Shared electric scooter injuries admitted to Auckland City Hospital: a comparative review one year after their introduction.

AIM: E-scooters were introduced to New Zealand in 2018 as a means of city transport. Since their introduction, their use has resulted in high injury rates. No studies have directly compared e-scooters to other forms of transport. METHOD: The Auckland City Hospital trauma registry was retrospectively searched for patients admitted with an e-scooter injury. A comparison group of patients admitted with an injury secondary to cycling during the same period was collected. RESULTS: 178 patients were identified: 69 with e-scooter injuries and 109 with injuries sustained while cycling. The hospitalisation rate for e-scooter injuries was 326 hospitalisations per million hours. There was a significant difference found in blood ethanol levels (18.6 vs 6.4% positive, p-value=0.01), mechanism of injury (isolated falls: 87 vs 60.6%), time of injury (55.1 vs 40.4% between 5pm-8am) and protective gear use (worn in 10.1 vs 78.9%). No differences were found in injury severity, ICU admissions, length of stay or mortality. CONCLUSION: This study demonstrates a concerningly high e-scooter-related hospitalisation rate and suggests e-scooters are currently not as safe as cycling. Strategies to improve e-scooter safety are needed and could include zero tolerance for alcohol, mandatory protective gear, restricted operating times and changes in road laws.

Diagnostic laparoscopy in penetrating abdominal trauma.

BACKGROUND: Penetrating abdominal trauma is uncommon in Australia. There are multiple potential approaches to the patient without an indication for immediate laparotomy. This study examined the management of patients with a penetrating anterior abdominal injury in a Level 1 trauma centre, and in particular investigated the outcomes of those patients who underwent diagnostic laparoscopy. METHODS: A retrospective review was undertaken of all patients presenting to a Level 1 trauma centre with an anterior abdominal stab wound over a 15-year period. Patient demographic, injury, examination, treatment and outcome data were extracted. These data were analysed using SPSS PASW version 20. RESULTS: A total of 318 patients were identified. Immediate laparotomy was performed in 121 of those patients. Of the remaining 197 patients, 146 underwent diagnostic laparoscopy. Peritoneal breach was identified in 87 patients, 79 of whom then had exploratory laparotomy. The laparotomy was therapeutic in 36 of 79 patients (45.6%). Multiple stab wounds were an independent predictor of therapeutic laparotomy (hazard ratio 2.39, 95% CI 1.16-4.93). Diagnostic laparoscopy was 100% sensitive, 60.9% specific and had a negative predictive value of 100% and a positive predictive value of 40%. Non-therapeutic laparotomy was associated with a median length of stay of 5.5 days and a complication rate of 9.3%. CONCLUSION: Diagnostic laparoscopy to detect peritoneal breach is a safe approach in the management of anterior abdominal stab wounds. However, utilizing peritoneal breach as an indication for laparotomy is associated with a moderate incidence of non-therapeutic laparotomy. Measures to decrease the negative laparotomy rate should be considered.

Crohn's disease presenting as gastric outlet obstruction.

We present a unique presentation of Crohn's disease in a 25-year-old male with a 3-month history of progressive gastric outlet obstruction symptoms including reflux, vomiting, postprandial pain and weight loss, with no other symptoms. Multiple imaging investigations as well as gastroscopic biopsies revealed a non-specific prepyloric lesion, without evidence of malignancy. A distal gastrectomy was performed. Subsequent histological evaluation revealed gastroduodenal Crohn's disease. Follow-up revealed no evidence of disease elsewhere in the gastrointestinal system or systemically. While it is not uncommon for Crohn's disease to involve the stomach and duodenum, it is rare for gastroduodenal disease to be the initial presentation. Isolated gastroduodenal Crohn's disease typically presents with non-specific gastritis-like symptoms over a number of years. This patient had a unique course of Crohn's disease with rapid onset of symptoms, predominantly relating to gastric outlet obstruction and no prior or subsequent history of gastrointestinal symptoms.

Predicting hollow viscus injury in blunt abdominal trauma with computed tomography.

