Foot Protective System : A Boon to Demining Soldiers

Background

A significant number of soldiers suffer serious injuries or die in the process of demining and a protective device is necessary in such operations.

Methods

All the patients involved in demining operations using the foot protection devices in last one year were analysed.

Results

We received 35 patients, of which only five had limb injuries and 30 had eye injuries. Of the five, three had closed calcaneal fractures and two contusion of foot. No fatality, amputation or compound fracture occured.

Conclusion

Early results after the use of this device during demining operations are encouraging.Key Words: Mine blast injury, Demining, Spider boot     

Study of Disabled Treated at Artifical Limb Centre

Background

Artificial Limb Centre (ALC), Pune provides comprehensive rehabilitation care to disabled soldiers of Armed Forces. A retrospective study of 16308 Armed Forces personnel treated at ALC, Pune was carried out to analyse the factors resulting in disability and their distribution among the soldiers.

Methods

Records of disabled soldiers treated at ALC, Pune from 14 May 1944 to 31 Dec 2003 were analysed with respect to their age, rank structure, nature of disability, causation and body part involved to find out various factors contributing to disablement and its distribution amongst the soldiers.

Result

Trauma was the commonest cause of disability in Armed forces personnel and mine blast injury was the most frequent mode of trauma followed by road traffic accident. Study also revealed that lower limb amputation is the most common type of disability and below knee amputation is the most common level of amputation. Maximum disabled personnel were in the age group of 21 to 40 years and other ranks accounted for 92.58 % of the total number.

Conclusion

War related injuries were the most common cause of disability in the Armed Forces personnel, which affect the young soldiers in their most productive period of life.Key Words: Rehabilitation, Disabled soldiers, Prosthesis     

Management of Combat Related Vascular Injuries in a Zonal Hospital

Background

The extremity gunshot wound (GSW) and penetrating splinter injuries from mine blast present a surgical challenge in the treatment of arterial trauma especially at non-vascular surgery centre. Adherence to specific principles of management is required for optimal limb salvage.

Methods

Fourteen vascular injuries in patients of GSW and mine explosions were managed at a zonal military hospital with successful outcome in two years. The diagnosis of arterial injury was done clinically.

Results

The commonest site of vascular injury was femoral. The methods of choice for repair were autogenous vein interposition or end-to-end anastomosis. All except for two patients retained a functional limb.

Conclusion

All surgeons in peripheral hospitals should be trained in vascular injury repair to save life and limb. Our series shows that right timing and prompt treatment of vascular injuries in a peripheral hospital, can give satisfactory results.Key Words: Gunshot wounds, Mine blast injuries, Vascular trauma, Autogenous vein interposition, Fasciotomy     

Bullet and Blast ENT Injuries in Counter-Insurgency Area

Background

Many ENT injuries are not recognized easily, but they have the potential of increasing the morbidity.

Methods

ENT injuries managed in two tertiary care Level-IV hospitals between 2006 and 2007 were studied with a view to formulate strategy in efficient management of these cases.

Result

Emergency bags did not carry readymade packs to control nasal bleeds. Routinely screening of ears in all blast injury cases in the ‘Blast Injury Program’ helped in early identification of hearing loss. Lack of sufficient stenting of nasal cavities resulted in severe nasal stenosis which was difficult to repair. Splinters lodged in pharyngeal wall escaped detection, resulting in concealed haemorrhage and shock.

Conclusion

Nasal packs and epistaxis catheters must be included in emergency bags to minimize blood loss at first contact. Screening for ear trauma in all blast injuries increases detection rate and is beneficial to the soldier. Stenting of injured nasal cavities and early transfer to a tertiary care hospital could reduce morbidity. Plain radiography of head and neck areas could help detect splinters in vital areas and guide management.Key Words: Combat injuries ENT, Blast injuries ear     

Management of Vascular Injuries in a Forward Hospital

Background

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

Methods

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

Results

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

Conclusions

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.Key Words: Vascular injuries, trauma, amputation     

Treatment of Casualties in a Forward Hospital of Indian Army : Nine year Experience

Background

To analyze the outcome of the management of casualties in a level II trauma centre of a forward hospital of Armed Forces over a nine year period. Retrospective analysis of all casualties received in a single forward hospital of Indian Army was carried out.

Method

During 9 years (1990-1998), a total of 5737 casualties were received in a single level II zonal hospital of the Army in a forward area. Majority of the injuries were caused by bullets, or by fragments of improvised explosive devices. A policy of aggressive resuscitation and early primary repair of injuries was followed. General surgeons routinely performed craniotomies, thoracotomies, laparotomies, stabilization of fractures by fixators and repair of vascular injuries.

