Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

The conundrum of polytrauma on the jos plateau.

BACKGROUND: The leading cause of morbidity and mortality from the end of the first year of life to the forty fifth is trauma. This is true worldwide but especially so in our environment. In no other situation are the complexities of the management of trauma more manifest than in the context of polytrauma. For this we undertake to study the problem of polytrauma in Jos. AIMS AND OBJECTIVES: To determine the frequency and pattern of occurrence of poly trauma in Jos university teaching hospital. PATIENTS AND METHODS: Consecutive patients presenting with polytrauma to the casualty department were prospectively studied. Data regarding demographics and a detailed description of injuries were entered into a proforma and collated over a one-year period. RESULTS: A total of 131 patients were studied. There were 103 males and 28 females giving a male to female ratio of 3.7:1. The ages ranged from 2 to 61 years with a mean of 28.4 ± 12.4 years. Road traffic accident was the most common aetiology in 113 (86.3%) patients, while falls 7 (5.3%), gunshots 5 (3.8%) and assaults 2 (1.6%) were observed. The most frequently encountered injuries were head, extremity and chest in 71.8%, 68.5% and 29.2% respectively. The combinations most frequently observed were head\extremity (43.5%), head\chest (17.6%) and chest\extremity (10.7%) injuries. Complications were observed in 20.6% while death occurred in 7.6%. CONCLUSION: Polytrauma occurs with sufficient frequency to warrant serious attention. As majority follow RTA, there is a need to intensify measures aimed at improving road safety. There is also a need to establish pre-hospital care\ambulance services. It is suggested that improved orthopaedic and neurosurgical care will lead to improved polytrauma care and most importantly, the establishment of dedicated trauma teams in tertiary institutions is proposed as a prelude to the establishment of regional trauma centers.

Motorcycle injuries in North-Central Nigeria.

BACKGROUND: The increasing use of commercial motorcycle as mode of transportation in urban cities in Nigeria has become important source of morbidity and mortality. This is coupled with poor helmet use, narrow roads, increasing traffic, and poor licensing of the motorcycle riders. The objectives of this study are to determine the pattern of injuries following accident involving motorcycles, the mortality rate, and the immediate causes of mortality. MATERIALS AND METHODS: This is a combined retrospective and prospective study spanning over 2 years (1 year each). Patient's records were retrieved to collate data for the retrospective study while all the patients presenting to the casualty unit of Jos University Teaching Hospital following involvement in motorcycle accidents between April 2006 and March 2007 were selected for the study. RESULTS: Out of 485 motorcycle injured patients, 295 and 190 were recruited from the retrospective and prospective study respectively. The male: female (M: F) ratio was 4.8:1. The ages ranged from 2.5 to 84 years with a peak at 21-30 years. The total number of injuries was 559 with 443 patients singly injured and 42 patients multiply traumatized. Head injury (40.1%) was the most frequently occurring injury followed closely by extremity injuries (38.1%). None of the patients wore protective helmet. Thirty-six (36) mortalities (7.4%) were recorded and all dead patients had head injuries. All deaths occurred within 24 h. CONCLUSIONS: Head injury represents a common cause of morbidity and mortality following motorcycle injuries in our environment. Therefore, strict enforcement of helmet laws from May 10, 2010 may reduce morbidity and mortality.

Implementing a hospital based injury surveillance system: a case study in Nigeria.

A pilot study of violent injury surveillance was implemented in two hospitals in Kano, Nigeria, in two phases: a formative evaluation including training and arranging the collection of hospital information, followed by a 6 month prospective data collection. Road traffic injuries constituted about 80 per cent of the cases, gunshot injuries were the commonest in victims of interpersonal violence (IPV). The causes and context of IPV, the relationship of victims and perpetrators, and the place, related activities and anatomical site of injuries from IPV are summarized.

Determinants of patronage of traditional bone setters in the middle belt of Nigeria.

BACKGROUND: Traditional bone setting is a practice that is common in our environment. This is a community based survey of opinions concerning orthodox and traditional fracture management in four states of the middle belt of Nigeria. We set out to ascertain the factors influencing preference of treatment of fractures among populations in the middle belt of Nigeria. METHODOLOGY: A community based questionnaire survey of randomly selected adults regarding preference of choice of treatment between orthodox and traditional fracture management. RESULTS: One hundred and eighty-six questionnaires were found analyzable with a male to female ratio of 2:1. There was a preponderance of preference for orthodox fracture management (70.4%). Decisions were mainly collegiate, outside the influence of the individual; only 9.9% decided to attend traditional bone setters on their own. CONCLUSION: Reasons adduced for preference of traditional bone setters were incongruous and inconsistent. A fixated cultural outlook was recognized as being the motivating factor for patronage of traditional bone setters. Need for enlightenment campaign of the public against patronage of traditional bone setters is emphasized. A gradual phasing out of traditional bone setting with a road map towards making orthodox fracture management available to all is advocated.

