Filling the void : drafting surgery and Ebola guidelines / Sherry M. Wren and Adam L. Kushner -- The United States domestic response to Ebola : experience of the Nebraska biocontainment unit / Angela Hewlett and Daniel Johnson -- Closing the Medecins Sans Frontieres Maternity Hospital in Sierra Leone / Severine Caluwaerts -- Treating Ebola and non-Ebola patients at Connaught Hospital in Freetown, Sierra Leone / Thaim B. Kamara -- Anesthesia and Ebola : a loss of touch / Eva Hanciles, Mark J. Harris and Michael Koroma -- A clinical officer training program in Sierra Leone and the decline of surgical care due to Ebola / Hakon A. Balkon -- A way to deliver maternity care during the West Africa Ebola outbreak / Andrew M.R. Hall, Elizabeth Koroma, Andrew J. Michaels, Kathryn P. Barron, Oliver Johnson, Marta Lado -- Surgery in during a time of Ebola / Andrew J. Michaels, Ronald C. Marsh, Mohamed G. Sheku, Songor S.J. Koedoyoma, Andrew M.R. Hall, and Kathryn P. Barron -- Operating in PPE / Andrew J. Michaels, Ronald C. Marsh, Mohamed G. Sheku, Songor S.J. Koedoyoma, Andrew M.R. Hall, and Kathryn P. Barron -- A surgeon as outbreak investigator : Ebola in Liberia / Joseph Forrester
Abstract Background Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016–July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts.
Methodology A qualitative study design was used to examine the Mosul civilian trauma response. From August–December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified.
Results The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system.
Conclusions The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.
IMPORTANCE: The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States. OBJECTIVE: To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19–related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021. EXPOSURES: 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. MAIN OUTCOMES AND MEASURES: Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications. RESULTS: A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures ...