Result

38% of patients had injuries to several body parts (polytrauma), resulting in a total of 8578 injuries. Region-wise distribution of injuries was as follows : 14.2% head and neck injuries, 13.3% chest wounds, 13.5% abdominal injury and 59% extremity wounds. The overall mortality rate was 3.6%. The complication rate was about 7% with infection as the major complication. The results of primary repair of colonic injuries were similar to those of staged repairs. The results after primary closure of war wounds were better than those treated with delayed primary closure in selected cases.

Conclusion

Prompt evacuation, speedy resuscitation and early definitive repair of war injuries results in low mortality and morbidity. A motivated and dedicated team and adequate availability of blood and ancillary services adds to the excellent outcome. The policy of primary repair of colonic and selected soft tissue injuries appears justified in selected cases.Key Words: Casualties, Improvised Explosive Devices, Militancy, Trauma     

Posterior Interosseous Artery Flap for Hand Defects

Background

Reconstruction of soft tissue defects in the hand need an early, single stage and well vascularised cover to achieve the best functional result. Usually a full thickness graft is required since vital structures like tendons, bones and joints are exposed and often there is need for secondary reconstruction.

Methods

We managed 12 cases of complex defects over the hand in the last 2 years with the posterior interosseous artery flap.

Results

In 5 cases the defect was due to blast injury and in 4 because of crush injury. Males predominated in the ratio of 5:1. The defect was most often in the 1^st web space and the largest flap was 11×8 cm. In all but one case the donor site was covered by split skin graft, which settled well. 2 patients had superficial flap necrosis needing debridement and skin graft.

Conclusion

Flap based on reverse flow in the posterior interosseous artery is a versatile and reliable source for full thickness cover of complex soft tissue defects in the hand.Key Words: Soft tissue defect of hand, Posterior interosseous artery flap     

Correction of Lower Limb Deformities Using Ilizarov's Technique

Background

India accounts for approximately 10 million orthopaedically handicapped children and adults with limb deformity. Ilizarov ring fixator could treat most of these deformities.

Methods

Twenty cases of deformities of lower limb managed with Ilizarov technique during period between March 2001 and February 2003 were studied.

Results

55% were in the age group of 11-30 years. Out of the 20 cases studied, 6 were congenital talipes equino varus, 8 were fixed flexion deformity of knee, 4 were equines deformity of the ankle and 2 were malunited fracture shaft of tibia.4 patients who had recurrence were operated for fixed flexion deformity of the knee. The main complication encountered was pin tract infection, which was seen in 15(75%) cases. In 16(80%) cases, the results were excellent with no recurrence of deformity and patients were able to walk independently. In 4 (20%) cases, recurrence was mild to moderate (10 to 20) but all of them were able to ambulate idependently and carry out their routine activities.

Conclusion

Ilizarov ring fixator is a superior compared to conventional methods for correction of deformities of lower limb.Key Words: Ilizarov method, Ligamentotaxis, Distraction     

Retrospective Study of Injuries in Military Parachuting

Background

This paper analyses the rate and patterns of parachuting injuries at the Sultans Oman Parachute Unit (SOPRA) in Oman.

Methods

Data on 150 patients referred to Rustaq Regional Referral Hospital was collected and analysed. The injuries were defined as severe (fractures, dislocation, head trauma) or minor (contusion, bruises, sprains).

Result

The rate of severe injuries was 9 % and ankle fractures were the commonest. The minor injury rate was 13.5%. The injury rate increased in relation to age (p < 0.001). The type and possible mechanisms of injury are discussed with the recommendation for reducing the injury rates.

Conclusion

We conclude that our data compares favourably with other studies except for higher incidence of severe injuries.Key Words: Parachute, Paratrooper, Parachuting injuries     

Maxillofacial Injuries in Counter Proxy War Posture of the Armed Forces

Background

Various maxillofacial injuries, sustained in counter insurgency operations in the counter proxy war posture (CPWP) of the Armed Forces in the Kashmir valley are being treated at various maxillofacial surgical centres.

Method

Proper triage, documentation of injuries and mode of injuries along with various clinical, radiological and other investigations were carried out before operating these individuals for primary reconstruction of skeletal tissue and facial soft tissue.

Result

A total of 324 persons with various types of maxillofacial injuries were treated within the period ranging from 01 January 2000 to 30 June 2002 successfully in this centre as a part of the advanced trauma life support (ATLS) system of Combat Medical Support.

Conclusion

Proper primary reconstruction (soft tissue and skeletal tissue) of the facial region goes a long way in reducing subsequent disfigurement and morbidity. Improving the structural design of the combat head gear for safety and comfort will go a long way in preventing majority of maxillofacial injuries or can at least reduce the severity of these injuries.Key Words: Battle accident, Battle casualties, Counter proxy war posture, Maxillofacial injuries     

Terrorism,Trauma and Children

Background

Terrorist attacks, armed conflict and all forms of catastrophe, tax our ability to cope, understand and respond to the situation. Children are more vulnerable.

