Understanding adoption of Electronic Medical Records (EMRs) during a health emergency: An analysis of EMR usage logs from rural health facilities in the Philippines

Background and Objective@#The adoption of electronic medical records (EMRs) in the Philippines has been initiated and adjusted since the last decade through the Philippine eHealth Agenda framework. EMRs are known to improve clinical management and have been widely adopted in advanced economies. However, empirical research on EMR implementation remains limited. This study aims to determine how public primary health care facilities in the country interacted with EMRs before and during the COVID-19 pandemic to understand EMR adoption.@*Methods@#More than 270,000 records generated from EMR usage logs in six rural primary health facilities in Western Visayas were analyzed. Average time of EMR use during work hours was estimated and compared before and during the pandemic. EMR adoption based on specific EMR features used was also determined. @*Results@#In 2020, EMR use ranged from less than one hour to more than eight hours in selected rural health units (RHUs). There was a statistical increase and decrease in use of features during the pandemic. Some EMR users had efficient use indicated by complete adoption of EMR features although such features were not as frequently used as those pertaining to basic adoption. @*Conclusion@#This study demonstrates that for EMR use in rural settings, progressive use from basic to complete may vary among users. Public health emergencies such as a pandemic may also affect EMR use. Future research directions should explore other mechanisms which affect user behavior and encourage full adoption of technology such as use of games or non-monetary incentives.

When public health crises collide: 5 years of pediatric firearm injury prevention opportunities.

Objectives: Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies. Patients and methods: Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths. Results: There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%. Conclusions: Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness. Level of evidence: Level III; epidemiological study type.

Unexpected Stability of a Prodrug to Enzymatic Hydrolysis within a Hydrated HPMC Matrix Tablet.

The uptake of alkaline phosphate present in dissolution medium into a hydrating hydroxypropyl methylcellulose matrix tablet and that its activity was retained therein was demonstrated. This presents a risk to the stability of prodrugs that are substrates of this enzyme such as phosphonooxymethyl derivative prodrugs. It was found that fostemsavir, a phosphonooxymethyl derivative prodrug being developed for the treatment of HIV-1 infection, was unexpectedly resistant to hydrolysis within a hydrated HPMC matrix when subjected to drug release testing in media containing alkaline phosphatase. Studies indicated that this was not due to microenvironmental pH effects, osmolality effects or effective phosphate concentration effects associated with the presence of the prodrug. That the prodrug and not its parent could affect enzyme activity in a concentration dependent manner, and that another phosphate ester prodrug fosphenytoin did not inhibit alkaline phosphatase activity within a hydrated HPMC matrix suggested that the unexpected stability of the HIV-1 therapy prodrug may be associated with the ability of the phosphate group-containing compound itself to inhibit the enzyme at the concentrations it exists at in the hydrated dosage form and so enables the development of the compound in this type of dosage form.

The 2019 Philippine UHC Act, Pandemic Management and Implementation Implications in a Post-COVID-19 World: A Content Analysis.

The 2019 Philippine Universal Health Care Act (Republic Act 11223) was set for implementation in January 2020 when disruptions brought on by the pandemic occurred. Will the provisions of the new UHC Act for an improved health system enable agile responses to forthcoming shocks, such as this COVID-19 pandemic? A content analysis of the 2019 Philippine UHC Act can identify neglected and leverage areas for systems' improvement in a post-pandemic world. While content or document analysis is commonly undertaken as part of scoping or systematic reviews of a qualitative nature, quantitative analyses using a two-way mixed effects, consistency, multiple raters type of intraclass correlation coefficient (ICC) were applied to check for reliability and consistency of agreement among the study participants in the manual tagging of UHC components in the legislation. The intraclass correlation reflected the individuals' consistency of agreement with significant reliability (0.939, p < 0.001). The assessment highlighted a centralized approach to implementation, which can set aside the crucial collaborations and partnerships demonstrated and developed during the pandemic. The financing for local governments was strengthened with a new ruling that could alter UHC integration tendencies. A smarter allocation of tax-based financing sources, along with strengthened information and communications systems, can confront issues of trust and accountability, amidst the varying capacities of agents and systems.