Comparative analysis of urethral catheterization versus suprapubic cystostomy in management of neurogenic bladder in spinal injured patients.

BACKGROUND: The objective of this study was, to prospectively and retro respectively evaluate urethral catheterization (UC) versus supra-pubic cystostomy (SPC) in prevention of urinary tract infection (UTI) in patients with spinal cord injury lesion. METHODS: A total of 125 patients with neurogenic bladder and a mean age of 30 years had UC (n=80) and SPC (n=40) at the Jos University Teaching Hospital (JUTH) between January 1984 and June 2005. RESULTS: Episodes of UTI were significantly more; UC 65% versus 14% forS PC (P< O 0 5). Urinary tract infection occurred relatively late in the course of admission, in patient who had SPC. Patients in SPC group were significantly satisfied with this management option; 57% versus 8% for UC. Similarly, mortality at 1 year post admission was significantly less; 9% versus 36% for UC and death due to UTI related septicaemia was 33% versus 18% respectively. CONCLUSION: It was concluded that SPC was a better management option since it was associated with a low morbidity, better quality of life and a longer life expectancy than UC.

Bone setters' gangrene.

BACKGROUND: Gangrene usually supervenes following prolonged pressure of tight splintage by traditional bone setters (TBS) in the process of treating fractures. However, various complications such as blisters, pressure, sores, Volkmann's ischaemia/contracture, Crush syndrome and pregangrene occur by the same mechanism depending on degree of pressure and duration of splintage of the limb. METHOD: This is a guest lecture delivered to resident doctors. Literature search was done through the internet and some unlisted journals and texts. Experiences of various institutions in Nigeria and abroad concerning bone setters' gangrene were elucidated. Attempt was made to broaden the concept of bone setters' gangrene to include all complications that arise through the same mechanism. The aetiology, pathophysiology and treatment of the vsrious conditions were highlighted and the solution and way-forward suggested. RESULT: The various health institutions recorded unacceptably high percentage of amputations secondary to bone setters' gangrene e.g. Zaria--57% to 63%, Jos--60-77.8%. Enugu recorded mortality of 26.7% while Banjul had 11.1% mortality in their series. Nearly all the series suggested education of bone setters as a solution. CONCLUSION: A different approach to limiting bone setters' gangrene is suggested such as condemning bone setters' practice and expanding orthopaedic care.

A 5-year prospective study on chest trauma in children

Chest trauma is an important cause of mortality in children worldwide. In this study we present our experience with childhood chest trauma within a five years period. This was a 5-year prospective study of consecutive patients with chest trauma. Data entered into a pre-planned proforma included demographic information, type of injury, mechanism of injury, associated injuries, type of treatment given, outcome of management and duration of hospital stay. There were 36 children aged between 2 and 16 years (mean age: of= 10.5 ± 6.2 years). There were 24 males and 12 females (m:f 2:1). Twenty seven (75%) of the 36 patients had blunt trauma while nine (25%) had penetrating chest injury. Road traffic accident was responsible for chest trauma in 26 (72.2%) children, but 6 (16.7%) other children were victims of civil unrest while 4 (11.1%) fell from heights. Haemo-pneumothorax was common in 10 (27.8%) patients. Twenty five out of the 36(69.4%) patients had associated injuries, 10 (40%) were head injuries, followed closely by abdominal injury in 8 (32%). Chest trauma in children is common in our environment. Majority of the children suffered blunt trauma following road traffic accidents. Prompt recognition and treatment of affected children is needful for a successful outcome

Bone Setter's Gangrene

Gangrene usually supervenes following prolonged pressure of tight splintage by traditional bone setters (TBS) in the process of treating fractures. However; various complications such as blisters; pressure sores; Volkmann's ischaemia/ contracture; Crush syndrome and pregangrene occur by the same mechanism depending on degree of pressure and duration of splintage of the limb. Method: This is a guest lecture delivered to resident doctors. Literature search was done through the internet and some unlisted journals and texts. Experiences of various institutions in Nigeria and abroad concerning bone setters' gangrene were elucidated. Attempt was made to broaden the concept of bone setters' gangrene to include all complications that arise through the same mechanism. The aetiology; pathophysiology and treatment of the various conditions were highlighted and the solution and way-forward suggested. Result: The various health institutions recorded unacceptably high percentage of amputations secondary to bone setters' gangrene e.g. Zaria - 57to 63; Jos - 60-77.8. Enugu recorded mortality of 26.7while Banjul had 11.1mortality in their series. Nearly all the series suggested education of bone setters as a solution. Conclusion: A different approach to limiting bone setters' gangrene is suggested such as condemning bone setters' practice and expanding orthopaedic care