Material & Method

16 children, victims of a terrorist attack in an army residential camp were managed for their physical injuries and evaluated for psychological trauma.

Results

All patients recovered from physical injuries, except one baby of two months, who died due to severe chest trauma. 5 children presented with Acute Stress Reaction. 3 recovered well and two, showed persistent poor scholastic performance even after one year.

Conclusion

A terrorist attack, not only results in physiscal scars but also causes psychological trauma, which requires emotional support and needs to be followed up on a long term basis.Key Words: Terrorism, Trauma, Children, Gunshot injuries, Acute Stress Reaction     

Biliary complications during a decade of increased cholecystectomy rate

Background

Bile duct injury is a rare complication of cholecystectomy. The aims of this study were to analyse the mechanism and outcome of biliary complications and determine the Northern Ireland incidence of bile duct injury over the last decade.

Methods

Annual numbers of cholecystectomies were obtained from the Northern Ireland Hospital Inpatient System database. Bile duct injury referrals to a hepatobililary unit over an 11-year period from 2000 were reviewed. Mechanism and recognition of injury, referral interval, management and outcome were analysed.

Results

The annual incidence of laparoscopic cholecystectomy in Northern Ireland increased from 0.038% in 1995 to 0.101% in 2009. Thirty-five patients with biliary complications from cholecystectomy were referred from 2000. The incidence of bile duct injury associated with laparoscopic cholecystectomy during this period was 0.2%. Only 26% of injuries were recognised intra-operatively, only 40% were referred immediately and 91% required operative intervention.

Conclusion

The incidence of laparoscopic cholecystectomy has increased in Northern Ireland. The incidence of bile duct injuries over the last 11 years was 0.2%. Recognition and referral were delayed in most cases. The majority of injuries required operative management and long-term follow-up.     

Vaccine adverse event text mining system for extracting features from vaccine safety reports

Objective

To develop and evaluate a text mining system for extracting key clinical features from vaccine adverse event reporting system (VAERS) narratives to aid in the automated review of adverse event reports.

Design

Based upon clinical significance to VAERS reviewing physicians, we defined the primary (diagnosis and cause of death) and secondary features (eg, symptoms) for extraction. We built a novel vaccine adverse event text mining (VaeTM) system based on a semantic text mining strategy. The performance of VaeTM was evaluated using a total of 300 VAERS reports in three sequential evaluations of 100 reports each. Moreover, we evaluated the VaeTM contribution to case classification; an information retrieval-based approach was used for the identification of anaphylaxis cases in a set of reports and was compared with two other methods: a dedicated text classifier and an online tool.

Measurements

The performance metrics of VaeTM were text mining metrics: recall, precision and F-measure. We also conducted a qualitative difference analysis and calculated sensitivity and specificity for classification of anaphylaxis cases based on the above three approaches.

Results

VaeTM performed best in extracting diagnosis, second level diagnosis, drug, vaccine, and lot number features (lenient F-measure in the third evaluation: 0.897, 0.817, 0.858, 0.874, and 0.914, respectively). In terms of case classification, high sensitivity was achieved (83.1%); this was equal and better compared to the text classifier (83.1%) and the online tool (40.7%), respectively.

Conclusion

Our VaeTM implementation of a semantic text mining strategy shows promise in providing accurate and efficient extraction of key features from VAERS narratives.     

Management of Zygomatic Complex Fracture in Armed Forces

Introduction

The Armed Forces personnel are exposed to various kinds of injuries due to the nature of their duties. Increase in motorized population without taking protective measures and rise in violence has contributed towards maxillofacial injuries. The aim of this study was to determine the incidence, aetiology and management of injuries resulting in fracture of the Zygomatic complex in Armed Forces personnel and their families.

Methods

This study was conducted at Command Military Dental Centre (EC). Out of 90 maxillofacial injuries, 40 individuals (44.4%) were treated for Zygomatic complex fractures, majority were in their third decade of life and RTA was the leading cause.

Result

Thirty seven individuals (92.5%) recovered uneventfully, while three (7.5%) patients had post operative complications such as enophthalmos, paraesthesia, diplopia, facial asymmetry, palpability of implants and facial nerve paresis. These complications were subsequently treated successfully.

Conclusion

The midface is composed of fragile bones which get fractured easily. It is imperative to educate people regarding the use of protective headgears/seat belts while travelling in motorized transport.Key Words: Zygomatic complex, Road traffic accident (RTA)     

The Impact of Trans-thoracic Ultrasound on Cardiac Injuries

Objective:

To determine the impact of trans-thoracic ultrasound (TTUS) in patients with chest trauma and potential cardiac injuries and to determine the outcome of patients with cardiac injury detected on TTUS.

