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Trauma Care and Case Fatality during a Period of Frequent, Violent Terror Attacks and Thereafter

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Abstract

Background

From September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized.

Methods

We tracked case fatality rates (CFRs) initially during a period of terror attacks (1999–2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (n = 2,000 patients), and 51 level I U.S. trauma centers (n = 265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010.

Results

Five-year HHSTU CFR (2.62 %) was less than half that in 51 U.S. centers (5.73 %). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISS > 25 accounted for 170 (89 %) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISS < 25. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9 % up to 2010.

Conclusions

Sustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.

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Notes

  1. op cit. See Ref. [4].

  2. op cit. See Ref. [8].

  3. op cit. See Ref. [28].

  4. op cit. See Ref. [21].

References

  1. Johnston WR (2012) Johnston’s archive—terrorism, counterterrorism and unconventional warfare—chronology of terrorist attacks in Israel. 15th Jan 2012. Available at: http://www.johnstonsarchive.net/terrorism/terrisraelsum.html

  2. Statistical Report Summary regarding the Arab-Israeli conflict. Herzliya Interdisciplinary Center. Available at: http://www.ict.org.il

  3. Bogen KT, Jones ED (2006) Risks of mortality and morbidity from worldwide terrorism: 1968–2004. Risk Anal 26(1):45–49

    Article  PubMed  Google Scholar 

  4. Krug EG, Mercy JA, Dahlberg LL, Zwi AB (2002) The world report on violence and health. World Health Organization. Lancet 360:1083–1088

    Article  PubMed  Google Scholar 

  5. Mackenzie EJ, Rivara FP, Gurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO (2006) A national evaluation of the effect of trauma-center care on mortality. N Eng J Med 354(4):366–378

    Article  CAS  Google Scholar 

  6. Nathens A, Shafi S, Xiong W (2008) Ranking of trauma center performance: the bare essentials. J Trauma 65(3):628–635

    Article  PubMed  Google Scholar 

  7. Richter ED (2008) Israeli approvals for medical entry in the shadow of terror attacks at the Erez Crossing. Jerusalem Center for Public Affairs. Oct. 1, 2008. Available at: http://www.jcpa.org/JCPA/Templates/ShowPage.asp?DBID=1&LNGID=1&TMID=111&FID=283&PID=0&IID=2649. Accessed 5 Mar 2012

  8. Almogy G, Luria T, Richter E, Pizov R, Bdolah-Abram T, Mintz Y, Zamir G, Rivkind A (2005) Can external signs of trauma guide management? Lessons learned from suicide bombing attacks in Israel. Arch Surg 140(4):390–393

    Article  PubMed  Google Scholar 

  9. Franklin J, Doelp A (1980) Shock trauma. Fawcett Crest, New York

    Google Scholar 

  10. Krumer R (2006) Director. External Relations Department, Hadassah Medical Center, Jerusalem

  11. Seidman GI (2010) Is a flat-line a good thing? On the privatization of Israel’s healthcare system. Am J Law Med 36(2–3):452–481

    PubMed  Google Scholar 

  12. Health care in the United States. Wikipedia. Available at: http://en.wikipedia.org/wiki/Health_care_in_the_United_States. Accessed 15 Jan 2012

  13. From World Health Organization (May 2009). “World Health Statistics 2009”. http://www.who.int/whosis/whostat/2009/en/index.html. Accessed 2 Aug 2009

  14. Siegel-Izkovich J. Israel near bottom of list in OECD hospital bed rates. The Jerusalem Post. Available at: http://www.jpost.com/Home/Article.aspx?id=166612. Accessed 25 Jan 2010

  15. Health Care Resources: Hospital Beds. From Organisation for Economic Co-operation and Development (OECD) Health Data 2011. OECD STATExtracts. Available at: http://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_REAC. Accessed 5 Mar 2012

  16. A Comparison of National Trauma Data Bank (with Trauma Level I) of the American College of Surgeons Committee on Trauma 1999-2003. Israel National Center for Research on Trauma and Emergency Medicine. Tel-HaShomer-Sheba: Gertner Institute for Epidemiology and Health Policy. March 2005. PowerPoint presentation (Hebrew)

