Hospital preparedness assessment for road traffic accidents with mass casualties: a cross-sectional study in Kurdistan Province, Iran.

BACKGROUND: Road traffic accidents (RTAs) are predicted to become the world's seventh leading cause of death by 2030. Given the significant impact of RTAs on public health, effective hospital preparedness plays a pivotal role in managing and mitigating associated health and life-threatening issues. This study aims to meticulously evaluate the preparedness of selected hospitals in western Iran to handle road traffic accidents with mass casualties (RTAs-MC). METHODS: The study employed a descriptive-analytical approach, utilizing a reliable and valid questionnaire to measure hospitals' preparedness levels. Descriptive statistics (frequency distribution and mean) were utilized to provide an overview of the data, followed by analytical statistics (Spearman correlation test) to examine the relationship between hospital preparedness and its dimensions with the hospital profile. Data analysis, performed using SPSS software, categorized preparedness levels as weak, moderate, or high. RESULTS: The study found that hospitals in Kurdistan province had a favorable preparedness level (70.30) to respond to RTAs-MC. The cooperation and coordination domain had the highest preparedness level (98.75), while the human resource management (59.44) and training and exercise (54.00) domains had the lowest preparedness levels. The analysis revealed a significant relationship between hospital preparedness and hospital profile, including factors such as hospital specialty, number of beds, ambulances, staff, and specialized personnel, such as emergency medicine specialists. CONCLUSION: Enhancing preparedness for RTAs-MC necessitates developing response plans to improve hospital profile, considering the region's geographic and topographic features, utilizing past experiences and lessons learned, implementing of Hospital Incident Command System (HICS), providing medical infrastructure and equipment, establishing communication channels, promoting cooperation and coordination, and creating training and exercise programs.

Mortality in hypotensive combat casualties who require emergent laparotomy in the forward deployed environment.

INTRODUCTION: Mortality rates among hypotensive civilian patients requiring emergent laparotomy exceed 40%. Damage control (DCR) principles were incorporated into the military's Clinical Practice Guidelines (CPG) in 2008. We examined combat casualties requiring emergent laparotomy to characterize how mortality rates compare to hypotensive civilian trauma patients. METHODS: The DoD Trauma Registry (2004-2020) was queried for adults who underwent combat laparotomy. Patients who were hypotensive were compared to normotensive patients. Mortality was the outcome of interest. Mortality rates before (2004-2007) and after (2009-2020) DCR CPG implementation were analyzed. RESULTS: 1051 patients were studied. Overall mortality was 6.5% for normotensive casualties and 28.7% for hypotensive casualties. Mortality decreased in normotensive patients but remained unchanged in hypotensive patients following the implementation of the DCR CPG. CONCLUSION: Hypotensive combat casualties undergoing emergent laparotomy demonstrated a mortality rate of 29.5%. Despite many advances, mortality rates remain high in hypotensive patients requiring emergent laparotomy.

A ward level analysis of child pedestrian casualty frequencies in Greater London.

INTRODUCTION: Child pedestrian safety remains a challenge despite the remarkable progress that has been attained in recent years, particularly, in high income jurisdictions such as London. This study sought to identify and quantify the magnitude of the effects of various explanatory variables, from the domains of transport, built and natural environment, socio-demographic and economic factors, on ward level child pedestrian injury frequencies in Greater London. METHOD: We adopted a multilevel random parameters model to investigate the factors associated with child pedestrian injuries given the hierarchical nature of the data comprising of wards nested within boroughs. RESULTS: We found that crime, the Black, Asian, and Minority Ethnic (BAME) population, school enrollment, and the proportion of the population who walk five times a week had an increasing effect on the number of child pedestrian casualties. Conversely, the proportion of the population with a level 4 qualification and the number of cars per household had a decreasing effect. CONCLUSIONS: Our study identified high child pedestrian injury frequency wards and boroughs: Stratford and New Town had the highest expected child pedestrian injury frequencies followed by Selhurst, Westend, and Greenford Broadway. Some inner London boroughs are among the highest injury frequency areas; however, a higher number of high child pedestrian injury boroughs are in outer London. PRACTICAL APPLICATIONS: The paper provides recommendations for policy makers for targeted child pedestrian safety improvement interventions and prioritization to optimize the utilization of often constrained resources. The study also highlights the importance of considering social inequities in policies that aim at improving child traffic safety.

