Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015.

BACKGROUND: Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF's standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings AIM: This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC. METHOD AND MATERIALS: This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes. RESULTS: Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red. CONCLUSION: The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.

Epidemiology of Patients Treated at the Emergency Department of a Médecins Sans Frontières Field Hospital During the Mosul Offensive: Iraq, 2017.

BACKGROUND: Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts. OBJECTIVE: This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict. METHODS: During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant. RESULTS: The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately one-third of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED. CONCLUSIONS: The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflict-related injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.

Preventing avoidable hospital admissions after emergency care in humanitarian settings: a cross-sectional review of Médecins Sans Frontières emergency departments.

OBJECTIVES: The aim of this study was to describe the types of emergency departments (EDs), and the acuity, types and disposition of conditions managed at Médecins Sans Frontières (MSF)-supported EDs in humanitarian settings. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES: This was a multicentre, cross-sectional review of visits to MSF-supported EDs from 1 January 2014 to 31 December 2018. EDs were classified into advanced-level, general-level, paediatric and trauma. Variables analysed included: age group, condition, acuity and ED disposition. Frequencies and percentages stratified by ED type or region were reported. RESULTS: MSF supported 26 EDs in 12 countries, with a total of 1 388 698 visits between 2014 and 2018. Most patients were discharged home (n=1 097 456, 79%), with nearly 0% mortality (n=4692). The majority of visits at general-level and paediatric EDs were for medical conditions (n=600 088, 78% and n=45 276, 96%, respectively), while nearly half of advanced-level EDs visits were for surgical conditions (n=201 189, 48%). Almost all visits to trauma EDs were for surgical conditions (n=148 078, 98%). Overall, most surgical conditions were traumatic injuries (n=484 008, 94%), the majority unintentional (n=425 487, 82%). The top three most common classified medical conditions were respiratory infections, malaria and diarrhoea. CONCLUSIONS: EDs are critical in improving the agility and access to emergency care (EC) in humanitarian settings. This study demonstrated that EC provision resulted in the majority of patients being discharged from EDs, helping prevent avoidable hospital admissions. These results could help better understand the healthcare needs of vulnerable populations, improve responsiveness to emergency conditions and support programmatic planning in humanitarian settings.

The Effect of Conflict on Obstetric and Non-Obstetric Surgical Needs and Operative Mortality in Fragile States.

BACKGROUND: Médecins Sans Frontières (MSF) provides surgical care in fragile states, which are more vulnerable to conflict. The primary objective of this study was to compare the indications for operative intervention in surgical projects in fragile states during periods of active conflict (CON) and non-conflict (NON-CON). In addition, risk factors for non-obstetric and obstetric operative mortality were identified. METHODS: This was a retrospective analysis of MSF surgical projects in fragile states January 1, 2008-December 31, 2017. Variables considered in the analysis include age, gender, American Society of Anesthesiology physical status, emergency status, re-intervention status, indication for surgical intervention, and conflict/non-conflict time period. RESULTS: There were 30 surgical projects in 13 fragile states with 87,968 surgical interventions in 68,667 patients. Obstetric needs were the most common indication for surgical intervention (n = 28,060, 31.9%) but were more common during NON-CON (n = 23,142, 35.7%) compared to CON periods (n = 4,918, 21.2%, p < 0.001). Trauma was more common during CON (42.0%) compared to NON-CON (23.0%) periods (p < 0.001). Non-obstetric operative mortality was similar during CON (0.2%) compared to NON-CON (0.2%, p = 0.920), but obstetric operative mortality was higher (0.5%) during CON compared to NON-CON (0.2%, p < 0.001) periods. Risk factors for obstetric and non-obstetric mortality included age ≥ 30 years, ASA greater than 1, and emergency intervention. CONCLUSION: Humanitarian surgeons working in fragile states should be prepared to treat a range of surgical needs including trauma and obstetrics during conflict and non-conflict periods. The mortality in obstetric patients was higher during conflict periods, and further research to understand ways to protect this vulnerable group is needed.

Traumatic Injuries are the Main Indication for Limb Amputations During and After Humanitarian Crises.

