Interpersonal violence: quantifying the burden of injury in a South African trauma centre.

INTRODUCTION: Interpersonal violence is an epidemic in South Africa and remains an under-reported and expensive burden on health resources. In most of the developing world there is little or no descriptive information about the expense of treating the consequences of interpersonal violence. OBJECTIVE: To review the direct burden of interpersonal violence on a tertiary hospital in Northern KwaZulu-Natal, an area known to have high rates of poverty and violent crime. MATERIAL AND METHODS: A retrospective case note review of emergency hospital admissions between January and March 2013 was carried out. The reports included demographic characteristics, admitting diagnosis and surgical management. Case files were reviewed to determine cost drivers, such as radiological investigations, blood products, theatre usage and specialist care. RESULTS: Trauma accounted for 374 hospital admissions from the emergency department, of which 142 (38%) were attributable to interpersonal violence (16% of total admissions). One hundred and fifty-six hospital bed days were used over the study period. The average inpatient stay was 9.8 days with 58% requiring a resuscitation bed on admission. One-third of patients underwent emergency surgery and eight patients required postoperative intensive care. The minimum hospital expenditure for interpersonal violence injuries over 3 months was R8 367 788 ($783 960). DISCUSSION: Interpersonal violence is the source of a significant financial burden on the South African health system. Patients are often severely injured and require a high level of specialist investigations and surgical care. This study gives evidence to improve budget and workload planning for regional surgical departments and supports the need for more effective primary prevention.

Management of critical illness with non-invasive ventilation by an Australian HEMS.

BACKGROUND: Non-invasive ventilation (NIV) therapy is widely used for the management of acute respiratory failure. The objective of this study was to investigate the current use of NIV during interhospital retrievals in an Australian physician-led aeromedical service. METHODS: We reviewed patients receiving NIV during interhospital retrieval at the Greater Sydney Area Helicopter Medical Services (GSA-HEMS) over a 14-month period. The main objectives were to describe the number of retrievals using NIV, the need for intubation in NIV patients and the effect of the therapy on mission duration. RESULTS: Over the study period, 3018 missions were reported; 106 cases (3.51%) involved administration of NIV therapy during the retrieval. The most common indication for NIV was pneumonia (34.0%). 86/106 patients received a successful trial of NIV therapy prior to interhospital transfer. 58 patients were transferred on NIV, while 28 patients had NIV removed during transport. None of these 86 patients required intubation or died, although 17/86 ultimately required intubation within 24 hours at the receiving centre. 20/106 patients required intubation at the referring hospital after a failed trial of NIV therapy. NIV was successfully used in all available transport platforms including rotary wing. Patients receiving NIV were found to have prolonged mission durations compared with other GSA-HEMS patients (222.5 vs 193 min). This increase in mission duration was largely attributable to NIV failure, resulting in a need for Rapid Sequence Intubation at the referring hospital. CONCLUSIONS: With careful patient selection, the use of interhospital NIV is feasible and appears to be safe in a retrieval system with care provided by a critical care physician.

Use of prothrombin complex concentrates: 4-year experience of a national aeromedical retrieval service servicing remote and rural areas.

INTRODUCTION: Prothrombin complex concentrates (PCCs) are recommended as first-line treatment for acquired or congenital factor II, VII, IX and X deficiencies in situations of major haemorrhage. The Emergency Medical Retrieval Service (EMRS) provides critical care and aeromedical retrieval to patients in remote and rural Scotland. It has an important role in the care of these patients. METHOD: We sought to determine the incidence of haemorrhage requiring PCC administration in our cohort of patients, and to assess compliance with current national guidelines regarding their storage and use. We searched our database for all patients that received PCCs, or met current guidelines for their administration, and followed them through to hospital discharge. We also conducted a telephone survey of all hospitals served by the EMRS to determine compliance with national standards. RESULTS: During the 42-month study period, 1170 retrieval missions were conducted. Twenty-six retrieved patients had a congenital or acquired clotting factor deficiency and seven met criteria for PCC administration. Of these, only three received PCCs prior to transfer to definitive care. Telephone survey revealed that all the rural general hospitals were served by the EMRS stock PCCs, but only one out of 15 GP-led community hospitals had access to PCCs. CONCLUSIONS: In the remote and rural setting where access to definitive care may be limited or delayed, timely administration of PCCs in appropriate patients may improve outcomes. As many rural hospitals do not have access to PCCs, the ability of the EMRS to provide this treatment may improve patient care.

Emergency/disaster medical support in the restoration project for the Fukushima nuclear power plant accident.

The Fukushima Daiichi Nuclear Power Plant (1F) suffered a series of radiation accidents after the Great East Japan Earthquake on 11 March 2011. In a situation where halting or delaying restoration work was thought to translate directly into a very serious risk for the entire country, it was of the utmost importance to strengthen the emergency and disaster medical system in addition to radiation emergency medical care for staff at the frontlines working in an environment that posed a risk of radiation exposure and a large-scale secondary disaster. The Japanese Association for Acute Medicine (JAAM) launched the 'Emergency Task Force on the Fukushima Nuclear Power Plant Accident' and sent physicians to the local response headquarters. Thirty-four physicians were dispatched as disaster medical advisors, response guidelines in the event of multitudinous injury victims were created and revised and, along with execution of drills, coordination and advice was given on transport of patients. Forty-nine physicians acted as directing physicians, taking on the tasks of triage, initial treatment and decontamination. A total of 261 patients were attended to by the dispatched physicians. None of the eight patients with external contamination developed acute radiation syndrome. In an environment where the collaboration between organisations in the framework of a vertically bound government and multiple agencies and institutions was certainly not seamless, the participation of the JAAM as the medical academic organisation in the local system presented the opportunity to laterally integrate the physicians affiliated with the respective organisations from the perspective of specialisation.