Mental health, ethnicity and the UK armed forces: Historical lessons for research and policy.

BACKGROUND: UK armed forces have recruited from other races and ethnicities at times of crisis. To meet diversity targets, they have also recruited indigenous groups of non-White British heritage. Considered at greater risk of mental health problems generally, these populations are likely to suffer more in combat and in transition to civilian life. Yet, there is little data on how they fare. METHODS: A scoping review was conducted of peer-reviewed studies of psychological illnesses suffered by racial and ethnic minority soldiers from World War One to the present, together with research at the National Archives, Wellcome Trust Archives and the Imperial War Museum for unpublished studies. RESULTS: British commanders and psychiatrists argued that 'martial races' were protected against post-traumatic illnesses because of an innate resilience related to a rural heritage. Consequently, low morale and breakdown were interpreted as malingering to avoid combat. Indian troops received lower levels of psychiatric care than provided for British soldiers delivered with limited cultural understanding. Inferior terms and conditions were offered to Indian soldiers with lesser opportunities for promotion. These practices, established in both World Wars, continued for Gurkha and Commonwealth soldiers recruited to meet manpower and diversity targets. Disproportionate complaints of discrimination may explain why ethnic minority status is a risk factor for mental illness. CONCLUSION: Management patterns laid down during the Imperial era continue to influence current practice for ethnic minority service personnel. Yet, armed forces can play a positive role in fostering diversity and integration to provide protective factors against mental illness.

A comparative analysis of road and vehicle qualities as factors of road traffic carnage in Nigeria.

BACKGROUND AND OBJECTIVE: Carnage on roads is a growing concern in Nigeria. Over 27 persons, equivalent to more than 4 families, die daily from road traffic crashes. Two direct factors of a road crash are road quality and vehicle quality. To interrogate and compare both factors to road traffic accidents, the longitudinal study regressed secondary data on death tolls against road quality and vehicle quality. MATERIALS AND METHODS: Data on the estimated number of vehicles imported into Nigeria (1992-2021) served as the indicator of vehicle quality on Nigerian roads. The longitudinal study regressed secondary data on death tolls (2013-2019) against road quality (2006-2019) and vehicle quality (1992-2021). RESULTS: Results showed that road quality is degenerating as well as vehicle quality in Nigeria, resulting in increase in the number of road traffic crashes and the attendant death tolls. For every 1% decrease in road quality, death tolls from road traffic crashes in Nigeria increased by 0.00642% at 5% significance, and for every decrease in vehicle quality, death tolls from road traffic crashes in Nigeria increased by 0.327% at 5% significance. CONCLUSION: The study recommended increased advocacy on the sanctity of life and the need for all tiers of government to prioritize policy and implementation of improving the road quality and vehicle quality to reduce road traffic crashes and save lives on Nigerian roads.

Estimating conflict losses and reporting biases.

Determining the number of casualties and fatalities suffered in militarized conflicts is important for conflict measurement, forecasting, and accountability. However, given the nature of conflict, reliable statistics on casualties are rare. Countries or political actors involved in conflicts have incentives to hide or manipulate these numbers, while third parties might not have access to reliable information. For example, in the ongoing militarized conflict between Russia and Ukraine, estimates of the magnitude of losses vary wildly, sometimes across orders of magnitude. In this paper, we offer an approach for measuring casualties and fatalities given multiple reporting sources and, at the same time, accounting for the biases of those sources. We construct a dataset of 4,609 reports of military and civilian losses by both sides. We then develop a statistical model to better estimate losses for both sides given these reports. Our model accounts for different kinds of reporting biases, structural correlations between loss types, and integrates loss reports at different temporal scales. Our daily and cumulative estimates provide evidence that Russia has lost more personnel than has Ukraine and also likely suffers from a higher fatality to casualty ratio. We find that both sides likely overestimate the personnel losses suffered by their opponent and that Russian sources underestimate their own losses of personnel.

