The extent of soft tissue and musculoskeletal injuries after earthquakes; describing a role for reconstructive surgeons in an emergency response.

BACKGROUND: Earthquakes are the leading cause of natural disaster-related mortality and morbidity. Soft tissue and musculoskeletal injuries are the predominant type of injury seen after these events and a major reason for admission to hospital. Open fractures are relatively common; however, they are resource-intense to manage. Appropriate management is important in minimising amputation rates and preserving function. This review describes the pattern of musculoskeletal and soft-tissue injuries seen after earthquakes and explores the manpower and resource implications involved in their management. METHODS: A Medline search was performed, including terms "injury pattern" and "earthquake," "epidemiology injuries" and "earthquakes," "plastic surgery," "reconstructive surgery," "limb salvage" and "earthquake." Papers published between December 1992 and December 2012 were included, with no initial language restriction. RESULTS: Limb injuries are the commonest injuries seen accounting for 60 % of all injuries, with fractures in more than 50 % of those admitted to hospital, with between 8 and 13 % of these fractures open. After the first few days and once the immediate lifesaving phase is over, the management of these musculoskeletal and soft-tissue injuries are the commonest procedures required. CONCLUSIONS: Due to the predominance of soft-tissue and musculoskeletal injuries, plastic surgeons as specialists in soft-tissue reconstruction should be mobilised in the early stages of a disaster response as part of a multidisciplinary team with a focus on limb salvage.

The UK medical response to the Sichuan earthquake.

BACKGROUND: At 14:48 on 12 May 2008 an earthquake of magnitude 8.0 struck the Wenchuan area of Sichuan province, China. A decision to offer/receive UK medical assistance was agreed at a Sino/British political level and a medical team was despatched to the earthquake area. METHODS: This study describes the team's experience during the immediate aftermath of the earthquake and the following 18 months, during which there have been joint developments in emergency medicine, disaster planning/preparedness and the management of spinal cord injury. RESULTS: The long-term disability following sudden onset natural disaster and the wider impact on healthcare delivery may prove to be a greater burden to the country than the immediate medical needs, and, accordingly, emergency international aid may need to widen its focus. Although international teams usually arrive too late to support resuscitative measures, they can respond to specific requests for specialised assistance, for example plastic and reconstructive surgery to assist with the ongoing management of complex injury, relieve those who have worked continuously through the disaster, and when required maintain routine day-to-day services while local staff continue to manage the disaster. The timing of this does not necessarily need to be immediate. CONCLUSIONS: To maximise its impact, the team planned from the outset to build a relationship with Chinese colleagues that would lead to a sharing of knowledge and experience that would benefit major incident responses in both countries in the future. This has been established, and the linkage of emergency humanitarian assistance to longer term development should be considered by others the next time international emergency humanitarian assistance is contemplated.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

BACKGROUND AND OBJECTIVES: Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. METHODS: We examined the Coroners' inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. RESULTS: One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25-50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or "within minutes" in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. CONCLUSIONS: A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades.

BACKGROUND & OBJECTIVES: In 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes. METHODS: We examined the full Coroner's inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bull's probits to match the original protocol. RESULTS: One hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%. CONCLUSIONS: The number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.

Alcohol and conscious level.

Many patients presenting to the Emergency Medical Services have recently consumed alcohol. This may profoundly affect their behaviour, conscious level and response to illness and treatment. The blood alcohol level (BAL) is of little use in the evaluation of these responses. Abnormal conscious level should never be ascribed to alcohol intoxication alone. It is only a diagnosis of exclusion. The most commonly associated conditions are head injury, cerebro-vascular incidents, hypoglycaemia and other drug intoxications.

Are pre-hospital deaths from accidental injury preventable?

OBJECTIVE: To determine what proportion of pre-hospital deaths from accidental injury--deaths at the scene of the accident and those that occur before the person has reached hospital--are preventable. DESIGN: Retrospective study of all deaths from accidental injury that occurred between 1 January 1987 and 31 December 1990 and were reported to the coroner. SETTING: North Staffordshire. MAIN OUTCOME MEASURES: Injury severity score, probability of survival (probit analysis), and airway obstruction. RESULTS: There were 152 pre-hospital deaths from accidental injury (110 males and 42 females). In the same period there were 257 deaths in hospital from accidental injury (136 males and 121 females). The average age at death was 41.9 years for those who died before reaching hospital, and their average injury severity score was 29.3. In contrast, those who died in hospital were older and equally likely to be males or females. Important neurological injury occurred in 113 pre-hospital deaths, and evidence of airway obstruction in 59. Eighty six pre-hospital deaths were due to road traffic accidents, and 37 of these were occupants in cars. On the basis of the injury severity score and age, death was found to have been inevitable or highly likely in 92 cases. In the remaining 60 cases death had not been inevitable and airway obstruction was present in up to 51 patients with injuries that they might have survived. CONCLUSION: Death was potentially preventable in at least 39% of those who died from accidental injury before they reached hospital. Training in first aid should be available more widely, and particularly to motorists as many pre-hospital deaths that could be prevented are due to road accidents.

The North Staffordshire Trauma System.

The first trauma centre in the UK has been established at the North Staffordshire Hospital in Stoke-on-Trent. The early development of this centre and the wider system within which it functions is described. The Trauma Centre and corresponding evaluation project by the University of Sheffield have been funded by the Department of Health. The outcome for injured patients treated in the new trauma system over a 4-year period will be compared with outcomes from existing systems in and around comparator sites in Preston and Hull. These findings will inform the debate on the future of trauma care in the UK.

A trauma center for the United Kingdom.

In July 1991, a pilot trauma center was established in the United Kingdom as part of a government-funded evaluation of trauma services. The North Staffordshire Hospital is at the center of a trauma system that serves 2 million people. This system involves the five surrounding hospitals and the ambulance service. Key developments have been the provision of a consultant trauma team leader in the center 24 hours a day, closer networking of all the hospitals, and an expansion of the paramedic training program. Two comparator sites have been identified and are also being studied. The results of this three-year experiment are being evaluated independently and by the trauma research group of Keele University. Whatever the outcome, the project will have a significant influence on the future development of trauma care in the United Kingdom.

The work of the South Manchester Accident Rescue Team (SMART).

Skills acquired in the hospital do not necessarily translate to the scene of an accident. However, training in certain hospital specialties, particularly accident and emergency medicine, will expose doctors to dealing with very ill patients in a less rigidly structured environment. The operating theatre is a disciplined and controlled environment. Skill in anaesthesia, monitoring and operating, if tested only in these circumstances may be found to be gravely inadequate when exposed to the fluctuant and hostile environment at the site. Doctors who wish to do this sort of work or are designated to do it, must undergo regular and frequent training, especially if they are not trained in accident and emergency departments. This has long been recognised by the British Association for Immediate Care. In combination with the Royal College of Surgeons of Edinburgh they have now established a diploma in Immediate Medical Care. In urban areas the need for a doctor to attend at the scene of an accident is usually limited to entrapment. These occasions are likely to be infrequent and this can result in a lack of preparedness for such events. Interhospital transfer, primarily from peripheral hospitals to the specialist services of a teaching hospital, often involves critically ill and injured patients. The management of these cases by the mobile team provides regular, frequent exposure to working in a 'hostile' environment. Relationships with the rescue services are developed and staff become familiar with equipment and call-out procedures. The care of transported patients is improved. None of our patients have died in transit or within 6 h of arrival at base.(ABSTRACT TRUNCATED AT 250 WORDS)