Hybrid electronic record: An error reduction strategy for diverse medical prescription formats.

BACKGROUND:  This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. METHODS:  Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. RESULTS:  There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. CONCLUSION:  Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct.Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service.

Introduction: Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. Methods: We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. Results: We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. Conclusion: LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Outcomes of penetrating carotid artery injuries: A South African multicentre study.

BACKGROUND: This multicenter study examines the contemporary management of penetrating carotid artery injury (PCAI) to identify trends in management, outcomes, and to determine prognostic factors for stroke and death. METHODS: Data from three large urban trauma centers in South Africa were retrospectively reviewed for patients who presented with PCAI from 2012 to 2020. RESULTS: Of 149 identified patients, 137 actively managed patients were included. Twenty-four patients (17.9%) presented in coma and 12 (9.0%) with localizing signs (LS). CT angiography was performed on admission for 120 (87.6%) patients. Thirty patients (21.9%) underwent nonoperative management, 87 (63.5%) open surgery, and 20 (14.6%) endovascular stenting. Eighteen patients (13.1%) died, and 15 (12.6%) surviving patients had strokes. Ligation was significantly related to death and reperfusion to survival. A mechanism of gunshot wound, occlusive injuries, a threatened airway, a systolic blood pressure <90 mmHg, hard signs of vascular injury, a low GCS, coma, a CT brain demonstrating infarct, a high injury severity score and shock index, a low pH or HCO3, and an elevated lactate were significant independent prognostic factors for death. Ligation was unsurvivable in all patients with severe neurological deficits, whereas reperfusion procedures resulted in survival in 63% (12/19) patients with coma and 78% (7/9) with LS although with high stroke rates (coma: 25.0%, LS: 85.7%). CONCLUSIONS: Outcomes in PCAI, including patients with severe neurological deficit and stroke, are better when reperfused. Reperfusion holds the best promise of survival and ligation should be reserved for technically inaccessible bleeding injuries.

A decade long overview of damage control laparotomy for abdominal gunshot wounds.

PURPOSE: Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. METHODS: Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. RESULTS: There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). CONCLUSION: One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.

The use of C-reactive protein to predict uncomplicated appendicitis and increase uptake of laparoscopy in low resource hospitals-A retrospective cohort study.

BACKGROUND: Acute appendicitis remains the most common surgical emergency worldwide. There has been a low uptake of laparoscopic appendicectomy in the South African public sector. Preoperative identification of cases of uncomplicated appendicitis that are amenable to a laparoscopic approach may facilitate the implementation of laparoscopic appendicectomy programs in training hospitals. With limited access to preoperative imaging, alternative strategies for this preoperative prediction are needed. METHODS: A retrospective audit of patients over the age of 12 years with a histologically confirmed diagnosis of acute appendicitis over a 5-year period was performed. Patients were categorized as uncomplicated or complicated appendicitis and C-reactive protein (CRP) and white cell count (WCC) reviewed. Receiver operating characteristics curves were constructed for these blood tests and acute appendicitis severity. Youden's J statistic was used to determine optimal cut off values for diagnosing complicated appendicitis. RESULTS: 358 patients had confirmed appendicitis and complete blood results. Of these, 189 (52.79%) had complicated appendicitis with a 40.22% perforation rate. Median CRP in uncomplicated and complicated groups were 68 mg/L (IQR 19-142) and 216 mg/L (IQR 103-313) with an area under the curve (AUC) of 0.75 (95% CI: 0.70-0.80). The median WCC in the two groups were 12.6 × 109 cells/L (IQR 9.9-15.6) and 14.4 × 109 cells/L (IQR 11.5-18.28) with an AUC of 0.61 (95% CI: 0.56-0.67). The optimal cut off value for CRP was found to be 110 mg/L with a sensitivity of 74.74% and specificity of 69.23%. CONCLUSION: A cutoff value of 110 mg/dl CRP can distinguish patients with early appendicitis from those with complicated disease and when used in conjunction with clinical assessment may help identify patients in whom laparoscopic appendicectomy is appropriate.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds.

INTRODUCTION: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. METHODS: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. RESULTS: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. CONCLUSIONS: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma.

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa.

INTRODUCTION: The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade. MATERIALS AND METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022. RESULTS: Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed. CONCLUSIONS: Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.

Hybrid electronic record: An error reduction strategy for diverse medical prescription formats

Background: This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. Methods: Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. Results: There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. Conclusion: Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct. Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

Systematic Review of Procedural Skill Simulation in Health Care in Low- and Middle-Income Countries.

ABSTRACT: Low- and middle-income countries (LMICs) have adopted procedural skill simulation, with researchers increasingly investigating simulation efforts in resource-strained settings. We aim to summarize the current state of procedural skill simulation research in LMICs focusing on methodology, clinical area, types of outcomes and cost, cost-effectiveness, and overall sustainability. We performed a comprehensive literature review of original articles that assessed procedural skill simulation from database inception until April 2022.From 5371 screened articles, 262 were included in this review. All included studies were in English. Most studies were observational cohort studies (72.9%) and focused on obstetrics and neonatal medicine (32.4%). Most measured outcome was the process of task performance (56.5%). Several studies mentioned cost (38.9%) or sustainability (29.8%). However, few articles included actual monetary cost information (11.1%); only 1 article assessed cost-effectiveness. Based on our review, future research of procedural skill simulation in LMICS should focus on more rigorous research, cost assessments, and on less studied areas.

