Background The Army Medical Department (AMEDD) Military-Civilian Trauma Team Training (AMCT3) Program was developed to enhance the trauma competency and capability of the medical force by embedding providers at busy civilian trauma centers. Few reports have been published on the outcomes of this program since its implementation.Methods The medical and billing records for the two AMCT3 embedded trauma surgeons at the single medical center were retrospectively reviewed for care provided during August 2021 through July 2022. Abstracted data included tasks met under the Army’s Individual Critical Task List (ICTL) for general surgeons. The Knowledge, Skills, and Abilities (KSA) score was estimated based on previously reported point values for procedures. To assess for successful integration of the embedded surgeons, data were also abstracted for two newly hired civilian trauma surgeons.Results The annual clinical activity for the first AMCT3 surgeon included 444 trauma evaluations and 185 operative cases. The operative cases included 80 laparotomies, 15 thoracotomies, and 15 vascular exposures. The operative volume resulted in a KSA score of 21 998 points. The annual clinical activity for the second AMCT3 surgeon included 424 trauma evaluations and 194 operative cases. The operative cases included 92 laparotomies, 8 thoracotomies, and 25 vascular exposures. The operative volume resulted in a KSA score of 22 799 points. The first civilian surgeon’s annual clinical activity included 453 trauma evaluations and 151 operative cases, resulting in a KSA score of 16 738 points. The second civilian surgeon’s annual clinical activity included 206 trauma evaluations and 96 operative cases, resulting in a KSA score of 11 156 points.Conclusion The AMCT3 partnership at this single center greatly exceeds the minimum deployment readiness metrics established in the ICTLs and KSAs for deploying general surgeons. The AMEDD experience provided a deployment-relevant case mix with an emphasis on complex vascular injury repairs.

Objective: The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program. Summary Background Data: Traumatic injury is a leading cause of death and disability in the US. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city leading to a fallacy of distributive justice. Methods: A descriptive analysis of community partners, trauma program leadership, trauma surgeons and the violence intervention program director was performed. Results: The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes (P<0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018 developing both community-based and medical legal partnerships. Conclusions: The persistent efforts of the community and key stakeholders led to a system change improving trauma care for the South Side of Chicago.

OBJECTIVE:The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program.BACKGROUND:Traumatic injury is a leading cause of death and disability in the United States. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city, leading to a fallacy of distributive justice.METHODS:A descriptive analysis of community partners, trauma program leadership, trauma surgeons, and the violence intervention program director was performed.RESULTS:The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country, with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes ( P <0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018, developing both community-based and medical-legal partnerships.CONCLUSIONS:The persistent efforts of the community and key stakeholders led to a system change that improved trauma care for the South Side of Chicago.

OBJECTIVE:The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND:While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS:We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS:Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS:Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

INTRODUCTION AND DEFINITIONS:Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.PRE-HOSPITAL CARE:There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.ACUTE TREATMENT:Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.DEFINITIVE CARE:The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.RESOURCES AND ETHICS:There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Introduction: Self-inflicted injuries are the second leading cause of pediatric (10-18 y old) mortality. Self-inflicted firearm trauma (SIFT) was responsible for up to half of these deaths in certain age groups. We hypothesized that SIFT prevalence has increased and is associ-ated with specific demographics, injury patterns, and outcomes. Materials and methods: Data were abstracted from the 2007-2018 American College of Sur-geons (ACS) Trauma Quality Programs Participant Use Files (TQP-PUF). Pediatric (1-17 yold) victims of firearm violence were eligible. Age, race, gender, anatomic region, and intent were abstracted. Variables were analyzed using chi-squared tests, t-tests, and single-variate linear regression models. Temporal trends were analyzed using ANCOVA tests. Multivariate logistic regressions were conducted to identify factors influencing mortality. Significance was P < 0.05.Results: There were 41,239 pediatric firearm trauma patients (SIFT: 5.5% [n = 2272]). SIFT incidence increased over the 12-y period (2007 (n = 67) versus 2018 (n = 232), P < 0.05). SIFT was significantly associated with Caucasian race, 67% (n =1537), teenagers, 90% (n = 2056), male gender, 87% (n = 1978), and a higher median injury severity score (ISS) than other intents of injury (SIFT: 20.0 (IQR: 9.0, 25.0) versus other: 9.0 (IQR: 1.0-13.0), P < 0.001). The SIFT mortality rate was 44% (n = 1005). On multivariate regression head gunshot wounds (OR: 21.1, 95% C.I.: 9.9-45.2, P = 0.001), and ISS (OR:1.1, 95% C.I.: 1.1-1.1, P = 0.001) were significantly associated with mortality. Compared to other intents, SIFT mortality rates increased at a higher annual rate (P < 0.001).Conclusions: Comprehensive local and federal policy changes to reduce firearms access and increase pediatric mental health support may mitigate these injuries.(c) 2022 Elsevier Inc. All rights reserved.

