Mer än hälften av världens befolkning saknar tillgång till säker och ekonomiskt överkomlig kirurgi.

Nästan tre fjärdedelar av all kirurgi utförs i den rika tredjedelen av världen.

En tredjedel av den globala sjukdomsbördan kan behandlas kirurgiskt.

Brister i organisation, utbildning och finansiering är några av anledningarna till den begränsade tillgången till kirurgi i världen.

För att öka tillgången till kirurgi krävs långsiktiga nationella planer, internationella samarbeten samt ledarskap som prioriterar att skapa kompletta och fungerande sjukvårdssystem.

More than 5 billion humans cannot access essential surgery if needed. Surgery was for a long time not a part of the global health agenda, generally considered a luxury. However, the realization that a large proportion of the global burden of disease can be reduced by surgery has gained momentum. The publication of the Lancet Commission on Global Surgery and the Disease Control Priorities volume on surgery, along with the WHO resolution on access to essential and emergency surgical care, has been pivotal in this paradigm shift.

Access to surgery is in many settings hampered by a mix of lack of leadership, skilled workforce, equipment, and financial risk protection for patients, to name a few. Importantly, the provision of surgery requires comprehensive health systems which, once established, allow for numerous other health interventions. This cannot be achieved without partnerships, responsible leadership and good governance that prioritizes health care in general and surgery in particular.

Background

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

Methods

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society’s website, and shared on the society’s Twitter profile.

Results

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

Discussion

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Background: In armed conflicts, infected wounds constitute a large portion of the surgical workload. Treatment consists of debridements, change of dressings, and antibiotics. Many surgeons advocate for the use of honey as an adjunct with the rationale that honey has bactericidal and hyperosmotic properties. However, according to a Cochrane review from 2015 there is insufficient data to draw any conclusions regarding the efficacy of honey in treatment of wounds. We, therefore, decided to evaluate if honey is non-inferior to gentamicin in the treatment of infected wounds in a highly translatable porcine wound model. Material and methods: 50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topically applied Manuka honey or intramuscular gentamicin for eight days. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological, immunohistochemical assays, and inflammatory response. Results: Topically applied Manuka honey did not reduce bacterial count or wound area for the duration of treatment. Intramuscular gentamicin initially reduced bacterial count (geometric mean 5.59*,0.37 - 4.27 *,0.80 log10 (GSD) CFU/g), but this was not sustained for the duration of the treatment. However, wound area was significantly reduced with intramuscular gentamicin at the end of treatment (mean 112.8 +/- 30.0-67.7 +/- 13.2 (SD) mm(2)). ANOVA-analysis demonstrated no variation in bacterial count for the two treatments but significant variation in wound area (p = 0.0001). The inflammatory response was more persistent in the pig with wounds treated with topically applied Manuka honey than in the pig treated with intramuscular gentamicin. Conclusion: At the end of treatment S. aureus count was the same with topically applied Manuka honey and intramuscular gentamicin. The wound area was unchanged with topically applied Manuka honey and decreased with intramuscular gentamicin. Topically applied Manuka honey could consequently be non inferior to intramuscular gentamicin in reducing S. aureus colonization on the wounds surface, but not in reducing wound size. The use of Manuka honey dressings to prevent further progression of a wound infection may therefore be of value in armed conflicts, where definite care is not immediately available.

Background

Humanitarian healthcare workers are indispensable for treating weapon-wounded patients in armed conflict, and the international humanitarian community should ensure adequate preparedness for this task. This study aims to assess deployed humanitarian healthcare workers’ self-perceived preparedness, training requirements and mental support needs.

Methods

Medical professionals deployed with the International Committee of the Red Cross (ICRC) between October 2018 and June 2020 were invited to participate in this longitudinal questionnaire. Two separate questionnaires were conducted pre- and post-deployment to assess respondents’ self-perceived preparedness, preparation efforts, deployment experiences and deployment influence on personal and professional development.

