < 0.05) and intentional falls (8.4% vs 1.2%, p < 0.05), whereas the pandemic restrictions reduced road- related injuries (35.6% vs 60%, p < 0.05). Deaths on scene were significantly increased (17.7% vs 6.8%, p < 0.001). CONCLUSIONS: The COVID-19 outbreak affected the epidemiology of severe trauma patients. An increase in trauma patient admissions to a few designated facilities with high level of care obtained satisfactory results, while COVID-19 patients overwhelmed resources of most other hospitals.

Impact and Modifications of In-Hospital Trauma Care Workflow Due to COVID 19 Pandemic: Lessons Learnt for the Future.

OBJECTIVE: To describe the restructuring in-hospital systems of care at a Level -1 trauma center in India and to analyze an injury volume and patterns for future preparedness as well as to establish a specific injuries preventive measures during health emergencies like COVID-19. METHODS: Data was extracted from a prospectively managed trauma registry at level-1 trauma center in India. We have compared the data in lockdown period with the same day's number from the pre-lockdown period. Patients were categorized according to age, gender, injury cause, injury place, injury severity, and injury outcome to compare the statistical analysis between two periods. RESULTS: Total emergency department (ED) trauma footfall decreased significantly by 73% during lockdown period. The injuries result increased significantly due to blunt forces. There was a significant decrease in the major injury of the patient's percentage. The road traffic injuries (RTIs) in individuals were less than the reported falls number, which increased significantly during lockdown. The less number of patients significantly presented without receiving primary care. Majority of the patients had been transferred by using private cars, police vehicle, and two wheelers during lockdown; however, patients' less number were transferred significantly by three wheelers as expected. The comparative analysis between quantitative data points shows significant differences in median Injury Severity Score (ISS) and length of stay during lockdown. CONCLUSION: This study highlighted that the preparedness should not focus solely on the response to treat infectious disease during health emergencies but also on ensuring access and provision of reasonable quality of care for non-infectious illnesses especially acute conditions like trauma.

COVID-19-Induced Hypoxia With Accompanying Syncope Event and Traumatic Injury.

The Centers for Disease Control and Prevention identified the first case of the novel coronavirus disease 2019 (COVID-19) on January 21, 2020 in the United States. Since its arrival, the virus has caused widespread havoc on the nation as a whole as well as on all individuals. The coronavirus family is not new to the field of medicine. In fact, the viral pathogenicity dates back to the early 1960s, with more information on the respiratory preference and the ability to cause acute respiratory pathology coming later in 2002. The novel coronavirus, severe acute respiratory syndrome coronavirus 2, causes a disease commonly referred to as COVID-19, which has a well documented course of severe respiratory pathology along with interesting systemic consequences that often complicate the clinical picture. This case presents an otherwise healthy young 35-year-old male who contracted the novel coronavirus, leading to multi-organ hypoxia and triggering a syncopal episode which resulted in physical trauma to the head leading to a minor subarachnoid hemorrhage.

Embracing the change: Resuming advanced trauma training in the COVID-19 era.

BACKGROUND: Trauma is slowly regaining its pre-COVID-19 status in terms of prevalence. Advanced trauma training cannot be deferred indefinitely in the current pandemic owing to defense requirements and disaster preparedness in vulnerable regions. Advanced Trauma Life Support (ATLS) India resumed ATLS and Advanced Trauma Care For Nurses (ATCN) courses at one civilian and one military site. METHODS: Stakeholders of respective centers for advanced trauma training deliberated over safe means to resume ATLS and ATCN. Meticulous screening of all participants and pre- and post-course tracking were deemed the most important components for the safe resumption of courses. 'Paperless' course, 'open-air' skill stations, 'payment protection', 'buddy system', point of care sanitizer installation, packed food, and potable beverages were major organizational changes. Participants above 60 years and with uncontrolled comorbidities were not enrolled. RESULTS: Two ATCN, one ATLS (civilian), and one combined ATLS-ATCN (military) were conducted. 78 delegates trained by 32 faculties and 13 personnel. All underwent daily thermal scanning and smartphone application-based COVID-19 tracking. Manikins were utilized instead of moulages and instructors took up the role of nursing assistants in Initial Assessment. Exit exams were conducted with full PPE precautions at the military site and mask-distancing precautions at the civilian site. High fidelity simulator was used at one station at the civilian site. Expenses at the civilian site per course were USD 570 lower than conventional courses. There was no incidence of COVID-19 in any of the 123 participants at 14 days follow up. CONCLUSION: With stringent participant selection and moderate precautions, ATLS and ATCN can be resumed safely in the current COVID-19 pandemic. To the best of our knowledge and after a thorough search of published English literature, this is the first paper reporting on resuming Advanced trauma training in the COVID-19 era.

Gadgets and Armamentarium of Maxillofacial Surgeons during Coronavirus Pandemic.

INTRODUCTION: We all know about the grave situation caused by the novel coronavirus in recent times. Although the maxillofacial surgeons are not at forefront of dealing with the coronavirus directly, they are at increased risk due to their working area on face, mouth, and oral cavity. There is an urgent need to upgrade the already set guidelines and follow them stringently. Any procedure done within the oral cavity is a high-risk procedure and this upgradation is necessary because present means are insufficient to prevent infection from this deadly virus. This article aims to review and discuss all the new gadgets and armamentarium required to deal with patients during and post coronavirus pandemic. MATERIALS AND METHODS: The authors performed a thorough literature search on various armamentarium and new gadgets introduced into the field of dentistry during the coronavirus pandemic worldwide. The relevant armamentarium is discussed under three broad headings, namely, those required before, during and after the procedures for easy understanding. RESULTS: A total of 15 gadgets and armamentarium related to oral and maxillofacial surgical practice are named and discussed in the literature review. DISCUSSION: We are particularly vulnerable to the transmission of diseases easily both due to the field of interest of work and type of instrumentation. Thus, we need to be extremely cautious about the procedure. Since, the literature is scarce about the sequelae of the coronavirus disease; shift to the automated, contactless gadgets is the way to look forward to a healthy dental practice. CONCLUSION: These gadgets are user friendly for any small dental set-up as well. The choice of these upgraded instruments are prerogative of the individual professionals according to their exclusive practice. Yet, the authors encourage all health care professionals to focus on better training in infection control and cross-contamination.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]. / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.