Not according to plan: Cognitive failures in marksmanship due to effects of expertise, unknown environments, and the likelihood of shooting unintended targets.

Shooting errors have multi-faceted causes with contributing factors that include sensorimotor activity and cognitive failures. Empirical investigations often assess mental errors through threat identification, yet other cognitive failures could contribute to poor outcomes. The current study explored several possible sources of cognitive failures unrelated to threat identification with live fire exercises. Experiment 1 examined a national shooting competition to compare marksmanship accuracy, expertise, and planning in the likelihood of hitting no-shoot or unintended targets. Experts demonstrated an inverse speed/accuracy trade-off and fired upon fewer no-shoot targets than lesser skilled shooters, yet overall, greater opportunity to plan produced more no-shoot errors, thereby demonstrating an increase in cognitive errors. Experiment 2 replicated and extended this finding under conditions accounting for target type, location, and number. These findings further dissociate the roles of marksmanship and cognition in shooting errors while suggesting that marksmanship evaluations should be re-designed to better incorporate cognitive variables.

TREATMENT OF COMBAT GUNSHOT SHRAPNEL TRAUMA OF LARGE DEFECTS OF THE SOFT TISSUES OF THE LOWER EXTREMITIES WITH PLASTIC SURGERY IN COMBINATION WITH VACUUM ASSISTED WOUND CLOSURE (VAC).

OBJECTIVE: The aim: To evaluate efficacy of the tissue defect closure techniques in combination with VAC in the treatment of battle casualities of the lower extremities. PATIENTS AND METHODS: Materials and methods: The results of wound healing until complete wound closure, of 62 patients with shrapnel defects of the lower extremities where assessed. RESULTS: Results: Treatment of patients with soft tissue defects of the lower extremities using rotational flaps on the vascular pedicle and VAC significantly reduces the incidence of infectious complications (18.75% in the main group vs. 30% in the control group (p<0.05)), reduces the intensity of pain according to the VAS scale during the first week of treatment in the main group to 5±0.5 versus 7±0.8 in the control group (p<0.05) and reduces the length of hospital stay by 7 days. CONCLUSION: Conclusions: The use of rotational flaps on the vascular pedicle and local tissue closure techniques in combination with VAC is an effective method of treating patients with combat gunshot wounds of the soft tissues of the lower extremities.

[Cricothyrotomy : Data situation, guidelines and techniques for the definitive surgical airway]. / Koniotomie : Datenlage, Leitlinien und Techniken zum definitiven chirurgischen Atemweg.

Cricothyrotomy represents the final approach to secure the airway, in the course of which less invasive measures have failed. It can also primarily be carried out to establish a secure airway. This is essential to protect the patient from a significant hypoxia. This is a cannot ventilate-cannot oxygenate (CVCO) situation, which presumably all colleagues in emergency intensive care medicine and anesthesia have already been confronted with. Evidence-based algorithms for the management of a difficult airway and CVCO have been established. If oxygenation using an endotracheal tube, an extraglottic airway device or bag-valve mask ventilation all fail, the airway must be surgically secured, i.e. using cricothyrotomy. The prevalence of the CVCO situation in a prehospital setting is ca. 1%. No valid prospective randomized in vivo studies have been carried with respect to the question of the best method.

Cars dent, horse riders break: Analysis of police-recorded injury incidents involving ridden horses on public roads in Great Britain.

