The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries.

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ±â€Š4.21 hours vs 3.77 ±â€Š2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

Time after time: individuals with multiple fractures and injury recidivists in long eighteenth-century (c. 1666-1837) London.

Investigating injury recidivism and individuals with multiple injuries is an area of growing interest in bioarchaeology. Differentiating between whether an individual sustained multiple injuries, represented by antemortem healed fractures, in one incident or in multiple incidents over the life course, is a major challenge. This research analyzed the skeletal remains of 721 adults (402 males, 319 females) from five post-medieval cemeteries from London, UK, known to include working class individuals for evidence of skeletal trauma - fractures, myositis ossificans, subluxations/dislocations, blunt force trauma, and sharp force trauma. A total of 164 individuals had more than two fractures; males were significantly more likely to have multiple (2+) fractures than females. An investigation of fracture recidivism incorporating a relative timeline of fracture events was possible because 14 individuals (12 males, two females) were identified as injury recidivists, meaning they had a combination of antemortem healed, antemortem healing, and/or perimortem fractures. This paper examines the distribution and relative timing of these fractures, incorporating contemporary clinical as well as social and historical context, noting that the majority of the fractures were likely to be caused by accidental mechanisms.

Multiple Sharp Force Injuries to the Head - The Crime of Passion.

INTRODUCTION: The Institute of Forensic Medicine was founded by Professor Milovan Milovanovid (1884-1948) in 1923 as part of School of Medicine of the University of Belgrade, and also established the Institute's forensic collection worthy of a museum.This paper illustrates the way Professor Milovanovie made this collection into a teaching aid for student education. We present a case of crime of passion from the year 1931, from our Institute's collection. CASE OUTLINE: The victim was a 30-year-old woman with multiple stab wounds of the head, neck and arms. It was noted in the case history that the deceased woman was a maid with a wealthy merchant, as well as that she had "dubious morals" for that time, with three wooers at the same time. Injuries to the forearms and the index finger prove that the victim tried to defend herself. In the autopsy record there is a drawn figure of a kitchen knife with a rounded blade tip, which explains the absence of stab wounds to the skull, and the presence of the impression skull fractures and crushed skull bones. It was concluded that the death occurred due to exsanguination, in turn due to transection of the left carotid artery, probably caused by sharp force, while the manner of death was homicide. Some of the most prominent autopsy findings were multiple mutilating overkill sharp force injuries, localized on the head, indicated sexually motivated murder. CONCLUSION: Combining the museum specimen, diagrams with injuries, drawn figure of the kitchen knife used, and photographs taken during the autopsy and the police investigation, Professor Milovanovie was able to properly illustrate this intriguing case to students without a computer or a PowerPoint presentation.

Diagnosis of contact injuries in a mediaeval skeleton analysed by µCT and histology.

During an archaeological excavation in Altenberg/Linz (Upper Austria), the well-preserved skeletal remains of a mature male dated the 13th century AD were recovered. Several elements of the skeleton yielded alterations caused by trauma: beside a malunion of the left ulna which was accompanied by shortening of the diaphysis, a luxation and deformation of the left radial head was observed (Monteggia-type lesion, Bado-type I). Moreover, at the anterior aspect of the corresponding humerus, a chalice-shaped, newly built bone structure that framed the displaced capitulum radii was visible. This structure formed a sort of "alternative joint" that functionally even allowed some movements, although considerably restricted in regard to flexion/extension and even more in pronation/supination.To verify the assumption of a "single event", we not only investigated the concerned skeletal portions by gross-anatomical examination, but also by non-invasive conventional radiological, micro-computed tomographical, and histological techniques. Particular morphological features, injuries at the calvarium, and fractures of other postcranial elements imply the scenario of a close combat; although survived, the traumata obviously resulted in partial invalidity.

The evolution of damage control surgery.

The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.

[A murder case from 900 years ago? Analysis of extensive cranial trauma observed in a historical skeleton recovered in central Poland]. / Morderstwo sprzed 900 lat? Analiza rozleglych urazów czaszki zaobserwowanych na szkielecie historycznym odkrytym w centralnej Polsce.