Tracking the Trauma Epidemic in KwaZulu-Natal, South Africa.

BACKGROUND: Trauma remains an important cause of morbidity and mortality in South Africa, but attempts to track the epidemic are often based on mortality data, or derived from individual health facilities. This project is based on the routine collection of trauma data from all public health facilities in the province of KwaZulu-Natal (KZN), between 2012 and 2022. METHODS: Hospital level data on trauma over the past ten years was drawn from the district health information system (DHIS). Data relating to assaults, gunshots and motor vehicle collisions (MVCs) were recorded in the emergency rooms, whilst data on admissions are recorded in the wards and intensive care units. RESULTS: There were 1,263,847 emergency room visits for assaults, gunshots and MVCs over the ten-year period and trauma admissions ranged between four and five percent of the total number of hospital admissions annually. There was a dramatic decrease in trauma presentations and admissions over 2020/2021 as a result of the COVID lockdowns. Over the entire period, intentional injury was roughly twice as frequent as non-intentional injury. Intentional trauma had an almost equal ratio of blunt assault to penetrating assault. Gunshot-related assault increased dramatically over the 2021/2022 collecting period. CONCLUSIONS: The burden of trauma in KZN remains high. The unique feature of this burden is the excessively high rate of intentional trauma in the form of both blunt and penetrating mechanisms. Developing injury-prevention strategies to reduce the burden of interpersonal violence is more difficult than for unintentional trauma.

The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma.

INTRODUCTION: The open abdomen (OA) is a necessary component of damage control surgery and closure is often challenging. Our aim was to review our ten-year experience with OA in trauma patients and to compare the success of a dual closure technique termed vacuum-assisted, mesh-mediated fascial traction (VAMMFT) to an exclusively Bogota Bag (BB) approach. METHODS: A retrospective analysis was performed using the HEMR database from 2012 to 2022, comparing demographics, mechanism of injury, admission vitals and biochemistry between patients with BB and VAMMFT applications. Rate of secondary abdominal closure and complications were assessed in both groups. Logistic regression was used to find predictors of closure. RESULTS: OA was required by 348 patients at index laparotomy. Of these, 133 (38.2%) were managed with VAMMFT and 215 (61.8%) exclusively with a BB. There were no statistical differences between the BB and VAMMFT groups in terms of demographics, injuries, admission vitals and biochemistry. The VAMMFT group achieved a closure rate of 73% compared to 54.9% in the BB group (OR of 2.2 [1.4-3.7]). There was no significant difference in fistulation rate between the two groups (p = 0.103). Length of hospital stay was 30 versus 17 days in the VAMMFT and BB groups, respectively (OR 1.41 [1.30-1.54]). There were no independent predictors of closure identified in the VAMMFT group. Older patients were less likely to achieve closure when BB was used (OR 0.97 [0.95-0.99]). VAMMFT failure was commonly due to lack of stock (39%) and protocol violations (33%). CONCLUSION: The VAMMFT approach to the OA is efficacious and safe. VAMMFT achieves a much higher rate of secondary closure than BB alone with a low rate of enteric fistula formation.

Laparotomy for Abdominal Stab Wound With Combined Omental and Organ Evisceration: 10-Year Experience From a Major Trauma Centre in South Africa.

INTRODUCTION: Combined omental and organ evisceration following anterior abdominal stab wound (SW) is uncommon and there is a paucity of literature describing the management and spectrum of injuries encountered at laparotomy. METHODS: A retrospective study was undertaken on all patients who presented with anterior abdominal SW involving combined omental and organ evisceration who underwent laparotomy over a 10-year period from January 2008 to January 2018 at a major trauma centre in South Africa. RESULTS: A total of 61 patients were eligible for inclusion and all underwent laparotomy: 87% male, mean age: 29 years. Ninety-two percent (56/61) had a positive laparotomy whilst 8% (5/61) underwent a negative procedure. Of the 56 positive laparotomies, 91% (51/56) were considered therapeutic and 9% (5/56) were non-therapeutic. In addition to omental evisceration, 59% (36/61) had eviscerated small bowel, 28% (17/61) had eviscerated colon and 13% (8/61) had eviscerated stomach. A total of 92 organ injuries were identified. The most commonly injured organs were small bowel, large bowel and stomach. The overall complication rate was 11%. Twelve percent (7/61) required intensive care unit admission. The mean length of hospital stay was 9 days. The overall mortality rate for all 61 patients was 2%. CONCLUSIONS: The presence of combined omental and organ evisceration following abdominal SW mandates laparotomy. The small bowel, large bowel and stomach were the most commonly injured organs in this setting.

The "weekend effect" does not impact on outcome of trauma laparotomy - Experience from a level 1 trauma centre in New Zealand.