Results

Response rates for the pre- and post-deployment questionnaires were 52.5% (114/217) and 26.7% (58/217), respectively. Eighty-five respondents (85/114; 74.6%) reported feeling sufficiently prepared to treat adult trauma patients, reflected by predeployment ratings of 3 or higher on a scale from 1 (low) to 5 (high). Significantly lower ratings were found among nurses compared to physicians. Work experience in a high-volume trauma centre before deployment was associated with a greater feeling of preparedness (mean rank 46.98 vs. 36.89; p = 0.045). Topics most frequently requested to be included in future training were neurosurgery, maxillofacial surgery, reconstructive surgery, ultrasound, tropical diseases, triage, burns and newborn noncommunicable disease management. Moreover, 51.7% (30/58) of the respondents regarded the availability of a mental health professional during deployment as helpful to deal with stress.

Conclusion

Overall, deployed ICRC medical personnel felt sufficiently prepared for their missions, although nurses reported lower preparedness levels than physicians. Recommendations were made concerning topics to be covered in future training and additional preparation strategies to gain relevant clinical experience. Future preparatory efforts should focus on all medical professions, and their training needs should be continuously monitored to ensure the alignment of preparation strategies with preparation needs.

Background 

In armed conflicts, civilian health care struggles to cope. Understanding the relationship between demographics, injury mechanism, and injury patterns to predict what surgical resources are needed is therefore vital. In the 1990s the International Committee of the Red Cross (ICRC) implemented the Red Cross Wound Score (RCWS) for the assessment of penetrating injuries. It is unknown to what extent RCWS can be used to predict surgical resource consumption and in-hospital mortality. A substantial portion of surgical resources in conflicts are used in the treatment of infected wounds, which entails antibiotics, debridements, and change of dressings. Many health care providers advocate for the use of honey as an adjunct due to its bactericidal and hyperosmotic properties. However, the scientific evidence to support this notion is insufficient. If efficacy for honey could be demonstrated, the need for repeated debridements and antibiotics could potentially be reduced, subsequently allowing for more efficient use of surgical resources.  

Objectives 

To increase knowledge regarding the relationship between demographics, injury mechanism, injury patterns, treatment received (Paper I), treatment trends (Paper II), and surgical resources consumption (Paper III). To identify predictive methods (Paper III) and practices (Paper IV) that can improve how surgical resources are used in resource-constrained conflict settings.  

Materials and Methods 

In Papers I – III routine clinical data from patients treated at three ICRC hospitals were used. The patients had weapon-related injuries from either the conflict around the Afghanistan – Pakistan border or the conflict in the Kivu region in the Democratic Republic of the Congo (DRC). In Paper I, the relationships between gender, injury mechanism, injury patterns, and treatment received were examined with univariate statistics. In Paper II, differences in treatment practices between 1992 – 1995 and 2009 – 2012 for extremity injuries were analysed with univariate statistics and logistic regression to adjust for differences in injury mechanism and severity. In Paper III, univariate statistics, logistic regression, receiver operating characteristics curves, and goodness of fit were used to determine the predictive ability of RCWS and commonly used trauma scores for surgical resource consumption. In Paper IV, 50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topical honey or intramuscular gentamicin to determine if topical honey is non-inferior to systemic gentamicin treatment. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological and immunohistochemical assays, as well as assessment of inflammatory response.  

Main findings 

In both conflicts, most of the patients were males in their mid-twenties with injuries to the extremities. Injuries from indiscriminate weapons (such as bombs, missiles, and explosives) were more predominant in the Afghanistan – Pakistan border conflict, and gunshot injuries were more frequent in the Kivu conflict. Soft tissue procedures were the most common type of surgery. Less than 20% of the patients were subjected to major surgery, and in-hospital mortality was under 5% (Papers I – III). Females were more frequently injured by indiscriminate weapons, had more severely affected vital parameters, received more blood transfusions, and were subjected to more extensive surgery than the males (Paper I). During the last decades, the risk for amputation remained unchanged, while the use of external fixation and split skin grafts decreased (Paper II). RCWS predicted high surgical resource consumption better than and in-hospital mortality at least equal to commonly used trauma scores (Paper III). Wound size was unchanged with topical honey and decreased with intramuscular gentamicin. However, there was no difference in bacterial count between honey and gentamicin at the end of treatment (Paper IV). 