BACKGROUND: Shock index, pediatric age adjusted (SIPA), has been widely applied in pediatric trauma but has limited precision because of the reference ranges used in its derivation. We hypothesized that a pediatric shock index (PSI) equation based on age-based vital signs would outperform SIPA. METHODS: A retrospective cohort of trauma patients aged 1 to 18 years from Trauma Quality Programs - Participant Use File 2010 to 2018 was performed. A random 70% training subset was used to derive Youden index-optimizing shock index (SI) cutoffs by age for blood transfusion within 4 hours. We used linear regression to derive equations representing the PSI cutoff for children 12 years or younger and 13 years or older. For children 13 years or older, the well-established SI of 0.9 remained optimal, consistent with SIPA and other indices. For children 12 years or younger in the 30% validation subset, we compared our age-based PSI to SIPA as predictors of early transfusion, mortality, pediatric intensive care unit admission, and injury severity score of >= 25. For bedside use, a simplified "rapid" pediatric shock index (rPSI) equation was also derived and compared with SIPA. RESULTS: A total of 439,699 patients aged 1 to 12 years met the inclusion criteria with 2,718 (1.3% of those with available outcome data) requiring transfusion within 4 hours of presentation. In the validation set, positive predictive values for early transfusion were higher for PSI (8.3%; 95% confidence interval [CI], 7.5-9.1%) and rPSI (6.3%; 95% CI, 5.7-6.9%) than SIPA (4.3%; 95% CI, 3.9-4.7%). For early transfusion, negative predictive values for both PSI (99.3%; 95% CI, 99.2-99.3%) and rPSI (99.3%; 95% CI, 99.2-99.4%) were similar to SIPA (99.4%; 95% CI, 99.3-99.4%). CONCLUSION: We derived the PSI and rPSI for use in pediatric trauma using empiric, age-based SI cutoffs. The PSI and rPSI achieved higher positive predictive values and similar negative predictive values to SIPA in predicting the need for early blood transfusion and mortality. Copyright (C) 2022 Wolters Kluwer Health, Inc. All rights reserved. LEVEL OF EVIDENCE: Prognostic/Epidemiological; level III.

Objective: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. Background: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. Methods: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. Results: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. Conclusions: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

BACKGROUND Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality. METHODS Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system’s mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant ( p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems. RESULTS There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients ( p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT’s cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT ( p < 0.001). CONCLUSION Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages. LEVEL OF EVIDENCE Clinical outcomes, Level IV.

Military and civilian trauma is often associated with vascular injuries from both penetrating and blunt mechanisms. Mechanical stabilization of an injured extremity and early revascularization has resulted in better patient outcomes and improved limb-salvage rates. Temporary vascular shunts (TVS) are now utilized as “damage control” bridges between ischemia time and definitive vascular repair. Due to minimal resources in far-forward military settings, and the potential for delayed evacuations to higher echelons of military care, TVS are frequently deployed in an attempt at limb salvage for the warfighter. TVS are less utilized in civilian trauma. The intent of this review is to ascertain if TVS shunts are effective extremity damage control adjuncts for limb preservation, and do TVS decrease primary and secondary amputation rates for trauma patients sustaining vascular injuries in military and civilian settings.

In general, we agree with the Comment by William Sargent and colleagues, calling for development of paediatric-specific injury severity scoring systems. 1 Sargent W Wild H Mayhew E Wren SM Counting the costs of trauma: the need for a new paediatric injury severity score. Lancet Child Adolesc Health. 2021; 5: 391-392 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Few injury scoring systems account for differences between paediatric and adult patients with trauma. However, one critical point the authors omitted is that the age of a paediatric patient with trauma is a key factor in not only the patterns of injury seen, but more importantly, how they physiologically compensate for that injury. Therefore, future paediatric-specific injury scoring systems must incorporate the child's age to accurately estimate injury severity.

Lang, Patrick MD, PhD; Keskey, Robert MD; Hagen, Edward MD; Millis, J. Michael MD; Prakash, Priya MD; Wilson, Kenneth MD; Zakrison, Tanya MD; Leef, Jeffrey MD; Ahmed, Osman MD Author Information

Keskey, Robert MD; Lynn Allen, Debra MSN; Turney Cone, Jennifer MD, MHS; Lam, Adam MD; Biermann, Henry BS; Wilson, Kenneth MD, FACS; Olweston Rogers, Selwyn MD, MPH, FACS; Hampton, David A. MD, MEng Author Information

BACKGROUND The United States has the highest per-capita incarceration rate and the largest prison population in the world. More than two thirds of recently incarcerated individuals will be arrested again within 3 years of release and may commit crimes as serious as homicide soon after discharge. The pattern of homicidal violence currently remains unknown for recently incarcerated homicide suspects (RIHS) and their victims. METHODS A retrospective analysis of the 36 states included in the 2003 to 2017 National Violent Death Reporting System was performed with a focus on RIHS and their victims. Pearson chi(2) and Wilcoxon rank sum tests were used for comparison. RESULTS There were 249 RIHS in the database of the 14,561 homicides where suspect recent incarceration status was documented. Compared with not-recently incarcerated suspects, RIHS were more likely to be White (41% vs. 29%, p < 0.001) and male (97% vs. 91%, p < 0.001). Recently incarcerated homicide suspects more often had a known relationship with the victim (75% vs. 51%, p < 0.001), and these homicides more often occurred in the victim's own home (43% vs. 34%, p = 0.006). Intimate partner violence was a factor in 31% of the RIHS cases (vs. 17%, p < 0.001). The homicide weapon was most likely to be a firearm (57.8%, p < 0.001). Only 6.4% of homicides were due to mental health illness. Gang violence, while more common in the RIHS group, was still only a precipitating factor in 12.0% of the homicides (vs. 7.4%, p = 0.006). CONCLUSION Recently incarcerated homicide suspects are more likely to kill a known person in their own home with a firearm, and these homicides are frequently categorized as intimate partner homicides. Gang violence and mental health are not frequent precipitating factors in these deaths. Additional future interventions are urgently needed to eliminate these preventable deaths by alerting previous or current intimate partners of those being discharged from the prison system.

Gun violence is an epidemic that affects hundreds of thousands of Americans each year. Despite gun violence being disproportionately more lethal than other leading causes of trauma, there is a dearth of research being carried out on its root causes and prevention strategies. For the past 20 years, lobbying and politics have interfered with the forward progress of gun violence research. Physicians have a history of producing actionable public-health change and have an ethical obligation to fight for the research that will benefit their patients.