INTRODUCTION: Police-recorded road injury data are frequently used to approximate injury risk for different road user groups but a detailed analysis of incidents involving ridden horses has not previously been conducted. This study aims to describe human injuries resulting from interactions between ridden horses and other road users on public roads in Great Britain and identify factors associated with severe to fatal injuries. METHOD: Police-recorded road incident data involving ridden horses (2010-2019) were extracted from the Department for Transport (DfT) database and described. Multivariable mixed-effects logistic regression modeling was used to identify factors associated with severe/fatal injury outcomes. RESULTS: A total of 1,031 injury incidents involving ridden horses were reported by police forces, involving 2,243 road users. Out of 1,187 road users injured, 81.4% were female, 84.1% were horse riders, and 25.2% (n = 293/1,161) were in the 0-20 year age category. Horse riders represented 238/267 serious injuries and 17/18 fatalities. Vehicle types involved in incidents where horse riders were seriously/fatally injured were mostly cars (53.4%, n = 141/264) and vans/light goods vehicles (9.8%, n = 26). Horse riders, cyclists, and motorcyclists had higher odds of severe/fatal injury compared to car occupants (p < 0.001). Severe/fatal injuries were more likely on roads with 60-70 mph speed limits versus 20-30 mph roads, while odds of severe/fatal injury increased with increasing road user age (p < 0.001). CONCLUSIONS: Improved equestrian road safety will largely impact females and young people as well as reducing risk of severe/fatal injuries in older road users and those using modes of transport such as pedal-cycles and motorcycles. Our findings support existing evidence that reductions in speed limits on rural roads would help reduce the risk of serious/fatal injuries. PRACTICAL APPLICATIONS: More robust equestrian incident data would better inform evidence-based initiatives to improve road safety for all road users. We suggest how this can be done.

Diffusion simulation and risk assessment model establishment of chlorine gas leakage based on terrain conditions.

This study researches the impact of terrain factors on chlorine gas diffusion processes based on SLAB model. Simulating the law of wind speed changing with altitude by calculating the real-time speed with vertical height combing actual terrain data, and integrating the influence of terrain on wind speed by using Reynolds Average Navier-Stokes (RANS) algorithm, K-turbulence model, and standard wall functions, then plotting the gas diffusion range in the map with terrain data according to the Gaussian-Cruger projection algorithm and dividing the hazardous areas according to the public exposure guidelines (PEG). The accidental chlorine gas releases near Lishan Mountain, Xi'an City, were simulated by the improved SLAB model. The results show that there are obvious differences analyzing contrastively the endpoint distance and area of chlorine gas dispersion under real terrain condition and ideal condition at different times; it can be found that the endpoint distance of the real terrain conditions is 1.34 km shorter than that of the ideal conditions at 300 s with terrain factors, and also the thermal area is 3,768,026m2 less than that of the ideal conditions. In addition, it can predict the specific number of casualties within different levels of harm at 2 min after chlorine gas dispersion, and casualties are constantly changing over time. The fusion of terrain factors can be used to optimize the SLAB model, which is expected to provide an important reference for effective rescue.

Evaluating green productivity of the regional transport sector in South Asia considering environmental and safety constraints: the evolution from static and dynamic perspectives.

The assessment of green productivity not only establishes the production ability but also involves economic, environmental, and social aspects which are the ultimate goals in achieving the sustainability. In this context, unlike the majority of previous literature, we have simultaneously considered the environmental and safety aspects to measure the static and dynamic evolution of green productivity to achieve a safe, eco-friendly, and sustainable development of the regional transport sector in South Asia. First, we proposed the super-efficiency ray-slack-based measure model with undesirable output to assess the static efficiency, which can effectively characterize weak and strong disposability relationship between desirable and undesirable outputs. Second, the biennial Malmquist-Luenberger index has been adopted to examine the dynamic efficiency, which can overcome recalculation issue once an additional time period is included in the data. Therefore, the proposed methodology provides more comprehensive, robust, and reliable insight in comparison to the conventional models. The results indicate (i) both static and dynamic efficiencies decreased during 2000-2019, implying that the transport sector in South Asia follows an unsustainable green development path at the regional level; (ii) dynamic efficiency was primarily held back by green technological innovation whereas green technical efficiency had a modest positive contribution. The policy implications suggest effective ways to improve green productivity of the transport sector in South Asia by promoting coordinated development among the transport structure, environmental and safety aspects, strengthening advance and innovative production technologies, endorsing green transportation practices, and implementing safety regulations and emission standards for the sustainable transport sector.