BACKGROUND: Populations at risk during humanitarian crises can suffer traumatic injuries or have medical conditions that result in the need for limb amputation (LA). The objectives of this study were to describe the indications for and associations with LA during and after humanitarian crises in surgical projects supported by Médecins Sans Frontières (MSF). METHODS: MSF-Operational Center Brussels data from January 1, 2008, to December 31, 2017, were analyzed. Surgical projects were classified into (annual) periods of crises and post-crises. Indications were classified into trauma (intentional and unintentional) and non-trauma (medical). Associations with LA were also reported. RESULTS: MSF-OCB performed 936 amputations in 17 countries over the 10-year study period. 706 (75%) patients were male and the median age was 27 years (interquartile range 17-41 years). Six hundred and twenty-one (66%) LA were performed during crisis periods, 501 (53%) during conflict and 119 (13%) post-natural disaster. There were 316 (34%) LA in post-crisis periods. Overall, trauma was the predominant indication (n = 756, 81%) and accounted for significantly more LA (n = 577, 94%) in crisis compared to post-crisis periods (n = 179, 57%) (p < 0.001). DISCUSSION: Our study suggests that populations at risk for humanitarian crises are still vulnerable to traumatic LA. Appropriate operative and post-operative LA management in the humanitarian setting must be provided, including rehabilitation and options for prosthetic devices.

Evaluation of multiple open-source deep learning models for detecting and grading COVID-19 on chest radiographs.

Purpose: Chest x-rays are complex to report accurately. Viral pneumonia is often subtle in its radiological appearance. In the context of the COVID-19 pandemic, rapid triage of cases and exclusion of other pathologies with artificial intelligence (AI) can assist over-stretched radiology departments. We aim to validate three open-source AI models on an external test set. Approach: We tested three open-source deep learning models, COVID-Net, COVIDNet-S-GEO, and CheXNet for their ability to detect COVID-19 pneumonia and to determine its severity using 129 chest x-rays from two different vendors Phillips and Agfa. Results: All three models detected COVID-19 pneumonia (AUCs from 0.666 to 0.778). Only the COVID Net-S-GEO and CheXNet models performed well on severity scoring (Pearson's r 0.927 and 0.833, respectively); COVID-Net only performed well at either task on images taken with a Philips machine (AUC 0.735) and not an Agfa machine (AUC 0.598). Conclusions: Chest x-ray triage using existing machine learning models for COVID-19 pneumonia can be successfully implemented using open-source AI models. Evaluation of the model using local x-ray machines and protocols is highly recommended before implementation to avoid vendor or protocol dependent bias.

Hippopotamus bite morbidity: a report of 11 cases from Burundi.

Hippopotamus is one of the most-loved animals in Africa, yet it is aggressive and dangerous. The co-existence of humans in close proximity to their natural habitat increases the probability of human injury. Hippopotamus attacks have long been recognized to cause serious injuries, but its magnitude and burden are still unknown. The medical literature is very scarce when it comes to documenting hippopotamus bite injuries and their outcomes. We present a cohort of 11 patients who suffered hippopotamus bite injuries in Burundi. To our knowledge, this is the largest case series reporting on the clinical presentation, injury patterns and surgical outcomes of hippopotamus bites. The results show a high incidence of wound infections, amputations and permanent disability among other complications. Hippopotamus-inflicted injuries should, therefore, be triaged as major trauma rather than just 'mammalian bites'.

Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years.

OBJECTIVE: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. DESIGN: Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). SETTING: Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. PARTICIPANTS: The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. PRIMARY OUTCOME MEASURE: Volume and nature of surgical workload of different anaesthesia providers. RESULTS: Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. CONCLUSION: Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.

Comparison of Operative Logbook Experience of Australian General Surgical Trainees With Surgeons Deployed on Humanitarian Missions: What Can Be Learnt for the Future?

