Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study.

BACKGROUND: In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings. METHODS: A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC's hospitals in Peshawar, 2009-2012 and Goma, 2012-2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC). RESULTS: A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74-0.78) than for KTS (0.53, 95% CI 0.50-0.56) and RTS (0.51, 95% CI 0.48-0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79-0.88) than for KTS (0.71, 95% CI 0.65-0.76) and RTS (0.70, 95% CI 0.63-0.76) for all patients, but not for patients with complete data. CONCLUSION: RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings.

Trends in Demographics and Surgical Treatment of Weapon-Related Limb Injuries Over Two Decades in a Resource-Scarce Setting.

BACKGROUND: In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. METHODS: Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. RESULTS: Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. CONCLUSION: In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.

Hospital Workload for Weapon-Wounded Females Treated by the International Committee of the Red Cross: More Work Needed than for Males.

BACKGROUND: Civilians constitute 33-51% of victims in armed conflicts. Several reports on civilian injuries exist, but few have focused on injuries afflicting females. We analyzed routinely collected data on weapon-related injuries from the International Committee of the Red Cross (ICRC) hospital in northwestern Pakistan in order to define injury patterns and types of surgical treatment for females. METHODS: A total of 3028 patient files (376 females) from consecutively admitted patients to the ICRC-hospital in Peshawar from February 2009 to May 2012 were included. Information regarding injury-mechanism, time since injury, vital parameters at admission, type of injury, treatment and basic outcome was extracted from the files and analyzed. Comparisons between gender and age-groups were done by cross-table analyses or nonparametric tests. RESULTS: Females were younger than males (20 vs. 25 years), arrived sooner after injury (24 vs. 48 h) (p < 0.001 for both) and were victims of bombs and missiles more frequently (64.4 vs. 54.6%) (p < 0.001). Vital parameters such as systolic blood pressure (110 vs. 113 mmHg) and pulse rate (100 vs. 86) were more affected at admission (p < 0.001 for both). Females were subjected to surgery (83.0 vs. 77.4%) (p < 0.05) and were given blood transfusions more often (18.8 vs. 13.6%) (p < 0.01). No differences in amputations or in-hospital mortality were found. CONCLUSIONS: Females treated at the ICRC-hospital in northwestern Pakistan are markedly affected by indiscriminate weapons such as bombs and missiles. Their average consumption of surgery is greater than for males, and this might be relevant in planning for staffing and facility needs in similar contexts.

Chronic osteomyelitis management in austere environments: the International Committee of the Red Cross experience.

BACKGROUND: Chronic osteomyelitis (COM) causes major physical disability. In situations of limited resources and war zones, western world treatments are neither affordable nor sustainable. The International Committee of the Red Cross has established a COM treatment project in the Democratic Republic of Congo, with emphasis on affordability and sustainability. METHODS: One hundred and sixty-eight patients were treated for COM. The protocol focused on surgical excision of necrotic bone, physiotherapy and an open wound dressing method using granulated brown sugar. RESULTS: Seventy-one patients could be reviewed with a mean follow-up of 13.7 months (5-28 months). 46 patients (63.4%, 95% CI 52.5-75.6) had excellent/good results in terms of clinical cure of the infection, and 36 patients (50.7%, 95% CI 38.7-62.7) had seen excellent/good improvement in their functional status compared with before treatment. CONCLUSIONS: The above-mentioned treatment protocol has shown encouraging results: almost two-thirds of the patients had their infection clinically cured, and half the patients saw significant functional improvement.