Urban dystopia
One of the frequent topics of discussion in the coffee rooms of my busy district general hospital (which serves almost a million people on the outskirts of London) has been the relative lack of ruptured AAAs coming through the ED over the past year or two. Given that on a typical day of emergency operating I can find myself doing 4 or 5 laparotomies for a number of weird and wonderful pathologies, the absence of ruptured AAAs seems something of an anomaly. The commonly held theory in our unit is that COVID took the lives of most of the folks likely to have been brewing these vascular emergencies. The co-morbidities that led the to development of their aneurysms will have also made them most susceptible to the ravages of COVID. There can be little doubt that the global pandemic has had a significant and enduring impact on the demographics and outcomes of emergency admissions across all specialties, not least in trauma.
With lockdowns in place, road-traffic collisions decreased as expected, with one LA trauma centre reporting a 43% reduction in the automobile versus pedestrian admissions, a near 40% reduction in motorcycle injuries and a 28% decrease in bicycle accidents. Similar reports emerged from places such as New Zealand, Italy and Canada suggesting fewer sports-related and traffic-related traumas in the weeks following lockdowns compared to similar time periods prior to lockdowns. A study from the heavily-hit Lombardia region of Italy showed a significant increase in elderly falls as the trauma demographics shifted. There was a seven-fold increase in ‘intentional falls’ i.e. suicides and significant increase in deliberate self-harm as the compound psychological traumas of close bereavement, social isolation and economic hardship tipped at-risk people over the edge. These findings are mirrored elsewhere, with the aforementioned LA group reporting a 40% increase in suicides.
Unsurprising, outcomes in COVID-positive trauma patients differed significantly. Some groups reported higher mortalities in surgical patients infected with COVID, a pattern noted across all specialties and in both elective and emergency surgery. Kaufmann et al in Pennsylvania showed a threefold adjusted increase in mortality in COVID -positive patients, with the over-65s and least severely injured being most at risk.
From Lombardia to California to Texas, widespread reconfiguration of regional trauma systems was required to maintain service capacity. In some cases such as Lombardia this involved greater system exclusivity with trauma services and staff consolidated at fewer dedicated high-level trauma centres, thus increasing the proportion of trauma patients they saw despite an overall reduction in absolute numbers. In some ways a contrasting situation unfolded in New York City where lower-level trauma centres were unable to transfer patients to Level 1 centres because of the knock-on effects of ICU beds saturated with COVID patients. In London the triage tool was streamlined to ensure more patients could be safely admitted to their nearest ED rather than clogging up the Major Trauma Centres. Universally, elective lists were cancelled, operating rooms were converted to critical care units and new standard operating procedures introduced for high-risk procedures such as intubation.
In contrast to the reduction in blunt RTC-related trauma, an increase in penetrating trauma and interpersonal violence was noted in a number of urban centres across the country. In Philadelphia, Quasim et reported an increase in penetrating trauma from a baseline of 29% to 35% following lockdown, despite an overall 20% reduction in trauma admission numbers. Several factors may explain this pattern. The inability for the poorest in society to work from home combined with the psychological stress of the pandemic may have contributed. Other possibilities include the increase in unstructured time, increased gun sales, and higher rates of redundancy and unemployment. Put simply, highly populated poor neighbourhoods which were most susceptible to the worst impacts of COVID saw a similar increase in violence owing to shared risk factors.
For future pandemics urban trauma centres should perhaps prepare for a significant increase in violence and penetrating trauma, which kind of fits neatly in with what you’d imagine a dystopian apocalyptic cityscape to look like in any disaster movie you care to name. Whilst we as health professionals may not be able to directly tackle the socioeconomic issues behind the phenomenon, we can anticipate and mitigate its impact.
Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.