OBJECTIVE: General surgical training in Australia has undergone considerable change in recent years with less exposure to other areas of surgery. General surgeons from many high-income countries have played important roles in assisting with the provision of surgical care in low- and middle-income countries during sudden-onset disasters (SODs) as part of emergency medical teams (EMTs). It is not known if contemporary Australian general surgeons are receiving the broad surgical training required for work in EMTs. DESIGN: Logbook data on the surgical procedures performed by Australian general surgical trainees were obtained from General Surgeons Australia (GSA) for the time period February 2008 to February 2017. Surgical procedures performed by Médecins sans Frontières (MSF) surgeons during 5 projects in 3 SODs (the 2010 Haiti earthquake, the 2013 Philippines typhoon and the 2015 Nepal earthquake) were obtained from previously published data for 6 months following each disaster. SETTING AND PARTICIPANTS: This was carried out at the University of Sydney with input from MSF Operational Centre Brussels and GSA. RESULTS: Australian general surgical trainees performed a mean of 2107 surgical procedures (excluding endoscopy) during their training (10 6-month rotations). Common procedures included abdominal wall hernia repairs (268, 12.7%), cholecystectomies (247, 11.8%), and specialist colorectal procedures (242, 11.5%). MSF surgeons performed a total of 3542 surgical procedures across the 5 projects analyzed. Common procedures included Caesarean sections (443, 12.5%), wound debridement (1115, 31.5%), and other trauma-related procedures (472, 13.3%). CONCLUSIONS: Australian general surgical trainees receive exposure to both essential and advanced general surgery but lack exposure to specialty procedures including the obstetric and orthopedic procedures commonly performed by MSF surgeons after SODs. Further training in these areas would likely be beneficial for general surgeons prior to deployment with an EMT.

North American pediatric surgery fellows' preparedness for humanitarian surgery.

INTRODUCTION: The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones. METHODS: We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests. RESULTS: ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05). CONCLUSION: While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets. LEVEL OF EVIDENCE: III.

A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare.

Importance: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective: To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants: An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures: The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results: Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance: Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti.

BACKGROUND: Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA. METHODS: Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18-65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit. RESULTS: One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group "before" (adjusted odds ratio 0.3, 95%confidence interval 0.1-0.8). They also had a significantly shorter hospital length of stay (p = 0.02). CONCLUSIONS: Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan.

INTRODUCTION: There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. MATERIALS AND METHODS: This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. RESULTS: Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). CONCLUSION: Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.

Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings.

INTRODUCTION: Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings. METHODOLOGY: This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays. RESULTS: We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7). CONCLUSIONS: Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.

South African General Surgeon Preparedness for Humanitarian Disasters.

BACKGROUND: Humanitarian medical organizations provide surgical care for a broad range of conditions including general surgical (GS), obstetric and gynecologic (OBGYN), orthopedic (ORTHO), and urologic (URO) conditions in unstable contexts. The most common humanitarian operation is cesarean section. The objective of this study was to identify the proportion of South African general surgeons who had operative experience and current competency in GS, OBGYN, ORTHO, and URO humanitarian operations in order to evaluate their potential for working in humanitarian disasters. METHODS: This was a cross-sectional online survey of South African general surgeons administered from November 2017-July 2018. Rotations in OBGYN, ORTHO, and URO were quantified. Experience and competency in eighteen humanitarian operations were queried. RESULTS: There were 154 SA general surgeon participants. Prior to starting general surgery (GS) residency, 129 (83%) had OBGYN, 125 (81%) ORTHO, and 84 (54%) URO experience. Experience and competency in humanitarian procedures by specialty included: 96% experience and 95% competency for GS, 71% experience and 51% competency for OBGYN, 77% experience and 66% competency for ORTHO, and 86% experience and 81% competency for URO. 82% reported training, and 51% competency in cesarean section. CONCLUSIONS: SA general surgeons are potentially well suited for humanitarian surgery. This study has shown that most SA general surgeons received training in OBGYN, ORTHO, and URO prior to residency and many maintain competence in the corresponding humanitarian operations. Other low- to middle-income countries may also have broad-based surgery training, and the potential for their surgeons to offer humanitarian assistance should be further investigated.

Are American Surgical Residents Prepared for Humanitarian Deployment?: A Comparative Analysis of Resident and Humanitarian Case Logs.

BACKGROUND: Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment. METHODS: We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets. RESULTS: US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases (p < 0.01) and fewer orthopedic cases (p < 0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation. CONCLUSION: Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.

