Patterns of Traumatic Injury Volume during First Year of COVID-19 Pandemic

Prelockdown

During the early months of 2020, prior to enforcement of social distancing mandates in the state of Louisiana on 18th March 2020, the number of weekly trauma patients was not significantly different compared to previous years. Likewise, there was no difference between the number of GSW during these months compared to the same months of previous year.

Lockdown

The state of emergency declared on 18th March 2020 closed all nonessential businesses such as bars, casinos, theaters, and dine-in restaurants. Essential facilities were allowed to stay open with minimal capacity (25%) limits or outdoor operations. Most notably, bars were closed during the 3-month period of March to May. This phase was termed “lockdown,” with no definitive end date provided, however, it eventually ended on 15th May 2020, with progression into the first stages of reopening.

During this initial period of strictest lockdown, we observed a significant decrease in the total number of traumatic injuries compared to previous years in the months of March, April, and May of 2020. Early during this phase, many hospitals also saw a decrease in stroke and heart attack activations, prompting worry that potential patients who would have gone to a hospital for concerning symptoms, forwent treatment.¹⁵,¹⁶ Similarly, especially during the early weeks of the pandemic, when social fears were at a high, patients with traumatic injuries may have been reluctant to seek care at a large hospital due to concerns of exposure to COVID-19 at a hospital. For this reason, it may be difficult to truly collect an accurate census regarding patient injuries, however, we would hope that patients with injuries severe enough to be included in this study would sought some form of healthcare.

Reopening

State-wide stay-at-home orders were in effect through 15th May, until “Phase One” opening of businesses allowed 25% capacity at select businesses including childcare, food services establishments, houses of worship, and gyms. On 5th June restaurants were allowed to open to 50% capacity, indoor gatherings of up to 50 people were allowed, and bars opened. In June, the monthly and weekly counts of trauma patients rose to higher than average numbers. Once this reopening began, there were significantly more total injuries and GSWs compared to previous years.

From June onwards, the average weekly and monthly numbers of trauma patients treated was above average. Overall, despite the decrease in number of patients during the first 3 months of lockdown, more trauma patients were treated at our hospital in 2020 than the average of the three preceding years.

On 1st October restaurants and other businesses were allowed to run at 75% capacity, liquor sales were allowed from 8 am until 11 pm, public schools resumed in-person learning. Despite these additional reopenings, there was a constant threat that lockdowns could revert back to tighter restrictions if the number of new COVID-19 cases increased significant or placed too high of a burden on local hospitals.

There were significantly more tier I and tier II activations during 2020, but no difference in trauma consults. While we did not have access to formal injury severity scores, tier I and II activation status can be used as a proxy for severity. Thus, it appears that in 2020, there was an increase in the number of critically injured patients compared to previous years. Our area did not experience a rearrangement in the regional trauma system due to overwhelming capacity issues, so it is unlikely that differences in traumatic injury volume at our hospital were due to decreased access to other hospitals. Additionally, the volume of patients transferred to our trauma center from outside hospitals was comparable to previous years.

As more injuries were due to assault (including penetrating wounds, specifically GSWs) and fewer to accidents (like falls and pedestrian/bicycle accidents), multiple conclusions can be made regarding injury patterns. Assaults may have increased in rate due to increased interpersonal conflict fueled by more time spent at home, stress caused by the COVID-19 pandemic and other world events, increased unemployment rates, or other interpersonal stressors. Accidents may have presented in decreased rates to our hospital due to an actual decreased number of accidents. Conversely, those who experienced accidents such as falls may have justified not seeking medical care at a hospital treating COVID-19 patients by the lack of obvious signs of severe like hemorrhage after a penetrating wound, which perhaps more obviously require medical care.

The number of firearms sold legally in the US doubled between March and August 2020 (n = 12,233,3000) compared to those months in 2019 (n = 6,38,6000).¹⁷ While this may have contributed to an increase in gun-related violence, there was also concern about the effects this would have on self-inflicted injuries, given that approximately 66% of firearm-related deaths are due to self-injury or suicide. While our data did not show an increase in self-inflicted wounds, future studies should be performed using national data or coroner records to determine accurate suicide rates, as many patients may have died on-scene and thus were transported directly to a coroner rather than a hospital.

Limitations

There are limitations to our study, which only includes data from a single level I trauma center, and thus injury characteristics may vary compared to other areas and national trends. Our trauma database only includes patients transported to our hospital, and thus does not include deaths outside of the hospital transported directly to the coroner including suicides, fatal traumatic injuries on-scene, and deaths of traumatically injured patients who did not seek medical attention. Additionally, our database had access to tier level of trauma activation, and while this does correlate to injury severity, our data had a large number of database entries with no tier level information, thus use of injury severity scores will be useful in similar future studies.