Trends in Violent Penetrating Injuries During the First Year of the COVID-19 Pandemic.

Importance: Public health measures instituted to reduce the spread of COVID-19 led to severe disruptions to the structure of daily life, and the resultant social and financial impact may have contributed to an increase in violence. Objective: To examine the trends in violent penetrating injuries during the first COVID-19 pandemic year compared with previous years. Design, Setting, and Participants: This retrospective cross-sectional study was performed to compare the prevalence of violent penetrating injuries during the first COVID-19 pandemic year, March 2020 to February 2021, with the previous 5 years, March 2015 to February 2020. This study was performed among all patients with a violent penetrating injury presenting at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. Data were analyzed from January 4 to November 29, 2021. Main Outcomes and Measures: The primary outcomes were the incidence and timing of emergency department presentation for violent penetrating injuries during the first year of the COVID-19 pandemic compared with the previous 5 years. Patient demographics and injury characteristics were also assessed. Results: A total of 2383 patients (median [IQR] age, 29.5 [23.4-39.3] years; 2032 [85.4%] men and 351 [14.6%] women) presenting for a violent penetrating injury were evaluated, including 1567 Black patients (65.7%), 448 Hispanic patients (18.8%), and 210 White patients (8.8%). There was an increase in injuries during the first pandemic year compared with the previous 5 years, with an increase in shootings (mean [SD], 0.61 [0.89] injuries per day vs 0.46 [0.76] injuries per day; P = .002) but not stabbings (mean [SD], 0.60 [0.79] injuries per day vs 0.60 [0.82] injuries per day; P = .78). This surge in firearm violence began while Massachusetts was still under a stay-at-home advisory and before large-scale racial justice protests began. Patients presenting with violent penetrating injuries in the pandemic surge months (April-October 2020) compared with the same period in previous years were disproportionately male (153 patients [93.3%] vs 510 patients [87.6%]; P = .04), unemployed (70 patients [57.4%] vs 221 patients [46.6%]; P = .03), and Hispanic (40 patients [26.0%] vs 99 patients [17.9%]; P = .009), with a concurrent decrease in White patients (0 patients vs 26 patients [4.7%]), and were more likely to have no previous history of violent penetrating injury (146 patients [89.0%] vs 471 patients [80.9%]; P = .02). Conclusions and Relevance: These findings suggest that unprecedented measures implemented to mitigate the spread of COVID-19 were associated with an increase in gun violence. As the pandemic abates, efforts at community violence prevention and intervention must be redoubled to defend communities against the epidemic of violence.

Examining Violence Against Women at a Regional Level 1 Trauma Center During the COVID-19 Pandemic.

INTRODUCTION: There is a growing concern that certain public health restrictions imposed to prevent the spread of coronavirus disease 2019 (COVID-19) could result in more violence against women (VAW). We sought to determine if the rates and types of VAW changed during the COVID-19 pandemic at our level 1 trauma center (L1TC). METHODS: We performed a retrospective review of female patients who presented to our L1TC because of violence from 2019 through 2020. Patients were grouped into a pre-COVID or COVID period. The primary aim of this study was to compare rates of VAW between groups. Secondary aims sought to evaluate for any difference in traumatic mechanism between periods and to determine if a temporal relationship existed between COVID-19 and VAW rates. RESULTS: There was no difference in rates of VAW between the pre-COVID and COVID period (3.1% vs 3.6%, P = .6); however, rates of penetrating trauma were greater during the COVID period (38.2% vs 10.3%, P = .01). After controlling for patient age and race, the odds of penetrating trauma increased during the pandemic (OR 5.8, 95% CI 1.6-28.5, P < .01). From February 2020 through October 2020, there was a direct relationship between rates of COVID-19 and VAW (r2 .78, P < .01). CONCLUSION: Rates of VAW were unchanged between the pre-COVID and COVID periods, yet the odds of penetrating VAW were 5 times greater during the pandemic. Moving forward, trauma surgeons must remain vigilant for signs of violence and ensure that support services are available during future crises.

A Retrospective Cohort Study on Health Insurance: Related Disparities in Trauma Patients After Penetrating Injuries: 2000-2014.

OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.

Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications.