Sex disparities among persons receiving operative care during armed conflicts.

BACKGROUND: Armed conflict increasingly involves civilian populations, and health care needs may be immense. We hypothesized that sex disparities may exist among persons receiving operative care in conflict zones and sought to describe predictors of disparity. METHODS: We performed a retrospective analysis of operative interventions performed between 2008 and 2014 at Médecins Sans Frontières Operation Center Brussels conflict projects. A Médecins Sans Frontières Operation Center Brussels conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering and population differences in conflict zones. RESULTS: Between 2008 and 2014, 49,715 interventions were performed in conflict zones by Médecins Sans Frontières Operation Center Brussels. Median patient age was 24 years (range: 1-105 years), and 34,436 (69%) were men. Patient-level variables associated with decreased interventions on women included: American Society of Anesthesiologists score (P = .003), degree of urgency (P = .02), mechanism (P < .0001), and a country's predominant religion (P = .006). Men were 1.7 times more likely to have an operative intervention in a predominantly Muslim country (P = .006). CONCLUSION: Conflict is an unfortunate consequence of humanity in a world with limited resources. For most operative interventions performed in conflict zones, men were more commonly represented. Predominant religion was the greatest predictor of increased disparity between sexes, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlie this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.

Regional Anesthesia for Painful Injuries after Disasters (RAPID): study protocol for a randomized controlled trial.

BACKGROUND: Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting. METHODS/DESIGN: The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction. DISCUSSION: Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02698228 ), registered on 16 February 2016.

Emergency department care for trauma patients in settings of active conflict versus urban violence: all of the same calibre?

BACKGROUND: Trauma is a leading cause of death and represents a major problem in developing countries where access to good quality emergency care is limited. Médecins Sans Frontières delivered a standard package of care in two trauma emergency departments (EDs) in different violence settings: Kunduz, Afghanistan, and Tabarre, Haiti. This study aims to assess whether this standard package resulted in similar performance in these very different contexts. METHODS: A cross-sectional study using routine programme data, comparing patient characteristics and outcomes in two EDs over the course of 2014. RESULTS: 31 158 patients presented to the EDs: 22 076 in Kunduz and 9082 in Tabarre. Patient characteristics, such as delay in presentation (29.6% over 24 h in Kunduz, compared to 8.4% in Tabarre), triage score, and morbidity pattern differed significantly between settings. Nevertheless, both EDs showed an excellent performance, demonstrating low proportions of mortality (0.1% for both settings) and left without being seen (1.3% for both settings), and acceptable triage performance. Physicians' maximum working capacity was exceeded in both centres, and mainly during rush hours. CONCLUSIONS: This study supports for the first time the plausibility of using the same ED package in different settings. Mapping of patient attendance is essential for planning of human resources needs.

Early physical and functional rehabilitation of trauma patients in the Médecins Sans Frontières trauma centre in Kunduz, Afghanistan: luxury or necessity?

BACKGROUND: In Afghanistan, Médecins Sans Frontières provided specialised trauma care in Kunduz Trauma Centre (KTC), including physiotherapy. In this study, we describe the development of an adapted functional score for patient outcome monitoring, and document the rehabilitation care provided and patient outcomes in relation to this functional score. METHODS: A descriptive cohort study was done, including all patients admitted in the KTC inpatient department (IPD) between January and June 2015. The adapted functional score was collected at four points in time: admission and discharge from both IPD and outpatient department (OPD). RESULTS: Out of the 1528 admitted patients, 92.3% (n = 1410) received at least one physiotherapy session. A total of 1022 patients sustained either lower limb fracture, upper limb fracture, traumatic brain injury or multiple injury. Among them, 966 patients received physiotherapy in IPD, of whom 596 (61.7%) received IPD sessions within 2 days of admission; 696 patients received physiotherapy in OPD. Functional independence increased over time; among patients having a functional score taken at admission and discharge from IPD, 32.2% (172/535) were independent at discharge, and among patients having a functional score at OPD admission and discharge, 79% (75/95) were independent at discharge. CONCLUSIONS: The provision of physiotherapy was feasible in this humanitarian setting, and the tailored functional score appeared to be relevant.