  17. Almogy G, Rivkind AI (2007) Terror in the 21st century: milestones and prospects–part I [review]. Curr Probl Surg 44(8):496–554. See section “Mechanism of Injury.” pp 515–517

  18. Peleg K, Aharonson-Daniel L, Stein M, Michaelson M, Kluger Y, Simon D, Noji EK, Israeli Trauma Group (ITG) (2004) Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel. Ann Surg 239(3):311–318

    Article  PubMed  Google Scholar 

  19. Shafi S, Nathens AB, Parks J, Cryer HM, Fildes JJ, Gentilello LM, Shafi S, Parks J, Nathens AB, Gentilello LM (2008) Trauma quality improvement using risk-adjusted outcomes. J Trauma 64(3):599–604 discussion 604–606

    Article  PubMed  Google Scholar 

  20. Provonost PJ, Angus DC, Dorman T et al (2002) Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 288:2151–2161

    Article  Google Scholar 

  21. Richter ED, Blum R, Rivkind A (2006) Access to emergency care in Palestinian West Bank: interpretation of results is flawed. BMJ 332:1276; Comment on Rytter et al. Effects of armed conflict on access to emergency health care in Palestinian West Bank. BMJ 332(7550):1122–1124

    Google Scholar 

  22. Stein Y (2004) Effect of waiting in the Emergency Department on various parameters of patients and on their medical outcome [MD thesis]. Hebrew University, Jerusalem, Israel

    Google Scholar 

  23. Committee on Trauma, American College of Surgeons (2006) Performance improvement and patient safety. In: American College of Surgeons, eds. Resources for optimal care of the injured patient 2006. Chicago, IL, p 108

  24. Nathens AB, Gurkovich GJ, MacKenzie EJ, Rivara FP (2004) A resource-based assessment of trauma care in the United States. J Trauma 56(1):173–178 discussion 178

    Article  PubMed  Google Scholar 

  25. Demetriades D, Martin M, Salim A, Rhee P, Brown C, Doucet J, Chan L (2006) Relationship between American college of Surgeons Trauma Center designation and mortality in patients with severe trauma (ISS > 15). J Am Coll Surg 202(2):212–215

    Article  PubMed  Google Scholar 

  26. Nathens AB, Maier RV, Jurovich GJ, Monary D, Rivara FP, MacKenzie E (2005) The Delivery of Critical Care Services in US Trauma Centers: is the standard being met? J Trauma Injury Infect Crit Care 60(4):773–784

    Article  Google Scholar 

  27. Committee on Trauma, American College of Surgeons (2006) Descriptions of trauma center levels and their roles in a trauma system. In: American College of Surgeons (eds) Resources for Optimal Care of the Injured Patient 2006. Chicago, IL, pp 17–20

  28. Broha K, Joseph T (2007) Email: Nov 24 2007. trauma-list-request@trauma.org discussing “Trauma: Who Cares?” by the National Confidential Enquiry into Patient Outcome and Death

  29. Rytter MJ, Kjaeldgaard AL, Brønnum-Hansen H et al (2006) Effects of armed conflict on access to emergency health care in Palestinian West Bank: systematic collection of data in emergency departments. BMJ 332(7550):1122–1124

    Article  PubMed  Google Scholar 

  30. Champion HR, Mabee MS, Meredith JW (2006) The state of US trauma systems: public perceptions versus reality–implications for US response to terrorism and mass casualty events. J Am Coll Surg 203(6):951–961

    Article  PubMed  Google Scholar 

  31. Soffer D, Zmora O, Klausner JB, Szold O, Givon A, Halpern P, Schulman CI, Peleg K (2006) Alcohol use among trauma victims admitted to a level I trauma center in Israel. Isr Med Assoc J 8(2):98–102

    PubMed  Google Scholar 

  32. Degenhardt L, Chiu WT, Sampson N et al (2008) Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med 5(7):e141

    Article  PubMed  Google Scholar 

  33. Richter ED, Friedman LS, Berman T, Rivkind A (2005) Death and injury from motor vehicle crashes: a tale of two countries. Am J Prev Med 29(5):440–449

