Discussion
The COVID-19 pandemic has changed the daily work and leisure routine for people throughout the world. This resulted in significant changes in the incidence of traumatic injury, with multiple regions reporting a substantial decrease in the incidence of trauma volume as social distancing and patterns of on-site work and in-person schooling changed.19–24
Regional strategies to mitigate the spread of COVID-19 as the pandemic reached the NCR included closure of schools to in-person education, closure of non-essential businesses, and issuance of stay-at-home orders. Collectively, this resulted in a marked decrease in vehicle and pedestrian traffic, gatherings both during the workday as well as after hours, and distancing of friends and families. Specifically, Apple Mobility Trends Reports demonstrates a precipitous drop in driving (approximately 55%), walking (approximately 60%), and transit (approximately 80%) in DC starting in early March and with a nadir in early April 2020.33 Similarly, Google Mobility Data, which provides information on mobility trends in different communities, identifies an approximately 70% drop for work and a 25% increase for at-home residence by April 2020 compared with a 5-week baseline period starting January 3, 2020 in DC.34 Our multicenter study found a 22.4% decrease in the regional trauma volume while these strategies were in place compared with the analogous period the previous year. This is more striking because trauma volume was rising with a 3.4% increase in incidence in the pre-COVID-19 period of 2020 relative to the same months of 2019. While the relative impact on specific injury mechanisms was not uniform, blunt trauma decreased during the regional height of the COVID-19 pandemic, while penetrating, and specifically firearm-related and stabbing trauma, increased. Urban locations saw a significant increase in gunshot injuries but not stabbings, whereas the opposite was true for suburban centers.
It is unlikely that our findings are explained by a more direct effect of the virus, such as a change in emergency medical service trauma referral patterns to centers outside the NCR. At no point during the study period did the region’s hospitals become overwhelmed, need to go on bypass, or alter their trauma triage criteria as a result of COVID-19.14 35 36 In addition, while it is possible that some patients chose not to seek medical care because of the pandemic, this study captures injuries of sufficient severity to necessitate evaluation in an emergency department. Patients admitted to the hospital due to injury would have been captured in the trauma registry.
Though many different injury mechanisms fall within the auspices of blunt trauma, we opted to evaluate three specific blunt mechanisms of injury which might be impacted the most by stay-at-home orders. Fall from standing is the most common MOI in the USA,37 with many of these events occurring at or near people’s residence or during recreational activities.38 Despite a potential increase in the number of hours people spent at home in the COVID-19 period, we did not find an increase in the incidence of injury related to this mechanism. Blunt force assault was examined as an index for non-firearm-related interpersonal domestic violence, which we thought might have increased due to stay-at-home orders and cohorting of people in the same residence. However, we did not find an increase in blunt assault during the COVID-19. Lastly, we examined MVCs as we anecdotally saw a large decrease in traffic volume in the NCR after issuance of stay-at-home orders. Although we did not find a statistically significant decrease in MVC-related injury during COVID-19 compared with the same months of 2019, there was a decrease in trend line for injury related to this mechanism (r=−0.246 vs. r=0.180) relative to January 2019 through the end of pre-COVID-19.
Shortly after the issuance of social distancing guidelines and/or mandates, trauma centers in some major cities began to report an increase in trauma due to a violent MOI, including firearm-related aggression.25–27 29 30 It is noteworthy that over 1 million more background checks for firearm sales were performed in March 2020 alone as compared with March 2019, and that this number does not include firearm transactions that occurred without a background check.39 Despite this, using publicly available police-recorded open crime data from eight cities in the USA, as compared with pre-COVID levels, Ashby found no significant change in the frequency of serious assaults, including aggravated assaults and homicides of all causes, during a similar time frame to our study.40 In contrast, Sutherland et al found a significant increase specifically in gun-related violence in three of four major US cities in 2020 compared with 2019, including two of the same cities (Baltimore and Los Angeles) evaluated by Ashby, when they analyzed police department and Federal Bureau of Investigation data.41 This could be related to the categorization of aggravated assault as violent crime in which a decrease in blunt assault would offset increases in firearm and stabbing violence.
Firearm-related trauma is particularly concerning in a resource-constrained environment that may be present during a pandemic. Despite a suspension of elective operations, the nation’s blood supply reached critical shortages during the March through May 2020 period.42 With a finite shelf lifespan, maintaining an appropriate blood product inventory depends on continuous collection from blood donors. Prior to the COVID-19 pandemic, approximately 80% of this occurred during blood drives, which had to be canceled because of social distancing requirements.43 44 Firearm-related injuries are frequently associated with hemorrhage and the need for transfusion.45 DeMario et al found that patients with GSWs were approximately five times more likely to require transfusion and received approximately 10 times more component units compared with non-ballistic injuries.46 The increase in firearm injuries identified in this study places additional stress on an already limited blood product inventory.
In addition, many health systems across the nation instituted substantial changes in staffing models to facilitate optimal management of patients with COVID-19, asking surgeons to assist in intensive care unit coverage. Depending on trauma center coverage models this could present significant challenges to select centers. Distribution of staff at trauma centers should consider potential increased demands related to penetrating trauma. Finally, proactive interventions to mitigate the pandemic-associated rise in stabbing and gun trauma should be considered.
This is the first regional and multicenter report on the impact that the COVID-19 pandemic has had on the incidence and nature of traumatic injury in a major metropolitan area in the USA. Although COVID-19 is the most prevalent pandemic seen since the influenza pandemic of 1918, there have been many recent instances of other viral outbreaks with the potential for widespread infection, and agencies such as the WHO regularly identify new potential threats. Therefore, we think the findings of this study are helpful in planning for future pandemic events, with the key finding being that overall trauma volume decreases significantly, but, in contrast to most reports from other Western countries, there may be a significant increase in stabbing and firearm-related injury in urban settings in the USA. Resource availability as part of planning for a pandemic should include supplies used with frequency in penetrating trauma, such as blood products or alternatives and equipment required for mitigation of infectious disease transmission. A comprehensive understanding of the regional variability of these findings is essential to any future pandemic preparation
This study has several limitations that we acknowledge. First, it is a retrospective study with all the limitations therein. Second, this study only captures data from the first 3 months of COVID-19 impact on the NCR; therefore, it is unclear how this will evolve over time. Third, other factors including year-to-year variability and seasonal variability could explain our findings, but we have tried to control for this by analyzing the same time periods in sequential years. Fourth, to maintain patient anonymity, we did not review data at the patient level. This precluded our ability to better characterize the nature of the injuries seen and/or exact treatments rendered. However, we were able to measure overall injury severity, which was unchanged, and the purpose of this article was to describe the incidence of injury and the types of injuries seen as opposed to outcomes obtained from specific treatments rendered. Lastly, this study does not include patients who either did not come to the hospital or went to a non-trauma center. However, that population most likely represents patients with lower acuity injury and thus does not alter the conclusions of this study regarding severe injury.