Method:

Data were obtained from the Trauma Registry for all patients presenting alive to the University Hospital of the West Indies during the 10-year period commencing January 1, 2001 and who were subjected to a TTUS or emergency thoracotomy for cardiac injuries, or had cardiac injuries at postmortem. In addition to demographics, variables analysed included mechanism and site of injury and outcome.

Results:

Of 405 patients being subjected to a TTUS during the period, 12 (3%) had cardiac injuries. During the same period, 63 patients in the Trauma Registry had proven cardiac injuries. Transthoracic ultrasound was thus conducted on 19% of all patients with cardiac injuries. Three patients had positive TTUS but no cardiac injuries. Of the patients with injuries, the mean age was 30.4 years, 92.1% were male and 65% were as a result of stab wounds, while 22% were as a result of gunshot wounds. The right ventricle was the most common site of injury, accounting for 41% of cases, while the left ventricle, both ventricles and other sites accounted for 27%, 17% and 14%, respectively. Ninety per cent of the group was subjected to emergency thoracotomy; mortality of the entire group was 48%, including one patient who had TTUS.

Conclusions:

This review demonstrates that cardiac injuries remain lethal, diagnosis is largely clinical and TTUS may be over-utilized, having little impact on clinical outcome of patients presenting with this injury.     

Performance factors of mobile rich media job aids for community health workers

Objective

To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented as interactive rich media job aids on small-format mobile platforms.

Design

A crossover study with one intervention (rich media job aids) and one control (traditional job aids), two periods, with 50 community health workers, each subject solving a total 15 standardized cases per period per period (30 cases in total per subject).

Measurements

Error rate per case and task, protocol compliance.

Results

A total of 1394 cases were evaluated. Intervention reduces errors by an average of 33.15% (p=0.001) and increases protocol compliance 30.18% (p<0.001).

Limitations

Medical cases were presented on human patient simulators in a laboratory setting, not on real patients.

Conclusion

These results indicate encouraging prospects for mHealth technologies in general, and the use of rich media clinical guidelines on cell phones in particular, for the improvement of community health worker performance in developing countries.     

The effectiveness of a new generation of computerized drug alerts in reducing the risk of injury from drug side effects: a cluster randomized trial

Context

Computerized drug alerts for psychotropic drugs are expected to reduce fall-related injuries in older adults. However, physicians over-ride most alerts because they believe the benefit of the drugs exceeds the risk.

Objective

To determine whether computerized prescribing decision support with patient-specific risk estimates would increase physician response to psychotropic drug alerts and reduce injury risk in older people.

Design

Cluster randomized controlled trial of 81 family physicians and 5628 of their patients aged 65 and older who were prescribed psychotropic medication.

Intervention

Intervention physicians received information about patient-specific risk of injury computed at the time of each visit using statistical models of non-modifiable risk factors and psychotropic drug doses. Risk thermometers presented changes in absolute and relative risk with each change in drug treatment. Control physicians received commercial drug alerts.

Main outcome measures

Injury risk at the end of follow-up based on psychotropic drug doses and non-modifiable risk factors. Electronic health records and provincial insurance administrative data were used to measure outcomes.

Results

Mean patient age was 75.2 years. Baseline risk of injury was 3.94 per 100 patients per year. Intermediate-acting benzodiazepines (56.2%) were the most common psychotropic drug. Intervention physicians reviewed therapy in 83.3% of visits and modified therapy in 24.6%. The intervention reduced the risk of injury by 1.7 injuries per 1000 patients (95% CI 0.2/1000 to 3.2/1000; p=0.02). The effect of the intervention was greater for patients with higher baseline risks of injury (p<0.03).

Conclusion

Patient-specific risk estimates provide an effective method of reducing the risk of injury for high-risk older people.

Trial registration number

clinicaltrials.gov Identifier: NCT00818285.     

The PSA tracker: A computerised health care system initiative in Northern Ireland

Intoduction

The follow-up of men with prostate cancer forms a large part of many urologists workload. However, a rising PSA usually announces disease progression long before any clinically apparent symptom. Thus, many men can be safely monitored with PSA measurement alone. To facilitate this process, PSA tracking software was introduced to remotely monitor PSA results, minimising the work required for follow-up.

Methods

Stable prostate cancer patients were into the PSA tracker. When each PSA test was performed, the result was reviewed. The program automatically generated patient reminder letters, summary reports for clinic use and all correspondence to patients and primary care physicians.

Results

Since 2006, 65 patients have been entered into the PSA tracker. Median age was 81 (57–94) years. 274 outpatient appointments have been saved, indicating a potential saving of £32,000. More importantly it increased the capacity of the department to assess new patients. For the individual patient, the system has saved them, a median of 3 appointments each.

Conclusion

Remote follow-up of prostate cancer is associated with significant savings for both healthcare organisations and individual patients. This example, further demonstrates the benefits of implanting healthcare software for patients and hospitals.