Open access Original research Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000567 on 20 October 2020. Downloaded from Shark- related injuries in Hawai’i treated at a level 1 trauma center Victoria A Scala ,1 Michael S Hayashi ,2,3 Jason Kaneshige,1,4 Elliott R Haut ,5 Karen Ng ,3 Sho Furuta2,3 1Orthopaedic Surgery, University ABSTRACT resultant major injuries.2 Therefore, this study will of Hawai’i at Manoa John Background Although rare, human–shark interactions refer to these interactions as “SRIs” to help promote A Burns School of Medicine, Honolulu, Hawaii, USA can result in a wide spectrum of injuries. This is the first scientific discourse. 2Surgery, University of Hawai’i study to characterize shark- related injuries (SRIs) in Prior studies on SRIs have either used three large at Manoa John A Burns School Hawai’i. independent databases (the Global Shark Attack of Medicine, Honolulu, Hawaii, Methods This is a retrospective review of the State of File (GSAF), the International Shark Attack File USA Hawai’i Division of Aquatic Resources Shark Incidents 3–5 3Trauma, The Queen’s Medical (ISAF), or the South African Shark Attack File), Center, Honolulu, Hawaii, USA List between January 1, 2009 and December 31, 2019. compared shark attack databases with local medical 4Orthopedic Surgery, The Trauma registry data and medical records of patients records (Virginia, USA,6 and La Réunion Island, Queen’s Medical Center, treated for SRIs at the only level 1 trauma center in France7), or presented individual case reports in Honolulu, Hawaii, USA Hawai’i were reviewed. South Africa8 and Mexico/Canada.9 In the few 5Surgery, Johns Hopkins University, Baltimore, Maryland, Results Sixty-one patients sustained SRIs in the studies that have identified the shark species impli- USA Hawaiian Islands: 25 in Maui, 16 in O’ahu, 12 in Hawai’i, cated in SRIs, the majority were caused by the great and 8 in Kaua’i. In cases where the shark species could white shark (Carcharodon carcharias) in South Correspondence to be identified, tiger sharks were the most frequent (25, Africa5 and by the bull shark (Carcharhinus leucas) Dr Sho Furuta; sfuruta@ queens. 41%). Four cases were fatal—all died on scene in Maui in La Réunion Island, France.7 org with the shark species unknown. Forty-five survivors This is the first study to characterize SRIs in the This paper was presented as a (79%) received definitive care at regional facilities. state of Hawai’i, where the predominant species of poster presentation at the 79th Twelve (21%) were treated at the level 1 trauma center, shark is the tiger shark (Galeocerdo cuvier).1 Hawai’i Annual Meeting of AAST and of which two were transferred in for higher level of care. is an isolated archipelago of eight major islands in copyright. Clinical Congress of Acute Care Of the 12 patients, 11 (92%) had extremity injuries, with Surgery. the Pacific Ocean, which poses unique challenges 3 lower extremity amputations (25%), 2 with vascular for patient treatment and transport. There is only Received 30 July 2020 injuries (17%), and 5 with nerve injuries (42%). One one level 1 trauma center in the Hawaiian Islands, Revised 11 September 2020 had an injury to the abdomen. All patients had local The Queen’s Medical Center (QMC), located in Accepted 14 September 2020 bleeding control in the prehospital setting, with 9 (75%) Honolulu, on the island of O’ahu. The purposes of tourniquets and 3 (25%) hemostatic/pressure dressings this study were to (1) determine when and where applied for truncal or proximal extremity injuries. The SRIs occurred in the state of Hawai’i; and (2) mean time from injury to emergency department arrival describe SRI patterns, interventions, and medical was 63 minutes. resource utilization in both the prehospital and Discussion Most SRIs are managed at regional hospital setting and the outcomes of the patients facilities, rather than at a level 1 trauma center. http://tsaco.bmj.com/ treated at QMC. Prehospital hemorrhage control is an important survival skill as time to definitive care may be prolonged. For cases treated at the level 1 trauma center, nerve injuries METHODS were common and should be suspected even in the A retrospective review of the State of Hawai’i absence of major vascular injury. Correlating shark Department of Land and Natural Resources Divi- behavior with observed injury patterns may help improve sion of Aquatic Resources (DAR) Shark Incidents public awareness and ocean safety. List between January 1, 2009 and December 31, on September 24, 2021 by guest. Protected Level of evidence Level V, epidemiological. 