A Micro-analysis Approach in Understanding Electronic Medical Record Usage in Rural Communities: Comparison of Frequency of Use on Performance Before and During the COVID-19 Pandemic.

In strengthening eHealth in the Philippines to support the universal health care (UHC) law, the scaling up and full adoption of electronic medical record (EMR) systems was strategically scheduled and supposedly completed in 2020. The Covid-19 pandemic, however, delayed these strengthening efforts. We wanted to assess the status of EMR adoption in primary clinics of rural health units (RHUs) and understand the frequency of use, particularly during the pandemic. Through analyses of EMR usage logs from selected RHUs in 2020, we estimated frequency of EMR usage based on duration of use and tested if this was influenced by the performing RHU and pandemic event. We also determined the most frequent EMR activities through process maps and tested if there were differences in the conduct of these activities before and during the pandemic. Results showed that EMR use during work hours was significantly dependent on the performing RHU (p<0.001). High-performing RHUs used EMRs more than 3 hours/day while low-performing RHUs used the systems for less. The pandemic either significantly decreased or increased EMR use during work hours by around 5 hours/day in some RHUs (p<0.01). Process maps revealed that there were additional activities performed by RHUs during the pandemic. Except for Update Patient Profile and Add Patient EMR features, significant differences (p<0.01) were observed in accessing frequently used features before and during the pandemic. The results suggest some uneven level of utilization of EMRs at the primary care level which can impact readiness to support full implementation of the UHC law. The study shows the potential of using a more granular approach in studying adoption to help improve the quality of EMR use and contribute to improving health service delivery and financing.

The Windlass Tourniquet: Is It Taking the Wind Out of the "Stop the Bleed" Sails?

BACKGROUND: Civilians are often first-line responders in hemorrhage control; however, windlass tourniquets are not intuitive. Untrained users reading enclosed instructions failed in 38.2% of tourniquet applications. This prospective follow-up study replicated testing following Stop the Bleed (STB) training. MATERIALS AND METHODS: One and six months following STB, first-year medical students were randomly assigned a windlass tourniquet with enclosed instructions. Each was given one minute to read instructions and two minutes to apply the windlass tourniquet on the TraumaFX HEMO trainer. Demographics, time to read instructions and stop bleeding, blood loss, and simulation success were analyzed. RESULTS: 100 students received STB training. 31 and 34 students completed tourniquet testing at one month and six months, respectively. At both intervals, 38% of students were unable to control hemorrhage (P = 0.97). When compared to the pilot study without STB training (median 48 sec, IQR 33-60 sec), the time taken to read the instructions was shorter one month following STB (P <0.001), but there was no difference at 6 months (P = 0.1). Incorrect placement was noted for 19.4% and 23.5% of attempts at 1 and 6 months. Male participants were more successful in effective placement at one month (93.3% versus 31.3%, P = 0.004) and at six months (77.8% versus 43.8%, p = 0.04). CONCLUSIONS: Skills decay for tourniquet application was observed between 1 and 6 months following STB. Instruction review and STB produced the same hemorrhage control rates as reading enclosed instructions without prior training. Training efforts must continue; but an intuitive tourniquet relying less on mechanical advantage is needed.

Age itself or age-associated comorbidities? A nationwide analysis of outcomes of geriatric trauma.