Bone Setter's Gangrene

Gangrene usually supervenes following prolonged pressure of tight splintage by traditional bone setters (TBS) in the process of treating fractures. However; various complications such as blisters; pressure sores; Volkmann's ischaemia/ contracture; Crush syndrome and pregangrene occur by the same mechanism depending on degree of pressure and duration of splintage of the limb. Method: This is a guest lecture delivered to resident doctors. Literature search was done through the internet and some unlisted journals and texts. Experiences of various institutions in Nigeria and abroad concerning bone setters' gangrene were elucidated. Attempt was made to broaden the concept of bone setters' gangrene to include all complications that arise through the same mechanism. The aetiology; pathophysiology and treatment of the various conditions were highlighted and the solution and way-forward suggested. Result: The various health institutions recorded unacceptably high percentage of amputations secondary to bone setters' gangrene e.g. Zaria - 57to 63; Jos - 60-77.8. Enugu recorded mortality of 26.7while Banjul had 11.1mortality in their series. Nearly all the series suggested education of bone setters as a solution. Conclusion: A different approach to limiting bone setters' gangrene is suggested such as condemning bone setters' practice and expanding orthopaedic care

The efficacy and toleration of celecoxib (Celebrex) in the treatment of osteoarthritis in Nigeria: a multicentre study.

BACKGROUND: Non-selective, non-steroidal anti-inflammatory drugs (NSAIDs) are effective in terms of pain relief and improving function in osteoarthritis. The advent of cyclooxygenase-2 (Cox-2) specific inhibitor, celecoxib, in the treatment of osteoarthritis has shown similar efficacy in relieving pain in osteoarthritis with low incidence of GI (Gastrointestinal) symptoms. OBJECTIVE: To determine the efficacy and toleration of celecoxib in treatment of osteoarthritis in Nigerian population. METHODS: Eighty patients were recruited from six tertiary health institutions scattered over Nigeria. A fixed dose of 200 mg celecoxib was administered daily with patient seen on the second and six weeks after commencement of study. Efficacy of the drug and safety were assessed during the study. RESULTS: The patients had a mean age of 57.8 years with a standard deviation of 13.3 year. The mean weight was 74.7 +/- 14.9kg while the female sex constituted the majority (73.8%) of the patients. Using the physician global assessment of osteoarthritis instrument, 36.3% of the patients were rated as having poor arthritis score at baseline. This value reduced to 2.6% at second visit and 0.00% at end of the study respectively. There was no significant difference between the vital signs, haematological indices, renal and hepatic function at baseline and the final visit. There was no case of serious adverse effect. CONCLUSION: The study showed statistically significant improvements in the symptoms of osteoarthristis following the administration of Celecoxib 200mg daily for six weeks.

Mass casualty management: Jos University Teaching Hospital experience.

Three experiences of management of mass casualties in Jos University Teaching Hospital were analysed. Classification into minor, moderate and major mass casualties was done using multiple criteria of number of casualties, number of doctors required to contain the situation, number of nurses and paramedical staff, degree of distruption of hospital services and time required to handle the immediate stabilisation of the casualties. The classification recognises a category called "regional disaster" and attempts to enunciate a principle of initiation, mobilisation and co-ordination of management of such disasters among hospitals and human and material resources within the region. It is envisaged that coalescence of "regional disaster preparedness" would from the bedrock of national ambulance services system.

Surgical experience with management of vascular injuries.

UNLABELLED: To highlight the problems that are associated with the causes, diagnosis and management of vascular injuries. MATERIALS AND METHODS: A retrospective study of 52 cases of vascular injuries managed at the Jos University Teaching Hospital (JUTH) during a ten year period. RESULTS: The sex ratio M:F was 6:1 and the mean age at presentation was 23 years. The most common causes of vascular injuries were road traffic accidents in 44 per cent, iatrogenic 27 per cent and industrial in 13 per cent. These resulted in 50 cases (96 percent) of penetrating vascular injuries and 2 (4 percent) of blunt injury to vessels. Fifty-four percent of patients presented in shock. Active bleeding was recorded in 81 percent, pulse deficit in 65 percent and frank gangrene in 16 per cent. Aneurysms of various types occurred in 14 percent. Associated injuries were fractures in 60 percent, soft tissue injuries in 56 per cent and peripheral nerve injuries in 10 per cent. Overall, 52 arteries and 51 veins were injured, resulting in 15 lacerations, 74 complete transactions and 2 vascular blunt injuries with intimal tears and intraluminal thrombosis. Direct lateral suture of vessels was employed in 13 vessels, anastomosis in 12 vessels, graft interposition in 4 cases, ligation in 49 cases and aneurysmectomy in 3 cases. Three primary amputations were performed versus 7 secondary amputations. Hospital mortality was 16 percent and was mainly due to hypovolaemic shock, acute renal failure and sepsis.