2019 was conducted. Both provoked and unpro- voked incidents were included. Provoked shark incidents are defined by the ISAF as incidents BACKGROUND “when a human initiates interaction with a shark For over half a century, the USA has had the highest in some way.” Examples of activities that provoke number of shark-related injuries (SRIs) of any shark incidents include harassing sharks while © Author(s) (or their country in the world. SRI rates have been increasing diving, spearfishing, feeding sharks, and so on.10 employer(s)) 2020. Re- use Only cases of shark attacks with human injury were permitted under CC BY-NC . No in higher population countries including the USA commercial re-use . See rights and specifically within the region of Hawai’i, but included. Twenty- one shark bites of objects such and permissions. Published the overall number of SRIs per year still remains as surfboards in which the victims were unharmed by BMJ. low.1 Although rare, human–shark interactions can were excluded. All known data associated with each To cite: Scala VA, cause a wide spectrum of injuries. Given this vari- case in the DAR Shark Incidents List were reviewed, Hayashi MS, Kaneshige J, ability of outcomes, one study called for a change including date and time, location, victim’s activity, et al. Trauma Surg Acute Care in nomenclature away from the loaded phrase of water clarity, water depth, treatment facility, injury Open 2020;5:e000567. “shark attack” that connotes shark intent and description, and shark species. Scala VA, et al. Trauma Surg Acute Care Open 2020;5:e000567. doi:10.1136/tsaco-2020-000567 1 Open access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000567 on 20 October 2020. Downloaded from Table 1 Characteristics of all shark- related injuries in the state of Hawai’i Survived, n (%) 57 (93) Fatal, n (%) 4 (7)—all on Maui Total 61 Island, n (%) Maui 25 (41) O’ahu 16 (26) Hawai’i 12 (20) Kaua’i 8 (13) Shark species, n (%) Unknown/data insufficient 26 (43) Tiger 25 (41) Cookiecutter 4 (6.6) Galapagos 2 (3.3) Requiem 2 (3.3) Galapagos or sandbar 1 (1.6) Whitetip reef 1 (1.6) Water clarity, n (%) Turbid 35 (57) Clear 24 (39) Unknown 2 (3.3) Activity of unprovoked incident, n (%) Surfing 20 (33) Swimming 14 (23) Figure 1 (A) Shark- related injuries by time of day. Intervals are from :00 to :59. Example: 06:00 is from 06:00 to 06:59. (B) Shark-related Snorkeling 8 (13) copyright. injuries by month. Body boarding 3 (5) Treading water 2 (3.3) provoked SRIs were swimming with sharks (4, 6.6%) and spear- Paddling 1 (1.6) fishing (2, 3.3%). The majority of cases (57%) occurred in turbid Stand- up paddle boarding 1 (1.6) water conditions. Floating 1 (1.6) Fifty-three (87%) shark injuries occurred during daylight Spearfishing 1 (1.6) hours between 08:00 and 17:00 (figure 1A). All four cook- Standing 1 (1.6) iecutter shark injuries occurred during the night between 08:00 and 04:00. Only four injuries (6.6%) occurred during twilight. Kite surfing 1 (1.6) There were insufficient data to identify the shark species involved Total 53 (87) in 26 (43%) injuries. In the 35 cases where the species could be http://tsaco.bmj.com/ Activity of provoked incident, n (%) identified, tiger sharks were the most frequently involved with Swimming with sharks 4 (6.6) 25 (71%). Thirteen of the 25 (52%) tiger shark injuries occurred Spearfishing 2 (3.3) between September and November, with the most injuries occur- Fishing 1 (1.6) ring in October (8, 32%) (figure 1B). Fishing from kayak 1 (1.6) Four cases (6.6%) were fatal—all died on scene in Maui, with the shark species unknown. Two fatalities sustained proximal Total 8 (13) upper extremity injuries—one victim was bitten on the right shoulder, underarm, and right side of the face, and the other on September 24, 2021 by guest. Protected victim sustained a right arm amputation below the shoulder. One Trauma registry data and medical records of patients treated fatality sustained a lower left leg amputation and avulsions to for SRIs at QMC were reviewed for further clinical details, the left arm and hand. For the fourth fatality, it was noted that including patient demographics, treatment provided, and patient the victim’s feet were dangling in the water while fishing from a outcomes. kayak when bitten by a shark; however, no further description Descriptive statistics summarizing patient characteristics were of the injury was provided. conducted using Microsoft Excel (Redmond, WA, USA). Of the 12 patients treated at QMC, the mean age was 36.6 (range 10–58) years and 83% were male. All patients had local RESULTS bleeding control in the prehospital setting, with 9 (75%) tour- Sixty- one patients sustained SRIs in the Hawaiian Islands during niquets and 3 (25%) hemostatic/pressure dressings applied for the study period. The island of Maui had the most SRIs with truncal or proximal extremity injuries.