PURPOSE: Geriatric trauma patients present physiological challenges to care providers. A nationwide analysis was performed to evaluate the roles of age alone versus age-associated comorbidities in the morbidity and mortality of elderly patients with blunt abdominal trauma (BAT). METHODS: Patients with BAT registered in the National Trauma Data Bank from 2013 to 2015 were analyzed using propensity score matching (PSM) to evaluate the mortality rate, complication rate, hospital length of stay (LOS), intensive care unit (ICU) LOS and ventilator days between young (age < 65) and elderly (age ≥ 65) patients. An adjusted multivariate logistic regression (MLR) model was also used to evaluate the effect of age itself and age-associated comorbidities on mortality. RESULTS: There were 41,880 patients with BAT during the study period. In elderly patients, the injury severity score (ISS) decreased with age, but the mortality rate increased inversely (from 5.0 to 13.5%). Under a similar condition and proportion of age-associated comorbidities after a well-batched PSM analysis, elderly patients had significantly higher mortality rates (8.0% vs. 1.9%, p < 0.001), higher complication rates (35.1% vs. 30.6%, p < 0.001), longer hospital LOS (8.9 vs. 8.1 days, p < 0.001), longer ICU LOS (3.7 vs. 2.7 days, p < 0.001) and more ventilator days (1.1 vs. 0.5 days, p < 0.001) than young patients. Furthermore, the MLR analysis showed that age itself served as an independent factor for mortality (odds ratio: 1.049, 95% CI 1.043-1.055, p < 0.001), but age-associated comorbidity was not. CONCLUSION: In patients with BAT, age itself appeared to have an independent and deleterious effect on mortality, but age-associated comorbidity did not.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation.

BACKGROUND: As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation. METHODS: Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05. RESULTS: A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission. CONCLUSION: Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level III.

Pediatric Firearm-Related Injuries: Taking Kids Out of Harm's Way Begins with Targeted Prevention.

BACKGROUND: Firearm-related injury is a public health crisis and remains the 3rd most common cause of death from ages 1 15 years. By evaluating events surrounding such injuries, evidence-based intervention strategies efforts may be targeted to maximize impact. MATERIAL AND METHODS: A retrospective chart review was performed for firearm-related injuries in patients 15 years-old and under at an urban Pediatric Level 1 Trauma Center between January 2016 and December 2020. Age, gender, race/ethnicity, injury severity score (ISS), reported cause of injury, timing of injury around school and curfew, and mortality were evaluated. Medical Examiner data identified other deaths that occurred within the hospital's catchment area. RESULTS: There were 195 injuries including 14 from the Medical Examiner. Overall, 82.6% were male with median age of 14 years (range 1-15; IQR 13-15), and median ISS of 5 (IQR 1-10). African-American children comprised 74.9% of the cohort while only representing 35.9% of local schools. Intentional interpersonal injuries comprised 65.6%; 17.4% were bystanders; 7.2% were negligent discharges; and 0.5% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 13-15) compared to 11 years (IQR 8-14, P = 0.03) for negligent discharges. Regarding timing, 6.9% of injuries occurred during school hours; 56.4% after school or during non-school days; and 36.7% were after legal curfew. Mortality rate was 17.4%. CONCLUSIONS: Firearm safety education and community-based violence intervention should start in the pre-teen years. Pediatric firearm-related injury prevention strategies must be multifaceted addressing structural racism, truancy, curfew violation, extra-curricular activities, childcare options, firearm safety education, violence reduction, suicide prevention, and recidivism.

Severe burn injury: Body Mass Index and the Baux score.

OBJECTIVE: The revised Baux score (age total body surface area (TBSA) burned and inhalation injury)) is predictive of mortality in burn patients. Our study objective was to assess whether the addition of body mass index (BMI) to the revised Baux score would be of value. We posited that increasing BMI follows a pattern similar to age and TBSA in the revised Baux score after severe burn injury. METHODS: Patient data from the burn registry was queried for patients admitted between 1/1/2013 to 8/31/2019. Patients 12 years or older with a TBSA of 20% or greater burn were included. Inpatient outcomes were analyzed based on BMI. RESULTS: 56 of 1365 patients met inclusion criteria. Mean age of the study population was 48.25 years and 64.3% of patients were male. Median BMI was 25.8 and median TBSA was 26.5. Inhalation injury was present in 44.6% (25/56) of patients. Median hospital length of stay (LOS) and ICU LOS were 21.5 and 17 days respectively. On bivariate analysis, non-survivors had higher TBSA (41.5% vs 25.5%, p = 0.034), more inhalation injury (83.3%, 10/12 vs 34.8%, 15/43 p = 0.003) and higher complication rates (91.6%, 11/12 vs 59.1 %, 25/43, p = 0.043). Survivors also had higher BMI (28.2 vs 23, p = 0.003) and increased hospital LOS (24 vs 5.5, p = 0.003). Automatic model fit in binary logistic regression showed a negative relationship between BMI and mortality. CONCLUSION: We found a negative relationship between BMI and mortality. Pre-obesity appears to have a protective role, but BMI was not found to be a useful addition to the revised Baux score. Larger sample sizes may be of benefit a for a for a more definitive understanding of the role of BMI with regards to burn survival.