This work presents the results of study of a human skeleton from the early Middle Ages recovered in Peclawice (province of Lódz), presenting signs of extensive cranial trauma suffered perimortem. The skeleton belonged to a 20-30 year-old male of sturdy build, with prominent bone processes, marked right-side asymmetry of the bones and joints of the upper extremities, and tallness (stature well above average for early medieval times). Except for the skull, the skeleton lacks any pathologic or traumatic lesions. The right side of the skull bears signs of three extensive injuries involving the frontal and parietal bones and the temporomandibular joint. Two of them penetrated deeply into the cranial cavity. The nature and location of the lesions suggests that the axe was used and that the victim was not confronted face-to-face. None of the lesions show any signs of healing. Fragmentation of the facial bones, which were mostly incomplete except for the well-preserved mandible, suggests additional blows to the face. These massive injuries must have been fatal due to damage to the brain and main blood vessels of the neck and thus they were recognized as the cause of death of the individual.

Beyond war and military medicine: social factors in the development of prosthetics.

Polytrauma is an immediate outcome of current warfare, and the need to investigate this condition is equally immediate. The value of historical analysis in this endeavor should not be underestimated. It is among the best tools we have to help ensure that current research and practice involve engagement with the social contexts of polytrauma as well as with the medical science of its treatment. This special communication provides historical perspective on certain aspects of the polytraumatic condition--namely, limb loss, prosthetic rehabilitation, and community reintegration after receiving a prosthesis. It discusses the influential role of societal factors in these areas to encourage greater understanding that the care of persons with polytrauma must involve critical thinking about their relationships to and participation in society as well as their treatment by medical science. This special communication also provides historical perspective to enrich appreciation of the value of history for the field of physical medicine and rehabilitation (PM&R), the PM&R clinician, and the PM&R clinical researcher. Readers will learn that historical knowledge puts PM&R research and practice into perspective, reminding us that rehabilitation should involve critical thinking not only about medicine, but also about social roles and the participation of people in society despite physical and psychologic challenges.

Continuity of interpersonal violence between Nubian communities.

Modern communities affiliated with the same culture have been shown to experience comparable levels of interpersonal violence, no matter what their size. It was hypothesized that a similar relationship would exist among ancient rural and urban people, but that accident-related trauma may be more prominent among rural dwellers due to their activity base. Through an analysis of antemortem trauma, this investigation contrasted the injury profile of Nubian adult villagers (N = 55) from the Kerma period (2500-1750 BC) to that of their urban neighbors (N = 223) at Kerma (2050-1500 BC). The injury pattern associated with interpersonal violence (cranial injury, direct-force ulna fractures, and multiple injuries) was similar between the two samples, as hypothesized. The rural group sustained significantly more nonviolence-related injuries that suggested occupational or environmental influences. The more severe cranial injuries observed among urban people are attributed to a preference for more lethal hand-wielded objects that may have accompanied increasing local tensions and incursions into Egypt during the 17th Dynasty.

Interpersonal violence in prehistoric San Pedro de Atacama, Chile: behavioral implications of environmental stress.

The prehistoric population of San Pedro de Atacama lived through periods marked by prosperity and interregional interaction, as well as times of severe drought, social stress, and widespread poverty. A sample of 682 crania was analyzed for evidence of cranial trauma in order to assess changing patterns of interpersonal violence during the occupation of the oasis. It was hypothesized that the level of traumatic injuries in this population would parallel some of the changes seen in the archaeological record. Low fracture rates would be expected in periods of affluence and environmental stability, while periods characterized by environmental extremes and state collapse would yield elevated rates of aggression. This analysis found that rates of trauma escalated from 5.1% (5/99) in the earliest period, to 10.9% (10/92) in the Middle Horizon (AD 600-950). Although it may reflect problems related to increasing population density in the oasis, this increase is surprising, given that the early period witnessed the shift to permanent settlements, and the middle period was one of prosperity and plentiful resource availability. Trauma rates peaked at 35.6% (16/45) in an early Late Intermediate period (AD 950-1400) cemetery, with other Late Intermediate cemeteries demonstrating similarly high rates of traumatic injury. The elevated trauma rates during this period correlate with major droughts, the concentration of settlements on the oasis' east side, fortified structures, and material poverty, all reflected in the archaeological record. As the Late Intermediate waned and environmental conditions improved, trauma concomitantly decreased (7.0%), and remained low throughout the Inka occupation (AD 1400-1532). This indicates that while the Atacama was not peaceful, violence became commonplace only during periods of great social change and resource stress.