Combat Casualties Treated With Intranasal Ketamine for Prehospital Analgesia: A Case Series.

Optimal pain management is challenging in Tactical Combat Casualty Care (TCCC), particularly in remote and austere settings. In these situations, appropriate treatment for prehospital analgesia can be limited or delayed due to the lack of intravenous access. Several guidelines suggest to implement intranasal (IN) analgesia in French Armed Forces for forward combat casualty care (Sauvetage au Combat), similar to the US TCCC. Four medical teams from the French Medical Military Service were deployed to the Middle East and Sahel from August 2017 to March 2019 and used IN ketamine for analgesia in 76 trauma patients, out of a total of 259 treated casualties. IN administration of ketamine 50mg appeared to be safe and effective, alone or in addition to other opioid analgesics. It also had minimal side effects and led to a reduction in the doses of ketamine and morphine used by the intravenous (IV) route. The French Military Medical Service supports current developments for personal devices delivering individual doses of IN ketamine. However, further studies are needed to analyze its efficacy and safety in combat zones.

Health effects of a ban on late-night alcohol sales.

This paper studies the impact of a ban on late-night off-premise alcohol sales between 10 p.m. and 5 a.m. in Germany. We use three large administrative data sets: (i) German diagnosis related groups-Statistik, (ii) data from a large social health insurance, and (iii) Road Traffic Accident Statistics. Applying difference-in-differences and synthetic-control-group methods, we find that the ban had no effects on alcohol-related road casualties, but significantly reduced alcohol-related hospitalizations (doctor visits) among young people by around 9 (18) percent. The decrease is driven by fewer hospitalizations due to acute alcohol intoxication during the night-when the ban is in place-but not during the day.

Experience With Trauma-Induced ARDS: A Retrospective Study of US Wartime Casualties 2003-2015.

BACKGROUND: The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. MATERIALS AND METHODS: We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). RESULTS: The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. CONCLUSION: By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.

Analysis of road traffic injuries and casualties in China: a ten-year nationwide longitudinal study.

Background: Road traffic injuries (RTIs) are a serious global problem, and a huge challenge for both economic development and public health. Methods: This longitudinal study was based on the national data from Chinese authorities. Descriptive analysis was utilized to analyze the prevalence and trend of RTIs among different types, groups and regions. In addition, ridge regression or/and curve regression were also used to explore the relationship between those possible influencing factors and RTIs. Results: From 2010 to 2019, the death toll from motor vehicle accidents (MVAs) decreased firstly and then increased, while the death toll from non-MVAs continued to rise since 2012, and the death toll from pedestrian and occupant accidents fluctuated only a little. The mortality rate of MVA was relatively stable from 2010 to 2012, and declined from 2013. The mortality rate of motor vehicle accidents was higher in rural than urban, the same to male compared with female. The results of ridge regression showed that gross domestic product (GDP)-per-capita, total population, number of health personnel and car ownership were positively correlated with the death toll of non-MVAs (P < 0.05). Additionally, the results of curve regression suggested that the quadratic or cubic relationship between each factor and the number of MVAs was well fitted, while only partially fitted in fatalities. Conclusions: In recent years, RTIs in China show different trends, and the problem of non-motor vehicle traffic injuries has been neglected which should be paid more attention. Moreover, according to the new trends and traffic conditions in RTIs revealed in this study, it is necessary to formulate targeted intervention measures establish a multi-faceted comprehensive safety system to reduce the disease burden of RTIs as well as the total injuries.