Obesity May Require a Higher Level of Trauma Care: A Propensity-Matched Nationwide Cohort Study.

OBJECTIVE: Stable patients with less severe injuries are not necessarily triaged to high-level trauma centers according to current guidelines. Obese patients are prone to comorbidities and complications. We hypothesized that stable obese patients with low-energy trauma have lower mortality and fewer complications if treated at Level-I/II trauma centers. Methods: Blunt abdominal trauma (BAT) patients with systolic blood pressures ≥90mmHg, Glasgow coma scale ≥14, and respiratory rates at 10-29 were derived from the National Trauma Data Bank between 2013-2015. Per current triage guidelines, these patients are not necessarily triaged to high-level trauma centers. The relationship between obesity and mortality of stable BAT patients was analyzed. A subset analysis of patients with injury severity scores (ISS) <16 was performed with propensity score matching (PSM) to evaluate outcomes between Level-I/II and Level-III/IV trauma centers. Outcomes of obese patients were compared between Level-I/II and Level-III/IV trauma centers. Non-obese patients were analyzed as a control group using a similar PSM cohort analysis. Results: 48,043 stable BAT patients in 707 trauma centers were evaluated. Non-survivors had a significantly higher body mass index (BMI) (28.7 vs. 26.9, p < 0.001) and higher proportion of obesity (35.6% vs. 26.5%, p < 0.001) than survivors. After a PSM (1,502 obese patients: 751 in Level-I/II trauma centers and 751 in Level-III/IV trauma centers), obese patients treated in Level-I/II trauma centers had significantly lower complication rates than obese patients treated in other trauma centers (20.2% vs. 26.6%, standardized difference = 0.151). The complication rate of obese patients treated at Level-I/II trauma centers was 20.6% lower than obese patients treated at other trauma centers. Conclusion: Obesity plays a role in the mortality of stable BAT patients. Obese patients with ISS < 16 have lower complication rates at Level-I/II trauma centers compared to obese patients treated at other trauma centers. Obesity may be a consideration for triaging to Level-I/II trauma centers.

Association between Torso Gunshot Wound Volumes of Trauma Centers and Outcomes of Torso Gunshot Wound Patients. A Propensity-Matched Nationwide Cohort Study.

Objective: The number and type of patients treated by trauma centers can vary widely because of a number of factors. There might be trauma centers with a high volume of torso GSWs that are not designated as high-level trauma centers. We proposed that, for torso gunshot wounds (GSWs), the treating hospital's trauma volume and not its trauma center level designation drives patient prognosis.Methods: The National Trauma Data Bank was queried for torso GSWs. The characteristics of torso GSWs in trauma centers with different volumes of torso GSWs were compared. The association between torso GSW volumes of trauma centers and the outcomes of torso GSWs were evaluated with propensity score matching (PSM) and multivariate logistic regression (MLR) analysis.Results: There were 618 trauma centers that treated 14,804 torso GSW patients in two years (2014-2015). In 191 level I trauma centers, 82 of them (42.9%, 82/191) treated <1 torso GSW per month. After well-balanced PSM, patients who were treated in higher volume trauma centers (≥9 torso GSWs/month) had a significantly lower mortality rate (7.9% vs. 9.7%). Patients treated in trauma centers with ≥9 torso GSWs/month had a 30.9% (odds ratio = 0.764) lower probability of death than if sent to trauma centers with <9 torso GSWs/month. Treatment in level I or II trauma centers did not significantly affect mortality.Conclusion: There is an uneven distribution of torso GSWs among trauma centers. Torso GSWs treated in trauma centers with ≥9 torso GSWs/month have significantly superior outcomes with regard to survival.

