The epidemiology of trauma during a pandemic.

Worldwide the last four months generated an unprecedented situation within the medical community due to the pandemic, which we had not experienced for a century. The problem is obviously not injury related but all trauma services and trauma surgeons were and are affected by it to some extent. Many of us have seen, previously invisible emerging experts within days of the outbreak from the field of virology, infection control, appropriate use of protective equipment and disaster management. Academic publishing went “viral”, based on PUBMED there were over 9,500 peer-reviewed scientific publications listed during the 5 months ending on 7th May 2020 for the search term “COVID-19”. The intention of this Editorial is to highlight an important academic responsibility of the trauma surgical community during a pandemic.

There is no active practicing clinician available from the last pandemic to lead with their experience and wisdom in our responses and the records regarding the Spanish Flu is very difficult to superimpose over our current situation. There was no comprehensive testing to monitor real-time new infected cases during the early 20th Century and the dynamics of the disease spread is interpreted from estimated figures available in retrospect. At that time there were no comprehensive trauma systems with registry data and specialised trauma care that had just started to be organised in very few centres. Even if there were trauma registry data available, the injury mechanism, population distribution were completely different and impossible to project to 2020. Based on these facts the effects of the pandemic on trauma care and injury epidemiology are completely unknown.

Whilst trauma is not an infectious disease, a pandemic with respiratory illness does have major effect on all key components of trauma care (emergency department, imaging, operating room, intensive care unit etc), where the two conditions are competing for limited resources and without careful planning can mutually compromise each other's optimal care. All expert opinions related to trauma epidemiology during the current pandemic are based on assumptions only. While most assumptions were expecting injury related hospital presentations to decrease, some specific mechanism and aetiologies (domestic violence, self-harm) were expected to increase. Beyond these the risk taking behaviour of the public immediately before lock-down implementation, during the lock-down and during the easing of the restrictions is also only speculative. Anecdotally, these assumption based decisions in some institutions meant they disassembled their trauma services and redeployed staff to other tasks and others maintained or even reinforced their trauma workforce.

Trauma services have highly specialised staff with unique skill set and management principles (activating treatment based on signs rather than on diagnosis), which are very difficult to replicate or replace quickly. The resources for trauma care are equally required in terms of quality for low or high volume situations. The quantity of resources is very important to properly understand and to make sure the management of the respiratory infection pandemic and major trauma care are able to run efficiently side by side rather than compromising each other.

It is essential for us to maintain quality data of the volume and nature of injuries during the different phases of the pandemic and the governmental response to it. Instead of a simple pre and post data it has to be evaluated in comparison to long term trends available from our trauma registries, operating room and intensive care unit databases. The efforts invested to collate and analyse such data is much more valuable for planning and saving lives than generating case reports about every possible injury pattern in a patient with a positive test for novel coronavirus. Trauma services’ work during a pandemic situation follows some important principles but beyond that it is institution specific and a large number of publications related to solutions from every corner of the world is also unlikely to change practice or even be read frequently.

As our preliminary data shows from a Level-1 Trauma Centre, which is a designated hospital for the pandemic related respiratory infections that major trauma does not disappear during pandemic, the frequency of severely injured may be numerically lower than usual but not dissimilar to some of the quieter periods during the last decade (Fig. 1 ). Orthopaedic trauma services usually perform most of the operations on major trauma patients with predominantly blunt mechanism. Fig. 2 shows that the number of orthopaedic trauma operations are seemingly unchanged during pandemic lockdown, which involved the second part of March and the entire April. Local situations can be slightly different and the absolute number of cases does not represent the severity, type of procedures, the resources required and outcomes. These are the details we need to identify for our local trauma networks to facilitate a pandemic response based on quality data when a similar situation occurs again.

Fig. 1

Level-1 Trauma Centre major trauma admissions during Aprils of 2011-2020.

Fig. 2

Number of Level-1 Trauma Centre orthopaedic trauma operations between 13/01/2020 and 28/04/2020.

The struggle and suffering of the community and health services at the hardest hit regions is sad and disturbing enough to experience, we should prevent creating a bigger problem caused by not accounting for injuries. Quality data based extrapolation of acute injury associated workload can help to run trauma services uninterrupted and could prevent evidence free ad hoc decisions about trauma care delivery during a pandemic.