Post-traumatic stress disorder in international surgeons undertaking trauma electives in a South African trauma centre.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a well-documented psychiatric outcome in patients who experience physical trauma. The phenomenon is less studied in the staff involved in caring for such patients. The aim was to investigate the prevalence of PTSD in visiting international surgeons undergoing elective trauma training and to compare to local and international rates. METHODS: A trauma screening questionnaire (TSQ) survey was conducted among surgeons completing their elective trauma service placements in the Pietermaritzburg Metropolitan Trauma Service. RESULTS: Nineteen surveys were completed (32% response rate). Mean age was 38.9 (SD 6.5). Median postgraduate working experience was 5 (2-10) years. Median time of stay in South Africa was 6 (1-72) months. Compared to preelective experience, there was a five-fold increase in the level of trauma resuscitation experience reported during elective placement. 10.5% of surgeons scored > 5 in the TSQ suggesting probable PTSD. No statistical differences in age, years of prior experience, prior trauma rotation, number of major resuscitations, or length of stay in South Africa were observed in those scoring positive versus negative screening in the TSQ questionnaire. CONCLUSION: Despite being exposed to increased levels of trauma related injury, we observed low rates of positive screening for PTSD in our cohort of visiting international surgeons involved in elective trauma service placements. Investigation of potential protective factors against PTSD in this South African tertiary trauma centre is warranted.

High-grade renal trauma in children and adolescents can be successfully managed non-operatively.

BACKGROUND: This paper reviews our experience with management of renal injuries in children and adolescents with a focus on the outcome of non-operative management (NOM). METHODS: Retrospective review of the clinical characteristics, injury grade (I-III, low grade and IV and V high grade), management and outcomes of children ≤ 18 years old with renal trauma presenting to a major trauma centre in South Africa between December 2012 and October 2020. RESULTS: Sixty-one children with a renal injury were identified with a median age of 13 (range 0-18) years. Forty-five were boys; blunt and penetrating mechanisms of trauma were sustained by 55 (90%) and six (10%) children, respectively. The median American Association for the Surgery of Trauma (AAST) grade of renal injury was 3 (range 1-5): this included eight (13%) with grade I, six (10%) with grade II, 17 (28%) with grade III, 20 (46%) with grade IV and 10 (16%) with grade V injuries. Forty children (66%) were successfully managed non-operatively and 21 required a laparotomy; of these six (28%) required nephrectomy. The overall renal salvage rate was 55/61 (90%). Children who required laparotomy were significantly more likely to have sustained a penetrating mechanism of injury (24% vs 2%) and have greater length of hospital stay (median 9 vs 3 days) compared to children managed non-operatively (p < 0.05). Children who underwent a nephrectomy had a significantly greater length of hospital stay (median 9 vs 4 days, p = 0.03); however, their demographics, outcomes developed complications. Two children (3%) died; one managed non-operatively and one with a laparotomy. CONCLUSION: Paediatric renal trauma can be successfully managed non-operatively in over two-thirds of cases in this middle-income country. High grade of renal injury does not absolutely predict need for surgery or nephrectomy and can be managed non-operatively.

The neglected epidemic of trauma from interpersonal violence against the elderly in South Africa.

BACKGROUND: Geriatric injuries comprise a significant burden in the developed world but much less are known in the developing world setting. This study aims to review our experience of geriatric injuries with a focus on interpersonal violence (IPV) managed at a major trauma centre in South Africa. METHODS: This was a retrospective study on all patients who were aged > 65 years admitted to our trauma centre from January 2013 to December 2020, based in Pietermaritzburg, South Africa. RESULTS: Over the 8-year study period, 323 cases were included (62% male, mean age 72 years). Mechanism of injury: 80% blunt, 16% penetrating and 4% others. The median injury severity score (ISS) was 9. The median Charlson comorbidity index (CCI) for all 323 cases was 3. Diabetes (n = 53) was the most prevalent comorbidity which was followed by pulmonary disease (n = 23), cerebral vascular accidents (n = 16) and myocardial infarction (n = 15). Fifteen patients were on antiretroviral therapy (5%). Twenty-four per cent required surgical intervention. Eight per cent of cases experienced one or more complications. Twenty-five per cent (80/323) were related to IPV, 61% (49/80) of these were penetrating injuries and the remaining 31 cases were blunt injuries. Of the 49 cases of penetrating injuries, 33 were gunshot wounds (GSWs) and 16 were stab wounds (SWs) (1 GSW and 2 SWs were self-inflicted and were not included in IPV). Those cases that resulted from IPV were significantly more likely to require operative intervention, experience complications and longer lengths of hospital stay. Geriatric patients had poorer outcomes than non-geriatric patients and rural geriatric patients had worse outcomes than urban geriatric patients. CONCLUSION: Although the burden of geriatric trauma in South Africa appears to be relatively low, it is associated with significant morbidity and mortality. Trauma from interpersonal violence is especially common and is associated with significantly worse outcomes than that of non-interpersonal violence-related trauma. Elderly rural trauma victims have worse outcomes than their urban counterparts.

An audit of trauma laparotomy in children and adolescents highlights the role of damage control surgery and the need for a trauma systems approach to injury in this vulnerable population.

BACKGROUND: This study reviews the indications and outcome of emergency laparotomy for paediatric trauma in a South African trauma centre. METHODS: This was a retrospective study of all children less than 18 years of age who underwent an emergency laparotomy for trauma between December 2012 and October 2020 at Grey's Hospital in Pietermaritzburg. RESULTS: During the eight-year period under review, a total of 136 children of which 107 were male underwent a laparotomy for trauma. The median age was 14 years. There were 80 (57.1%) blunt mechanisms, and the rest were penetrating mechanisms. A total of 46 (33%) patients required ICU admission. Thirty-four patients developed a complication. These included nine cases of pneumonia, one case of renal failure, two patients developed abdominal collections, three woundrelated complications, three neurological complications and one miscellaneous complication. There were seven (5%) deaths. The penetrating cohort were older than the blunt cohort. Solid viscera were more likely to be injured in the blunt cohort and hollow viscera more likely in the penetrating cohort. A total of 16 (11%) patients underwent damage control surgery (DCS). Of this cohort, there were three female children. Six sustained blunt trauma and ten penetrating trauma. A total of six (37%) of these children died. CONCLUSION: Emergency laparotomy for trauma in children is not infrequent in Pietermaritzburg and there is a high incidence of penetrating trauma in this cohort. The response to increased degrees of physiological derangement is the application of DCS. Ongoing efforts to develop and strengthen a paediatric trauma service appear to be justified.