Conclusions 

Females were more frequently injured by indiscriminate weapons, had more severe injuries, and had greater surgical treatment needs than the males (Paper I). Even though injuries to the extremities remain common in armed conflicts, the use of limb-preserving treatment techniques seems to have decreased during the last decades (Paper II). RCWS demonstrated a better predictive ability for surgical resource consumption compared to commonly used trauma scores (Paper III). Topical honey may be non-inferior to gentamicin in reducing S. aureus colonization on the wound’s surface, but not in reducing wound size (Paper IV).  

Väpnade konflikter leder till kollaps av existerande hälso-och sjukvårdssystem, vilket snabbt begränsar eller omöjliggör kirurgisk vård för patienter med potentiellt livshotande skador. Dessutom är skador i väpnade konflikter ofta mer komplexa och resurskrävande än skador som förekommer i fredstid. För vårdgivare behövs därför kunskap om vad som påverkar det kirurgiska resursbehovet i konflikter, men även metoder för att kunna följa och förutsäga det samma. Internationella Rödakorskommittén (ICRC) har sedan 1990-talet använt ett system för sårklassificering (RCWS) för att hjälpa kirurger att bedöma och prioritera penetrerande sårskador. Det är okänt i vilken utsträckning RCWS eller andra klassificeringssystem som används i civil traumasjukvård kan användas för att förutsäga kirurgiskt resursbehov och dödlighet i resursknappa konfliktmiljöer.

En betydande del av kirurgiska resurser i konflikter används för behandling av infekterade sår. Många vårdgivare förespråkar användande av honung som del i denna behandling. Detta på grund av honungs bakteriedödande och uttorkande egenskaper. Det saknas dock vetenskapligt stöd för denna uppfattning. Om honung kan påvisas vara effektivt som behandling för infekterade sår skulle behovet av antibiotika och upprepade kirurgiska behandlingar kunna minskas. Detta skulle möjliggöra mer effektivt användande av kirurgiska resurser.

Denna avhandling syftar till att öka kunskapen kring hur kirurgiska resurser används i resursknappa konfliktmiljöer. Detta med målsättningen att identifiera metoder för att förutsäga och mäta det kirurgiska resursbehovet och göra användandet av det samma mera effektivt.

I tre av de studier som ingår i avhandlingen har rutinmässigt insamlade journaluppgifter från patienter som behandlats vid tre ICRC sjukhus använts. Patienterna hade vapen-orsakade skador från konflikten vid gränsen mellan Afghanistan och Pakistan eller konflikten i Kivu-regionen i Demokratiska republiken Kongo (DRC). I den första studien undersöktes förhållandet mellan kön, skademekanism, uppkomna skador och erhållen kirurgisk behandling för patienter som behandlats vid ICRC sjukhuset i Peshawar, Pakistan. I den andra studien undersöktes hur behandlingen av vapen-orsakade extremitetsskador skilde sig mellan perioderna 1992 – 1995 och 2009 – 2012 vid ICRC sjukhus i Quetta och Peshawar, Pakistan. I den tredje studien prövades hur väl RCWS samt poängssystem som används i civil traumasjukvård kunde förutsäga det kirurgiska behandlingsbehovet hos patienter vid ICRC sjukhus i Peshawar, Pakistan, och Goma, DRC. I den sista studien jämfördes honung och antibiotika som behandling av infekterade sår i en försöksdjursmodell. De båda behandlingarna utvärderades och jämfördes genom bakterieodlingar, mätningar av såryta, histologiska och immunhistokemiska analyser samt inflammatoriskt svar.