BACKGROUND: Evaluation of blunt abdominal trauma is controversial. Computed tomography (CT) of the abdomen is commonly used but has limitations, especially in excluding hollow viscus injury in the presence of solid organ injury. To determine whether CT reports alone could be used to direct operative treatment in abdominal trauma, this study was undertaken. METHODS: The trauma database at Auckland City Hospital was accessed for patients who had abdominal CT and subsequent laparotomy during a five-year period. The CT scans were reevaluated by a consultant radiologist who was blinded to operative findings. The CT findings were correlated with the operative findings. RESULTS: Between January 2002 and December 2007, 1,250 patients were evaluated for blunt abdominal injury with CT. A subset of 78 patients underwent laparotomy, and this formed the study group. The sensitivity and specificity of CT scan in predicting hollow viscus injury was 55.33 and 92.06 % respectively. The positive and negative predictive values were 61.53 and 89.23 % respectively. Presence of free fluid in CT scan was sensitive in diagnosing hollow viscus injury (90 %). Specific findings for hollow viscus injuries on CT scan were free intraperitoneal air (93 %), retroperitoneal air (100 %), oral contrast extravasation (100 %), bowel wall defect (98 %), patchy bowel enhancement (97 %), and mesenteric abnormality (94 %). CONCLUSIONS: CT alone cannot be used as a screening tool for hollow viscus injury. The decision to operate in hollow viscus injury has to be based on mechanism of injury and clinical findings together with radiological evidence.

Penetrating thoraco-abdominal injuries: the Auckland City Hospital experience.

BACKGROUND: Penetrating injuries to the thoraco-abdominal region are rare in New Zealand. Most are low velocity wounds and are managed by general surgeons. However, injuries to major vascular structures and the heart are best managed by a multidisciplinary approach. METHODS: In Auckland, the cardiothoracic service was located at a different site to Auckland City Hospital (ACH) prior to December 2003. In December 2003, the cardiothoracic unit relocated to ACH. To determine what changes in practice eventuated from having an on-site cardiothoracic service, we reviewed all patients who had thoraco-abdominal injuries between 1998 and 2003 and subsequently. RESULTS: There were 60 patients with thoraco-abdominal penetrating injury between December 1998 and December 2003 (Group A), and 42 patients between December 2003 and September 2008 (Group B). Twelve patients in Group A and 13 patients in Group B underwent thoracotomy. Twenty-two patients in Group A and 27 patients in Group B required operations other than thoracotomy for their injuries. There was a trend of increasing involvement of cardiothoracic surgeons post-2003, in those patients undergoing thoracotomy, but not in the non-thoracotomy patients. There were six re-explorations in thoracotomy patients in the pre-2003 era: done for bleeding (3), air leak following lung resection (1) and missed cardiac injuries (2), but none in post-2003 period. There was one death in Group A but none in Group B. CONCLUSIONS: Our study demonstrates that a properly trained general surgeon can make appropriate decisions and perform life-saving surgery in thoraco-abdominal stab wounds. However, the on-site availability of cardiothoracic surgeons leads to surgery with fewer complications.

Acute care surgery: can New Zealand afford to wait?

Until about two decades ago, the provision of emergency surgery was implicitly linked to all aspects of surgical care in all surgical specialties. While this remains true in the smaller surgical specialties, in the larger specialties the development of subspecialisation has eroded the comprehensive nature of acute care provision. In general surgery, the numerically largest of the nine surgical specialties, the greatest challenges in provision of acute care exist. Availability of appropriately trained general surgeons to deliver generic acute and trauma care has reached crisis point. An attempt is being made in the Western World to remedy these problems. Recognising that it is increasingly difficult to span the knowledge and skill mix necessary to manage all aspects of acute care in general surgery as well as a subspecialty practice, the concept of acute care surgery has been born. To look at the status of acute care surgery in Australia and New Zealand, we conducted a PubMed search on all articles matching the words emergency, acute care, and general surgery, and reviewed any papers relevant to Australasia. Of the 270 papers found, 4 papers were relevant to Australia and New Zealand. These studies outline the advantages of an acute care model in dealing with emergency surgery and delineate few disadvantages. Whether a new training paradigm, "acute care surgery" will benefit patients, the health services, and the surgeons in New Zealand and elsewhere remains to be seen. Allowing the current trend towards inadequate numbers and training of surgeons to deliver acute care to continue is unacceptable.