The worst-case scenario: Bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias-a prospective multicenter study.

BACKGROUND: While modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh. METHODS: Prospective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses. RESULTS: A total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm2. The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified. CONCLUSION: In patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences.

Isolating Populations to Control Pandemic Spread in an Austere Military Environment.

BACKGROUND: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. METHODS: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. RESULTS: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. CONCLUSION: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.

Bronchoalveolar lavage and plasma Antithrombin and cytokines in inhalation and burn injury: a pilot study.

Systemic inflammatory response syndrome (SIRS) is initiated during the acute phase of thermal injury. The objective was to determine the SIRS impact on cytokine and Antithrombin (AT) levels in smoke inhalation and burn injury. This observational pilot study compared plasma and bronchoalveolar lavage fluid (BAL) cytokine and AT levels in the first six days post smoke inhalation and burn injury. Twenty-five patients, 14 with inhalation + burn injury > 10% total body surface area (TBSA) and 11 with inhalation injury and ≤ 10% TBSA participated. Human Th1/Th2 cytometric bead array kit from BD Biosciences Pharmingen determined cytokine levels; AT levels with Sigma Diagnostics and spectrophotometry. Results indicated no significant age difference between the two groups (42.1 ± 7.2) versus 49.6 ± 6.4 years. On admission, the inhalation group had 5.4 ± 3.9% TBSA compared to 35.0 ± 22.2% TBSA in the inhalation + burn group, P < 0.001. Comparing groups, AT plasma levels were significantly decreased (P = 0.025) and IL-2 levels significantly increased (P = 0.025) in the inhalation + burn group compared to the inhalation group; there was no significant difference in BAL AT or cytokine levels. Combined group plasma AT levels (65.41 ± 4.44%) were significantly increased compared to BAL AT levels (1.06 ± 0.71%), P < 0.001. In contrast, BAL TNF-α levels (35.61 ± 16.01 pg/ml) were significantly increased in relation to the plasma levels (4.68 ± 1.27 pg/ml), P = 0.02. On days 1-2, AT plasma levels were significantly decreased in the inhalation + burn group (41.01 ± 5.24%) compared to the inhalation group (81.02 ± 10.99%), P = 0.002. IL-6 plasma levels were higher in the inhalation + burn group compared to the inhalation group on admission, but both levels decreased by days 3-6. IL-6 BAL levels were elevated in both groups on days 1-2 and decreased by days 3-6. In the first six days of resuscitation, all plasma cytokines were increased in the two groups compared to controls. AT plasma and BAL levels were significantly reduced in both groups, contributing to the coagulopathy. Increased BAL TNF-α and IL-6 levels may have contributed to the pulmonary perturbations during the initial SIRS response in both groups.

Heroes in crisis: Trauma centers should be screening for and intervening on posttraumatic stress in our emergency responders.

BACKGROUND: Emergency responders face a crisis of rising suicide rates, and many resist seeking help due to the stigma surrounding mental health. We sought to evaluate the feasibility of an urban trauma center to screen for posttraumatic stress (PTS) among emergency responders and to provide mental health services. METHODS: Paramedics, firefighters, law enforcement, and corrections officers involved with patients in the trauma unit were asked to complete the Post-Traumatic Growth Inventory (PTGI) and Post-Traumatic Checklist for Diagnostic and Statistical Manual-5 (PCL-5). Additional factors known to affect PTS were correlated: occupation, age, sex, years of service, marital status, children, and pets. Willingness and barriers to seeking interventions for PTS were evaluated. RESULTS: A total of 258 responded: 36.7% paramedics, 40.2% law enforcement officers, 18.4% corrections officers, 0.8% firefighters, and 3.5% with multiple positions. Responders had a mean of 14.5 years of service (SD, 9.9 years). Mean PTGI and PCL-5 scores were 52.1 (SD, 25.1) and 17.2 (SD, 16.5), respectively. Overall, 24.7% had diagnostic PTS disorder with no difference seen in rates between professions. Of these, 80.7% had not sought care. Barriers included that they were not concerned (46%), did not recognize symptoms (24%), and were worried about consequences (20%). Concern over career advancement or losing one's job was the greatest barrier cited for seeking care. Among law enforcement, 47.7% were concerned that they would lose their ability to carry a firearm if they sought care for PTS. The PTGI score, divorce, and 46 years to 50 years were the only factors examined that correlated with increased PCL-5 score. There were 82.5% that felt the trauma center was the right place to screen and intervene upon PTS. CONCLUSION: Trauma centers are an ideal and safe place to both screen for PTS and offer mental health assistance. Comprehensive trauma-informed care by hospital-based intervention programs must expand to include emergency responders. LEVEL OF EVIDENCE: Epidemiological study type, Level II.