På de studerade ICRC sjukhusen var de flesta patienterna män i tjugoårsåldern med skador på armar eller ben. Skador från urskillningslösa vapen, som granater, missiler och bomber, var mer frekvent förekommande i gränskonflikten mellan Afghanistan och Pakistan, medan skottskador var vanligare i Kivu-konflikten. Behandling av mjukdelsskador var den vanligaste typen av kirurgi. Mindre än 20% av patienterna genomgick större operationer och dödligheten under sjukhusvistelsen var mindre än 5%. Kvinnor skadades i större omfattning av urskillningslösa vapen, hade allvarligare skador, fick oftare blodtransfusioner och behandlades med mera omfattande kirurgi än männen. Trots att skador på armar och ben är vanligt förekommande i väpnande konflikter så hade användandet av frakturstabiliserande åtgärder och hudtransplantationer minskat under de senaste årtiondena, medan risken för amputation var oförändrad.

RCWS var bättre på att förutsäga kirurgisk resursförbrukning än de poängsystem som används i civil traumasjukvård. Slutligen visade den sista studien i avhandlingen att varken honung eller antibiotika minskar antalet bakterier i sår efter avslutad behandling. Däremot minskade sårens storlek med antibiotika, men var oförändrade med honung. Möjligen skulle därför honung kunna vara effektivt för att förhindra bakterieväxt på sårytan. Det finns därför anledning att undersöka om honung kan vara ett värdefullt tillägg till antibiotika och kirurgisk behandling. Detta skulle kunna förbättra användandet av de begränsade kirurgiska resurser som finns tillgängliga i väpnade konflikter.

Introduction

Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them.

Material and methods

A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference

Results

An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects.

Conclusion

Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.

Background

Recent trauma guidelines recommend non-operative management for grade III splenic injury without contrast extravasation on computed tomography. Nevertheless, such recommendations rely on low-quality evidence, and practice variation characterizes clinical management for this type of injury. We aimed to identify the role of eleven selected clinical factors influencing the management of grade III splenic injury without contrast extravasation by expert consensus and a modified Delphi approach.

Methods

A questionnaire was developed with the endorsement of the World Society of Emergency Surgery (WSES). This was delivered and answered live by acute care surgeons attending the 6th WSES congress in Nijmegen in 2019. A dedicated mobile phone application was utilized to collect the answers. All answers were evaluated for areas of discrepancy with an 80% threshold for consensus between respondents.

Results

Three factors generated discrepancy in opinion for managing this pattern of injury: the patients’ injury severity, the presence of a bleeding diathesis, and an associated intra-abdominal injury. Agreement was obtained for the other eight factors.

Conclusion

Researchers should focus their efforts on the identified area of discrepancy. Clinicians should use additional care in the presence of the three factors for which discordant opinions were found.

Background: Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones.

Methods: Characteristics of children (age < 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years).

Results: Of the patients listed in the database, 15% (5843/38,088) were aged < 15 years. The median age was 10 years (IQR 6-12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1-3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates.

Conclusions: Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts.

Background Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel. Methods All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment. Results The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p amp;lt; 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150). Conclusion ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.

Objective Induced abortion is more frequent in Sweden than in many other Western countries. We wanted to investigate attitudes and knowledge about induced abortion among politicians responsible for healthcare in three Swedish counties. Method A study-specific questionnaire was sent to all 375 elected politicians in three counties; 192 (51%) responded. Results The politicians stated that they were knowledgeable about the Swedish abortion law. More than half did not consider themselves, in their capacity as politicians, sufficiently informed about abortion-related matters. Most politicians (72%) considered induced abortion to be primarily a womens rights issue rather than an ethical one, and 54% considered 12 weeks gestational age an adequate upper limit for induced abortion. Only about a third of the respondents were correctly informed about the number of induced abortions annually carried out in Sweden. Conclusion Information and knowledge on induced abortion among Swedish county politicians seem not to be optimal. Changes aimed at reducing the current high abortion rates will probably not be easy to achieve as politicians seem to be reluctant to commit themselves on ethical issues and consider induced abortion mainly a womens rights issue.