Operational Consideration for Definitive Airway Management in the Austere Setting: A Case Report.

In modern and asymmetric conflicts, traumatic airway obstruction caused by penetrating injury to the face and neck anatomy is the second leading cause of preventable mortality. Definitive airway management in the emergency setting is most commonly accomplished by endotracheal intubation. When this fails or is not possible, a surgical airway, usually cricothyrotomy, is indicated. The clinical choice for establishing a definitive airway in the austere setting is impacted by operational factors such as a mass casualty incident or availability and type of casualty evacuation. This is a case report of a patient with severe cervicofacial injuries with imminent airway compromise in the setting of a mass casualty incident, without possibility of sedation and mechanical ventilation during his evacuation. The authors seek to highlight the considerations and lessons learned for emergency cricothyrotomy.

Prevalence, characteristics, and consequences of verbal and physical violence against healthcare staff in Chinese hospitals during 2010-2020.

OBJECTIVES: This study investigated the characteristics of workplace violence (WPV) against Chinese healthcare staff and their casualties after severe physical violence (PV). METHODS: We scrutinized medical WPV incidents reported online and analyzed information on timing, location, violence, criminal incentives, and casualties following severe PV in China from 2010 to 2020. RESULTS: WPVs were mostly committed by young and middle-aged male family members of the patients, especially in the emergency department (49.1%), and mostly associated with dissatisfaction with treatment effect (28.9%) in general. High medical costs (62.5%) were the leading cause of verbal violence (VV), whereas men predominantly committed PV (OR = 4.217, 95% CI: 1.439-12.359) owing to dissatisfaction with the healthcare staff's attitude (P < 0.001). The victims were security personnel in most cases (81.1%). Nurses were generally more likely to experience PV (P < 0.05), while doctors were more likely to experience lethal PV (OR = 4.732, 95% CI: 1.42-15.772), which mostly happened in oncology (P < 0.05) and committed by visitors (P < 0.001). Slight injuries and mortality were more likely to be inflicted by being rejected for unreasonable demands and disappointed with the treatment effect (P < 0.05). CONCLUSIONS: Medical WPV has numerous reasons, locations, and diverse victims and offenders. Some severe WPVs have serious consequences. Therefore, it is recommended for the concerned authorities to adopt effective steps for appropriate legislative, security, and conflict-resolution measures.

Tactical Combat Casualty Care Maritime Scenario: Shipboard Missile Strike.

The types of injuries seen in combat action on a naval surface ship may be similar in many respects to the injuries seen in ground combat, and the principles of care for those injuries remain in large part the same. However, some contradistinctions in the care of combat casualties on a ship at sea must be highlighted, since this care may entail a number of unique challenges and different wounding patterns. This paper presents a scenario in which a guided missile destroyer is struck by a missile fired from an unmanned aerial vehicle operated by an undetermined hostile entity. Despite the presence of casualties who require care, the primary focus of a naval vessel that has just been damaged by hostile action is to prevent the ship from sinking and to conserve the fighting force on board the ship to the greatest extent possible. The casualties in this scenario include sailors injured by both blast and burns, as well as a casualty with a non-fatal drowning episode. Several of the casualties have also suffered the effects of a nearby underwater explosion while immersed. Challenges in the care of these casualties include delays in evacuation, the logistics of obtaining whole blood for transfusion while at sea, and transporting the casualties to the next higher level of care aboard a Casualty Receiving and Treatment Ship. As the National Defense Strategy pivots to a focus on the potential for maritime combat, the medical community must continue to maintain readiness by preparing fo.

Analgesia and Sedation for Tactical Combat Casualty Care: TCCC Proposed Change 21-02.

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?