BACKGROUND: Despite increasing popularity of prehospital tourniquet use in civilians, few studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous studies in civilian populations have focused on blunt trauma patients. The objective of this study was to determine if prehospital tourniquet use in patients with major penetrating trauma is associated with differences in outcomes compared to a matched control group. METHODS: An 8-year retrospective analysis of adult patients with penetrating major extremity trauma amenable to tourniquet use (major vascular trauma, traumatic amputation and near-amputation) was performed at a Level I trauma center. Patients with prehospital tourniquet placement (TQ) were identified and compared to a matched group of patients without tourniquets (N-TQ). Univariate analysis was used to compare outcomes in the groups. RESULTS: A total of 204 patients were matched with 127 (62.3%) in the prehospital TQ group. No differences in patient demographics or injury severity existed between the two groups. Average time from tourniquet application to arrival in the emergency department (ED) was 22.5 ± 1.3 minutes. Patients in the TQ group had higher average systolic blood pressure on arrival in the ED (120 ± 2 vs. 112 ± 2, p = 0.003). The TQ group required less total PRBCs (2.0 ± 0.1 vs. 9.3 ± 0.6, p < 0.001) and FFP (1.4 ± 0.08 vs. 6.2 ± 0.4, p < 0.001). Tourniquets were not associated with nerve palsy (p = 0.330) or secondary infection (p = 0.43). Fasciotomy was significantly higher in the N-TQ group (12.6% vs. 31.4%, p < 0.0001) as was limb amputation (0.8% vs. 9.1%, p = 0.005). CONCLUSION: This study demonstrated that prehospital tourniquets could be safely used to control bleeding in major extremity penetrating trauma with no increased risk of major complications. Prehospital tourniquet use was also associated with increased systolic blood pressure on arrival to the ED, decreased blood product utilization and decreased incidence of limb related complications, which may lead to improved long-term outcomes and increased survival in trauma patients. LEVEL OF EVIDENCE: Therapeutic, level IV.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status.

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013-2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88-6.69) (OR: 11.24; 95% CI: 8.53-13.95), more time spent in ICU (2.73; 1.70-3.76) (7.98; 6.10-9.87), and increased risk for surgical site infection (1.32; 1.03-1.68) (2.54; 1.71-3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Military Weapon Injury Among Illegal Immigrants at the Southern Border of Israel: A Single Level I Trauma Center Series.

This article describes the characteristics of injuries of illegal immigrants admitted to a Level I trauma center after being shot at the southern border of Israel. This is a retrospective descriptive study. Some of the variables were compared to a group of soldiers who sustained penetrating injury at the same region where the illegal migrant were injured. The study includes 162 patients. The lower body absorbed a higher percentage of the injuries (61 %). The hospitalization time is longer for the migrant patients compared to the soldiers (13 ± 2 vs. 3 ± 0.3 days p = 0.0001). This study on wounded immigrants shows that a conjoint military and civilian system can result in favourable outcomes. The manuscript is an attempt to bring this unique situation, its type of injuries, and the difficulties of the health system in coping with it, to the notice of all authorities that may address a similar challenge.

Characteristics and circumstances of injuries vary with ethnicity of different population groups living in the same country.

OBJECTIVE: To examine whether characteristics and circumstances of injuries are related to ethnicity. DESIGN: The study was based on the Israeli National Trauma Registry data for patients hospitalized between 2008 and 2011. Data included demographics, injury, hospital resource utilization characteristics and outcome at discharge. Univariate analysis followed by logistic regression models were undertaken to examine the relationship between injury and ethnicity. RESULTS: The study included 116,946 subjects; 1% were Ethiopian Born Israelis (EBI), 11% Israelis born in the Former Soviet Union (FSUBI) and 88% the remaining Israelis (RI). EBI were injured more on street or at work place and had higher rates of penetrating and severe injuries. However, FSUBI were mostly injured at home, and had higher rates of fall injuries and hip fracture. Adjusted analysis showed that EBI and FSUBI were more likely to be hospitalized because of violence-related injuries compared with RI but less likely because of road traffic injuries. Undergoing surgery and referral for rehabilitation were greater among FSUBI, while admission to intensive care unit was greater among EBI. CONCLUSION: Targeted intervention programmes need to be developed for immigrants of different countries of origin in accordance with the identified characteristics.

Racial disparities after vascular trauma are age-dependent.

OBJECTIVE: Different racial disparities exist between white and black all-cause trauma patients depending on their age group; however, the effects of race and age on outcomes after vascular trauma are unknown. We assessed whether the previously described age-dependent racial disparities after all-cause trauma persist in the vascular trauma population. METHODS: Vascular trauma patients were identified from the Nationwide Inpatient Sample (January 2005 to December 2012) using International Classification of Diseases-Ninth Edition codes. Univariable and multivariable analyses were used to compare in-hospital mortality and amputation for blacks vs whites for younger (16-64 years) and older (≥65 years) age groups. RESULTS: Black patients (n = 937) were younger, more frequently male, without insurance, and suffered from more penetrating and nonaccidental injuries than white patients (n = 1486; P < .001). On univariable analysis, blacks had a significantly higher risk of death (odds ratio, [OR], 1.78; 95% confidence interval [CI], 1.16-2.74) and a significantly lower risk of amputation (OR, 0.54; 95% CI, 0.38-0.77), but these differences were not sustained after adjusting for baseline differences between groups. When stratified by age, there were significant racial disparities in mortality and amputation on univariable analysis. After risk adjustment, these differences persisted in the older group (mortality: OR, 5.95; 95% CI, 1.42-25.0; amputation: OR, 4.21; 95% CI, 1.28-13.6; P < .001) but not the younger group (mortality: OR, 1.31; 95% CI, 0.71-2.42; amputation: OR, 0.92; 95% CI, 0.58-1.46; P = not significant). Differences in survival and amputation after vascular trauma appear to be related to a higher prevalence of nonaccidental penetrating injuries in the younger black population. Race was the single greatest predictor of poor outcomes in the older population (P ≤ .008). CONCLUSIONS: Older black patients are nearly five-times more likely to experience death or amputation after vascular trauma than their white counterparts. Contrary to reports suggesting that younger white patients have better outcomes after all-cause trauma than younger black patients, racial disparities among patients with traumatic vascular injuries appear to be confined to the older age group after risk adjustment.