Immediate mass casualty management in Jos University Teaching Hospital: a successful trial of Jos protocol.

Traumatic, injuries arising from high velocity means of mobility, increased industrialization, frequent ethnic and religious classes and terrorist activities by way of bomb blasts, etc., often result in sudden unexpected mass casualty presenting to a given secondary or tertiary health institution. The successful management of such situation involves multidimensional and multidisciplinary approach anchored on awareness, preplanning and alertness. In response to the challenge, the orthopaedic and trauma unit of Jos University Teaching Hospital worked out the "Jos Protocol" which embodies the principle and strategy for mass casualty management and response to field distress call to the hospital within the practical limitations of our infrastructure. On the sixth of April, 1997 a vehicular collision in a neighbouring village resulted in twenty nine severely injured patients being rushed to the hospital's accident and emergency unit. By activating the protocol and utilizing the cascade call our system, mutual aid, hospital mobilization, reach out system, modified hospital triage, team work, effective manoeuvers and treatment modification, the immediate rescucitation and stabilization of patients was achieved in five hours. The working team comprised fifteen doctors and some hospital workers who could be reached on a weekend. Out of the mortality of 6 patients, 3 died in the triage zone while 3 were brought in dead. The difficulties encountered during the management and recommendation for improved immediate mass casualty management are discussed. Further, we believe that it has become necessary for every secondary and tertiary health institution to work out a mass casualty management protocol adapted to its peculiar working circumstances. A case is made for the establishment of regional disaster committees.

Chronic osteomyelitis in patients with sickle cell disease.

OBJECTIVE: To determine the baseline pattern and audit management modalities of chronic osteomyelitis in patients with sickle cell disease. DESIGN: A retrospective study. SETTING: Jos University Teaching Hospital, Jos, Nigeria from August 1993 to July 1997. PATIENTS: Twenty four patients with concomitant chronic sickle cell disease. INTERVENTIONS: Fifteen patients had operations; eleven had sequestrectomy and curettage while four had incision and drainage. Eight patients were treated with antibiotics alone and one patient refused surgery. MAIN OUTCOME MEASURES: The demographic data of patients, aetiological agents, culture and sensitivity patterns, aetiopathogenesis, treatment modalities and outcome were analysed. RESULTS: Twenty four (36.9%) out of 65 patients who had chronic osteomyelitis also had sickle cell disease. Male:female ratio was 1.2:1. The peak age incidence (37.5%) was in the first decade of life. Seventy five per cent of infections were haematogenous. The most frequently isolated organism was Staphylococcus aureus (58.8%) while the rest were Gram negative organisms. There was no case of Salmonella osteomyelitis. The most sensitive antibiotics were gentamicin and the third generation cephalosporins. Twelve patients (50%) had good results while eight (33.3%) were still undergoing treatment. Complications recorded were persistent discharging sinuses in two cases, recurrence of symptoms in one and pathological fracture with non-union in one patient. CONCLUSION: Though the incidence of Gram negative organisms in causation of chronic osteomyelitis in patients who have sickle cell disease is high (41.2%), Salmonella osteomyelitis may be related to endemicity of the organism in a given locality.

Spinal injuries in the Plateau State, Nigeria.

OBJECTIVE: To highlight the epidemiology, management and outcome of spinal cord injuries (SCI) in the Plateau State of Nigeria. DESIGN: A retrospective study involving case note analysis of all patients with SCI admitted into the hospital. SETTING: The study was carried out at the Jos University Teaching Hospital to cover January 1984 and December, 1997. SUBJECTS: Sixty eight cases of SCI were studied. INTERVENTIONS: Patients were managed by conservative and operative interventions especially in cervical subluxations involving C5 on C6. MAIN OUTCOME MEASURES: Neurological function was assessed employing Frankel scale. RESULTS: There was an increased hospital incidence for SCI between 1994 and 1997. Means age of presentation was 30 years and sex ratio M:F was 10:1. Vehicular accidents accounting for 49 per cent of SCIs and collapsed tunnels (26 per cent) were the two common causes. Fracture dislocation of the spine (unstable) occurred in 52 per cent and flexion wedge fractures (stable) in 14 per cent. Ten per cent of patients had no neural deficits at presentation, 21 per cent had partial cord lesions and 69 per cent complete cord lesions. Hospital mortality was 26 per cent. The four patients subjected to posterior spinal fusion, (Frankel A to E) including 8 other patients that were conservatively managed. CONCLUSION: Centres for spinal injuries should be established incorporating hospital wards, theatres, gymnasia, nursing units, occupational therapy units, activity centres and workshops. These centres will generate comprehensive data on morbidity and morality needed for future planning.