PURPOSE: Trauma centres have been proven to provide better outcomes in developed countries for overall trauma, but there is limited literature on the systematic factors that describe any discrepancies in outcomes for trauma laparotomies in these centres. This study was conducted to examine and interrogate the effect of systematic factors on patients undergoing a trauma laparotomy in a developed country, intending to identify potential discrepancies in the outcome. METHODS: This was a retrospective study of all laparotomies performed for trauma at a level 1 trauma centre in New Zealand. All adult patients who had undergone an index laparotomy for trauma between February 2012 and November 2020 were identified and laparotomies for both blunt and penetrating trauma were included. Repeat laparotomies and trauma laparotomies in children were excluded. The primary clinical outcomes reviewed included morbidity, length of hospital stay, and mortality. All statistical analysis was performed using R v.4.0.3. RESULTS: During the 9-year study period, 204 trauma laparotomies were performed at Waikato hospital. The majority (83.3%) were performed during office hours (170/204), and the remaining 16.7% were performed after hours (34/204). And 61.3% were performed on a weekday (125/204), whilst 38.7% were performed on the weekend/public holiday (79/204). Most of the parameters in office hours and after hours groups had no statistically significant difference, except lactate (p = 0.026). Most of the variables in weekday and weekend groups had no statistically significant difference, except pH, lactate, length of stay, and gastrointestinal complications (p = 0.012, p < 0.001, p = 0.003, p = 0.020, respectively). CONCLUSION: The current trauma system at Waikato hospital is capable of delivering care for trauma laparotomy patients with the same outcome regardless of working hours or after hours, weekday or weekend. This confirms the importance of a robust trauma system capable of responding to the sudden demands placed on it.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds.

BACKGROUND: This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. MATERIALS AND METHODS: A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. RESULTS: Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. DISCUSSION: Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.

Military and Civilian Trauma System Integration: A Global Case Series.

INTRODUCTION: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers. METHODS: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration. RESULTS: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier. CONCLUSIONS: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

Penetrating buttock trauma is morbid but rarely fatal - A South African experience.

BACKGROUND: Penetrating injuries to the buttock are relatively rare but are associated with significant morbidity. This study aimed to review our experience in managing penetrating trauma to the buttocks to contextualize the injury, document the most common associated injuries, and generate an algorithm to assist with the management of these patients. METHODS: A retrospective study was conducted at a major trauma center in South Africa over 8 years (January 2012 to January 2020). All patients presenting with a penetrating buttock injury were included. RESULTS: Our study included 40 patients. Gunshot wounds accounted for 93% (37/40), stab wounds accounted for 5% (2/40), and 1 case was gored by a cow. The majority (98%) underwent further investigation in the form of imaging or endoscopy. Forty percent (16/40) required surgical intervention. Of these 16 cases, 14 required a laparotomy, and 2 required gluteal exploration. Fifty-six percent (9/16) required a stoma. Five percent (2/40) experienced one or more complications, both of whom had stomas. The median length of stay for all patients was 3 days, whereas for the patients with stomas was 7 days. There were no ICU admissions or mortality in this study. Only 3 of the 9 stomas were reversed, and the median time to reversal was 16 months. CONCLUSION: Penetrating trauma to the buttock may result in injuries to surrounding vital structures, which must be actively excluded. Rectal injury was the most common injury, and most required a defunctioning colostomy as part of the management resulting in significant morbidity.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country.

BACKGROUND: Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population. METHODS: A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system's Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC. RESULTS: The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery. CONCLUSIONS: PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Contemporary management of isolated free fluid on computed tomography scan in blunt abdominal trauma-experience from a Level 1 trauma centre in New Zealand.

AIMS: The management of patients with blunt abdominal trauma (BAT) who have isolated free fluid (IFF) with no solid organ injury (SOI) on computed tomography (CT) remains controversial. This study aims to determine if the volume of free fluid (FF) is a predictor of the need for operative management of traumatic intra-abdominal injuries, by reviewing the local cumulative experience with IFF at a major trauma centre in New Zealand. METHODS: A retrospective study was undertaken over nine years at a Level 1 trauma centre in New Zealand. Patients aged over 15 years who sustained BAT and had IFF with no SOI demonstrated on CT were included. All CT scans and patient notes were reviewed. The volume of free fluid was classified by the local interpreting radiologist on the CT report. RESULTS: Eighty-two out of 1,177 BAT patients (7%) had IFF with no SOI on CT. Thirty-eight percent were males, with a median age of 31 years. Nineteen (23%) underwent immediate operative management (OM) at the time of presentation. The remaining 63 patients had a trial of non-operative management (NOM), 10 (16%) of which were unsuccessful and required an operation. Overall, 29 patients (35%) required operative management. Eighty-nine percent of the OM group and 90% who failed NOM had positive operative findings, giving an overall true positive of 32%. CONCLUSIONS: The presence of IFF in itself is not an absolute indication for operative exploration and many patients with trace IFF can be managed non-operatively. Small amounts of IFF should be regarded with suspicion, and moderate or large amounts of fluid are likely to require operative exploration. Further work must make use of clinical scoring systems and laparoscopy or laparotomy to assess patients at high risk of surgically remediable intra-abdominal injury post BAT.