    Article  PubMed  Google Scholar 

  34. Spira RM, Reissman P, Goldberg S, Hersch M, Einav S (2006) Evacuation of trauma patients solely to level I centers: is the question patient or trauma center survival? Debate IMAJ 8:113–131

    Google Scholar 

  35. Sosna J, Sella T, Shaham D, Shapira SC, Rivkind A, Bloom AI, Libson E (2005) Facing the new threats of terrorism: radiologists’ perspectives based on experience in Israel. Radiology 237(1):28–36

    Article  PubMed  Google Scholar 

  36. Bala M, Rivkind AI, Zamir G, Hadar T, Gertsenshtein I, Mintz Y, Pikarsky AJ, Amar D, Shussman N, Abu Gazala M, Almogy G (2008) Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury. Ann Surg 248(2):303–309

    Article  PubMed  Google Scholar 

  37. Kmietowicz Z (2007) Hospitals without appropriate expertise should not offer trauma care. BMJ 335(7629):1067

    Article  PubMed  Google Scholar 

  38. Nathens AB, Rivara FP, MacKenzie EJ, Maier RV, Wang J, Egleson B, Sharfstein DO, Jurkovich GJ (2006) The impact of an intensivist-model ICU on trauma-related mortality. Ann Surg 244(4):545–554

    PubMed  Google Scholar 

  39. Melanie Neal, Manager, NTDB, ACS, Chicago. February 23, 2007. Email: MNeal@facs.org

  40. Sandra Goble, Statistician. NTDB American College of Surgeons. May 1, 2007

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Acknowledgments

All authors disclose no potential conflicts of interest, including specific financial interests and relationships and affiliations (other than those affiliations listed in the title page of the manuscript) relevant to the subject of their manuscript. The principal investigator had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. We thank Dr Lee Friedman of the University of Illinois for consultation on data analysis, Sandra Goble and Melanie Neal of the American College of Surgeons for helpful clarifications on the workings of its National Trauma Data Base, and Kobi Peleg of the Center for Research on Trauma and Emergency Medicine, Gertner Institute for Epidemiology and Health Policy, Tel-HaShomer Hospital, for his contribution.

Author information

Authors and Affiliations

  1. Department of General Surgery and Shock Trauma Unit, Hebrew University Hadassah Medical Center (Ein Kerem), P.O.B. 12000, 91120, Jerusalem, Israel

    Avraham I. Rivkind & Shula Coleman

  2. Behavioral Health Service, HHC-JMC Hospital, New York, NY, USA

    Rony Blum

  3. Trauma Registry, Hebrew University Hadassah Medical Center (Ein Kerem), Jerusalem, Israel

    Irena Gershenstein

  4. Unit of Occupational and Environmental Medicine, Faculty of Medicine, Hebrew University Hadassah Medical Center (Ein Kerem), Jerusalem, Israel

    Yael Stein

  5. Center for Innovative Surgery, Department of General Surgery and Shock Trauma Unit, Hebrew University Hadassah Medical Center (Ein Kerem), Jerusalem, Israel

    Yoav Mintz

  6. Laboratory for Surgical Research, Department of General Surgery and Shock Trauma Unit, Hebrew University Hadassah Medical Center (Ein Kerem), Jerusalem, Israel

    Gideon Zamir

  7. Center for Injury Prevention, School of Public Health and Community Medicine, Hebrew University Hadassah Medical Center (Ein Kerem), Jerusalem, Israel

    Elihu D. Richter

Authors
  1. Avraham I. Rivkind
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  2. Rony Blum
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  4. Yael Stein
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  5. Shula Coleman
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  6. Yoav Mintz
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  7. Gideon Zamir
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  8. Elihu D. Richter
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Corresponding author

Correspondence to Avraham I. Rivkind.

Appendix

Appendix

See Table 4.

Table 4 Time trends in CFRs for all patients and for patients with ISS > 16—HHSTU and 51 U.S. level I trauma centers (1999–2003)
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Rivkind, A.I., Blum, R., Gershenstein, I. et al. Trauma Care and Case Fatality during a Period of Frequent, Violent Terror Attacks and Thereafter. World J Surg 36, 2108–2118 (2012). https://doi.org/10.1007/s00268-012-1637-6

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