Lesiones inadvertidas en el politraumatizado: análisis de un registro de trauma / Missed injuries in patients with multiple trauma: analysis of a trauma registry

Introducción. La frecuencia de lesiones inadvertidas en pacientes con traumatismos oscila entre el 0,5 y el 38%, según los diferentes estudios y sus criterios de inclusión. En nuestro trabajo hemos evaluado la incidencia, los factores contribuyentes y la relevancia clínica de estas lesiones a partir del Registro de Trauma grave de nuestro centro. Pacientes y métodos. Se analiza de manera retrospectiva un registro de 912 traumatizados graves, recogidos de forma prospectiva. De éstos, 19 pacientes presentaron una lesión inadvertida (2%). Se comparan variables demográficas (edad y sexo) y clínicas (escalas de gravedad y mecanismo lesivo), y se evalúan los factores contribuyentes evitables, así como las lesiones inadvertidas clínicamente relevantes. Resultados. De los 19 pacientes con lesiones inadvertidas, el 58% sufrió traumatismos cerrados. En ninguna de las variables estudiadas se encontró diferencia estadística, aunque las lesiones penetrantes fueron claramente más frecuentes en los pacientes con lesiones inadvertidas que en el grupo sin ellas. El 47% fueron osteoarticulares, el 26% viscerales y el 21% vasculares. Las lesiones potencialmente evitables fueron el 63%, y el motivo más frecuente fue una incorrecta evaluación clínica. La mortalidad por lesiones diagnosticadas de manera tardía alcanzó el 21%. Conclusiones. Una incorrecta evaluación clínica es el factor evitable que más impacto tiene a la hora de disminuir el número de lesiones inadvertidas. Otro factor que claramente contribuye a la reducción es la adecuada interpretación de las imágenes radiológicas, en el contexto de una revisión terciaria. Todos los equipos que tratan a estos pacientes deberían conocer sus resultados e incidir en las fases diagnósticas donde reside el error (AU)

Introduction. The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. Patients and methods. We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. Results. Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%.Conclusions. Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses (AU)

Milestones in medical management of trauma.

Trauma care appears to be a relatively young science because of the major strides made after World War II. A historical foundation of today's practice is provided, with interesting anecdotes concerning some of the pioneers, their motivations, and the reactions of their medical peers. A chronology of trauma care highlights the growth of multiple fields of science that eventually blended to become the basis for modern care.

The Oklahoma City bombing: a personal account.

On April 19, 1995, Oklahoma City (and the United States) lost its innocence. Almost all Oklahomans can relate exactly what they were doing either at 9:02 AM that day or when they first learned of the bombing. Of course, the whole world watched the events unfold through around-the-clock television coverage. One of the resident physicians in the University Hospital Emergency Medicine program, Dr Carl Spengler, was the first physician on the scene and directed early triage efforts. Because the Journal of Child Neurology is the only major biomedical journal with editorial offices in Oklahoma, we considered it appropriate that his personal account of this disaster be published in JCN.

The 1986 terrorist bombing experience in Paris.

Between December 7, 1985 and September 17, 1986, eleven terrorist bomb explosions took place in Paris. Thirteen people died immediately, 255 others were injured. Forty were treated on-site and were not hospitalized, 205 were subjected to triage and stabilization and were then hospitalized. These latter 205 patients are analyzed in this study. None of them died during transportation, and seven eventually died in hospitals. Forty-seven per cent of all victims suffered from multiple injuries. All deaths except one occurred in the polytraumatized group. The policy of subjecting victims of terrorist bomb explosions to triage and stabilization before hospitalization is compared to the so-called "scoop and run" technique, more generally applied in mass casualty situations. Its limitations and advantages are discussed.