Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

BACKGROUND: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. METHODS: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. RESULTS: A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients. CONCLUSIONS: EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Safety and feasibility of a strategy of early central venous catheter insertion in a deployed UK military Ebola virus disease treatment unit.

PURPOSE: Early central venous catheter (CVC) insertion in Ebola virus disease (EVD) is a novel approach and has not previously been described. This report delineates the safety, feasibility and clinical implications of early CVC insertion as the optimum means of vascular access in patients with EVD, in the setting of a deployed military Ebola virus disease treatment unit in Sierra Leone. METHODS: In the gastrointestinal phase of EVD, a 7-French 20-cm triple-lumen CVC was inserted using aseptic technique. Data were collected prospectively on all cases to include baseline and subsequent blood test variables, insertion site and technique, and complications associated with CVC placement. RESULTS: Twenty-three patients underwent CVC insertion as follows: subclavian, 21 (88 %); internal jugular, 2 (8 %); axillary, 1 (4 %). The mean duration of CVC placement was 5 days. There were no significant procedure-related adverse events. Despite coagulopathy being present in 75 % of cases, CVC insertion was safe, and there was only 1 case of significant catheter site bleeding. A total of 152 needle venepunctures were avoided owing to the presence of a CVC, a mean of 7 (±3.8) per case over the average stay. CONCLUSION: The early use of CVCs in Ebola virus disease is safe, effective and facilitates patient care. It should be considered a feasible additional route of venous access, where physician expertise and resources allow.

The advantages gained by the use of modern materials in the post operative casting procedure for foot and ankle surgery.

BACKGROUND: In June 2006, the post operative plaster immobilisation protocol for patients undergoing hindfoot and ankle surgery, at our institution, changed from multiple plaster changes to the immediate application of a definitive removable and reusable split synthetic cast. This study aims to assess the savings to the hospital and patient, following this change in practice. METHODS: A retrospective analysis of plaster room records from June 2005 to June 2007 was performed. The difference in cost to the hospital of the two different post operative journeys was then calculated. RESULTS: Two-hundred and twenty-two patients from 2005 to 2006 were managed at a total cost of 97,125 euro. From 2006 to 2007, 203 patients were managed with the new technique at a total cost of 37,860 euro. The net saving to the hospital of this change in practice was 251 euro per patient and 50,953 euro in total, while 203 patient visits and costs associated therewith were also saved. CONCLUSIONS: This study demonstrates how small changes in local practice can result in significant financial and temporal savings for hospitals and patients.

The use of improvised bullet markers with 3D CT reconstruction in the evaluation of penetrating trauma.

Radio-opaque markers placed over entry and exit wounds, have been used to help evaluate penetrating injuries and provide a permanent record of wound location on plain radiographs. To date there are no published reports of the application of improvised bullet markers in the evaluation of penetrating injuries using computed tomography (CT). We report a series of 4 cases where bullet markers were used in combination with three-dimensional (3D) computerised tomography (CT) to ascertain the path of the bullets and to assess damage to vital structures. We believe that the use of bullet markers in penetrating trauma casualties undergoing CT is valuable in the surgical decision making process and allows planning of surgical approaches.

Ballistic fractures during the 2003 Gulf conflict--early prognosis and high complication rate.

BACKGROUND: Ballistic fractures are devastating injuries often necessitating extensive reconstructive surgery or amputation, particularly if associated with high-energy transfer wounds. Infective complications are common, particularly in the austere environment encountered in war. We present the management and early outcome of these injuries with reference to the mechanism of injury and bony injury. METHOD: Data on ballistic fractures was collected prospectively during the 'war-fighting' phase of the 2003 Gulf Conflict, between 19th March and 20th May. Fractures were scored using the Red Cross Fracture classification and early outcome analysed. RESULTS: Thirty-nine patients, with 50 ballistic fractures, were treated by British military surgeons. Patients were predominantly Iraqi (90%) and 50 per cent of ballistic fractures were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. There were seven traumatic amputations, and a further 2 limbs were amputated primarily. Methods of primary stabilisation for the remaining 41 fractures were: external fixation (22%), POP (14.5%), K-wires (14.5%) traction (10%), and no stabilisation (39%). Seven individuals were evacuated early after primary surgery, hence 43 ballistic fractures were available for follow-up. 13/43 (30%) of wounds became infected, 5/43 (11.5%) were deep infections necessitating surgical drainage. There were 4 late amputations (9.5%), 3 of which had initially been managed by external fixation. Infection occurred significantly more often in gunshot fractures (10/21, 48%), wounds closed primarily against the principles of war surgery (415, 80%) and intra-articular fractures (3/3, 100%) (p=0.022, 0.024 and 0.023 respectively). Differing methods of stabilisation had no bearing on the rate of postoperative infection. CONCLUSION: Ballistic fractures remain a challenge for trauma surgeons in times of war and still have a poor prognosis. Further work is required to determine the optimal treatment of these injuries during conflicts. In addition, there still seems to be a continued need to re-learn the principles of war surgery in order to minimise complications and optimise functional recovery.

Penetrating missile injuries during asymmetric warfare in the 2003 Gulf conflict.

BACKGROUND: War wounds produce a significant burden on medical facilities in wartime. Workload from the recent conflict was documented in order to guide future medical needs. METHODS: All data on war injuries were collected prospectively. This information was supplemented with a review of all patients admitted during the study period. RESULTS: During the first 2 weeks of the conflict, the sole British field hospital in the region received 482 casualties. One hundred and four were battle injuries of which nine were burns. Seventy-nine casualties had their initial surgery performed by British military surgeons and form the study group. Twenty-nine casualties (37 per cent) sustained gunshot wounds, 49 (62 per cent) suffered wounds from fragmentation weapons and one casualty detonated an antipersonnel mine. These 79 patients had a total of 123 wounds that were scored prospectively using the Red Cross Wound Classification. Twenty-seven (34 per cent) of the wounded were non-combatants; eight of these were children. Four patients (5 per cent) died. CONCLUSION: War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing non-combatants in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in preparation for future conflicts.

The role of laser Doppler flowmetry in assessing the viability of bone fragments in an open fracture.

The management of open fractures requires excision of all devitalised tissues, both bony and soft tissue, and failure to do so is likely to increase the risk of infection. This study evaluated the applicability of laser Doppler flowmetry for the objective evaluation of fracture fragment viability in an experimental open ballistic fracture over a period of 12 h. The results indicate that this technique could not be used to distinguish between vascularised and non-vascularised fragments at any time, and did not aid the surgeon in their decision making at the time of wound excision. Subjective evaluation, based upon the degree of soft tissue attachment of fragments, was a far better indicator of fragment vascularity, although it had a relatively low specificity. There remains the need for education and training for trauma surgeons in the evaluation of fragment viability to ensure adequate wound excision as part of fracture management.

Principles and problems underlying testing the effectiveness of blast protective footwear.

Anti-personnel landmines are a continuing threat to soldiers and civilians working overseas in post conflict situations. Several groups of governmental and commercial scientists are currently designing and/or testing footwear to protect the lower leg from the effects of close proximity blast. The general principles surrounding testing of protective footwear are examined together with an assessment of the known progress to date and the strengths and weaknesses of the designs produced.