Patients With Combined Thermal and Intraabdominal Injuries: More Salvageable Than Not.

This study aims to better characterize the course and outcome of the uncommon subset of trauma patients with combined thermal and intraabdominal organ injuries. The National Trauma Data Bank was queried for burn patients with intraabdominal injury treated in all U.S. trauma centers from July 1, 2011 to June 30, 2015. General demographics, Glasgow coma scale (GCS), shock index (SI), Abbreviated Injury Scale (AIS) for burn, Injury Severity Score (ISS), blood transfusions, and abdominal surgery were evaluated. During the 5-year study period, there were 334 burn patients with intraabdominal injury, 39 (13.2%) of which received abdominal surgery. Burn patients who underwent operations had more severe injuries reflected by higher SI, AIS, ISS, blood transfusion, and worse outcomes including higher mortality, longer hospital and ICU length of stay, and more ventilator days compared to patients who did not undergo an operation. Nonsurvivors also exhibited more severe injuries, and a higher proportion received abdominal operation compared to survivors. Multivariate logistic regression analysis revealed that GCS on arrival, SI, AIS, ISS, blood transfusion, and abdominal operation to be independent risk factors for mortality. Propensity score matching to control covariables (mean age, systolic blood pressure on arrival, GCS on arrival, SI, ISS, time to operation, blood transfusion, and comorbidities) showed that of trauma patients who received abdominal operation, those with concomitant burn injury exhibited a higher rate of complications but no significant difference in mortality compared to those without burns, suggesting that patients with concomitant burns are not less salvageable than nonburned trauma patients.

The scales of recovery: Balancing posttraumatic stress with resilience in the violently injured.

BACKGROUND: Community violence remains a clinical concern for urban hospitals nationwide; however, research on resilience and posttraumatic growth (PTG) among survivors of violent injury is lacking. This study intends to assess survivors of violent injury for resilience and PTG to better inform mental health interventions. METHODS: Adults who presented with nonaccidental penetrating trauma to an urban level 1 trauma center and were at least 1 month, but no more than 12 months, from treatment were eligible. Participants completed the Connor-Davidson Resiliency Scale, Posttraumatic Growth Inventory (PTGI), Primary Care Posttraumatic Stress Disorder screen, and a community violence exposure screen. Additional demographic, injury, and treatment factors were collected from medical record. RESULTS: A total of 88 patients participated. The mean resiliency score was 83.2, with 71.1% scoring higher than the general population and 96.4% scoring higher than the reported scores of those seeking treatment for posttraumatic stress disorder (PTSD). Participants demonstrated a mean PTGI score of 78 (SD, 20.4) with 92.4% scoring above the significant growth threshold of 45. In addition, 60.5% of patients screened positive for significant PTSD symptoms, approximately eight times higher than general population. Exposure to other traumatic events was high; an overwhelming 94% of participants stated that they have had a family member or a close friend killed, and 42% had personally witnessed a homicide. Higher resilience scores correlated with PTGI scores (p < 0.001) and lower PTSD screen (p = 0.02). CONCLUSION: Victims of violent injury experience a myriad of traumatic events yet are highly resilient and exhibit traits of growth across multiple domains. Resiliency can coexist with posttraumatic stress symptoms. Practitioners should assess for resiliency and PTG in addition to PTSD. Further investigation is needed to clarify the relational balance between resilience and posttraumatic stress. LEVEL OF EVIDENCE: Epidemiological study type, Level II.