Racial Differences in Treatment Approaches and Mortality Following Arterial Trauma.

OBJECTIVES: We sought to evaluate the impact of race on treatment approaches and mortality following arterial trauma. METHODS: The National Trauma Data Bank (version 7.2, American College of Surgeons) was queried from 2002 to 2012 to identify patients aged 18 to 65 years with arterial trauma. The association between race (white, black, and Hispanic) and mortality following arterial injury was assessed, stratified by penetrating or blunt injury. Temporal trends in the use of open and endovascular procedures were evaluated across the racial groups. Multivariable regression models adjusting for patient demographics, injury severity, hospital characteristics, insurance status, and type of intervention performed were used to evaluate potential contributors to the association of race with mortality. RESULTS: The study cohort consisted of 58 626 patients (52% white, 31% black, and 17% Hispanic). A majority (57%) of patients had penetrating injuries, with black and Hispanic patients being more likely to sustain penetrating injuries (80% and 65%, respectively) compared to white patients (41%, P < .001). Overall, black patients had higher mortality for penetrating injuries (16.8% vs 13.0% vs 7.8%, P < .001) when compared to Hispanic and white patients, correspondingly. Over the study period, there was increasing use of endovascular and decreasing open surgical procedures for treatment of arterial trauma. This finding was similar across all groups studied. In multivariable analysis, black race was found to be associated with higher mortality compared to white for both penetrating (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.33-1.75, P < .001) and blunt (OR 1.27 95%CI 1.09-1.47, P = .002) arterial trauma. CONCLUSION: Even after adjusting for potential confounders, minority patients had increased odds of mortality following arterial trauma compared to their white counterparts. Further studies are needed to understand and to eliminate these observed disparities in outcome.

Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes?

OBJECTIVES: To determine whether minority trauma patients are more commonly treated at trauma centers (TCs) with worse observed-to-expected (O/E) survival. BACKGROUND: Racial disparities in survival after traumatic injury have been described. However, the mechanisms that lead to these inequities are not well understood. METHODS: Analysis of level I/II TCs included in the National Trauma Data Bank 2007-2010. White, Black, and Hispanic patients 16 years or older sustaining blunt/penetrating injuries with an Injury Severity Score of 9 or more were included. TCs with 50% or more Hispanic or Black patients were classified as predominantly minority TCs. Multivariate logistic regression adjusting for several patient/injury characteristics was used to predict the expected number of deaths for each TC. O/E mortality ratios were then generated and used to rank individual TCs as low (O/E <1), intermediate, or high mortality (O/E >1). RESULTS: A total of 556,720 patients from 181 TCs were analyzed; 86 TCs (48%) were classified as low mortality, 6 (3%) intermediate, and 89 (49%) as high mortality. More of the predominantly minority TCs [(82% (22/27) vs 44% (67/154)] were classified as high mortality (P < 0.001). Approximately 64% of Black patients (55,673/87,575) were treated at high-mortality TCs compared with 54% Hispanics (32,677/60,761) and 41% Whites (165,494/408,384) (P < 0.001). CONCLUSIONS: Minority trauma patients are clustered at hospitals with significantly higher-than-expected mortality. Black and Hispanic patients treated at low-mortality hospitals have a significantly lower odds of death than similar patients treated at high-mortality hospitals. Differences in TC outcomes and quality of care may partially explain trauma outcomes disparities.

Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma.

BACKGROUND: Patients with penetrating injuries are known to have worse outcomes than those with blunt trauma. We hypothesize that within each injury mechanism there should be no outcome difference between insured and uninsured patients. METHODS: The National Trauma Data Bank version 7 was analyzed. Patients aged 65 years and older and burn patients were excluded. The insurance status was categorized as insured (private, government/military, or Medicaid) and uninsured. Multivariate analysis adjusted for insurance status, mechanism of injury, age, race, sex, injury severity score, shock, head injury, extremity injury, teaching hospital status, and year. RESULTS: A total of 1,203,243 patients were analyzed, with a mortality rate of 3.7%. The death rate was significantly higher in penetrating trauma patients versus blunt trauma patients (7.9% vs 3.0%; P < .001), and higher in the uninsured (5.3% vs 3.2%; P < .001). On multivariate analysis, uninsured patients had an increased odds of death than insured patients, in both penetrating and blunt trauma patients. Penetrating trauma patients with insurance still had a greater risk of death than blunt trauma patients without insurance. CONCLUSIONS: Insurance status is a potent predictor of outcome in both penetrating and blunt trauma.