View of a war from a pathology department: Croatian experience

Management of war-related burn injuries: lessons learned from recent ongoing conflicts providing exceptional care in unusual places

Thermal injury is a sad but common and obligatory component of armed conflicts. Although the frequency of noncombat burns has decreased, overall incidence of burns in current military operations has nearly doubled during the past few years. Burn injuries in the military environment do not need to be hostile in nature. Burns resulting from carelessness outnumber those resulting from hostile action. Unfortunately, civilians are becoming the major targets in modern-day conflicts; they account for more than 80% of those killed and wounded in present-day conflicts. The provision of military burn care mirrors the civilian standards; however, several aspects of treatment of war-related burn injuries are peculiar to the war situation itself and to the specific conditions of each armed conflict. Important aspects of management of burned military personnel include triage to ensure that available medical care resources are matched to the severity of burn injury and the number of burn casualties, initial management and resuscitation in the combat zone, and subsequent evacuation to higher echelons of medical care, each with increasing medical capabilities. Care of military victims is usually well structured and follows strict guidelines for first aid and evacuation to field hospitals by military personnel usually having had some form of training in first aid and resuscitation and for which necessary equipment and material for such interventions are more or less available. Options available for civilian injury intervention in wartime, however, are limited. Of all pre-hospital transport of civilian victims, 70% are done by lay public and 93% receive in the field, or during transport, some form of basic first aid administered by relatives, friends, or other first responders not trained for such interventions. Civilian casualties frequently represents 60% to 80% of all injured admitted to the level III facilities of overseas forces stationed throughout the host country. Unlike military personnel who are rapidly evacuated to higher echelons IV and V for definitive and long-term care, civilians must receive definitive burn treatment at these level III military facilities. The present review was intended to highlight peculiar aspects of war-related burn injuries of both military personnel and civilians and their management based on the most recently published material that, for the most part, is related to the recent conflicts in Iraq and Afghanistan.

Management of Vascular Injuries in a Forward Hospital

BACKGROUND

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

METHODS

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

RESULTS

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

CONCLUSIONS

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.

Injuries among Afghan refugees: review of evidence

BACKGROUND

Injuries are a public health problem in developing countries resulting in major financial and productivity losses. Injuries in vulnerable populations, such as refugees, make an even greater impact on loss of life. Afghan refugees in Pakistan continue to form one of the world's largest refugee populations. This study systemically reviews the literature to estimate the magnitude and prevalence of intentional and unintentional injuries in Afghan refugees, and explores the implications of the findings for refugee healthcare policy and development of potential interventions specifically for Afghan refugees.

METHODS

Electronic databases of MEDLINE, POPLINE, Refworld, and Winspirs were searched. In addition, a web search was conducted and specific organizational websites were reviewed. The search in developing countries was limited to studies in English or with an English abstract for the years 1966-2001.

RESULTS

The literature review identified patients with reported war injuries who presented to hospitals. Injuries to extremities (45%) were more frequent than injuries to the head or neck (36%, p < 0.001), and thorax/abdomen (14%, p < 0.001) regions. A majority of the injuries were caused by explosives, which included landmines (32.5%), fragmentations, such as shrapnel (33%), and firearms (27%). The mean incidence of mortality in these studies was 11%.

CONCLUSIONS

Despite such an extensive search, limited information was found pertinent to injuries in Afghan refugees residing in refugee camps. This dearth of literature on the prevalence of injuries, risk factors, and outcomes among this vulnerable group is a research and policy gap for public health. Specific quantitive and qualitative studies in this field are required to shape refugee healthcare policies and develop intervention programs.

Practical and legal aspects of forensic autopsy expert team operations

Finnish forensic experts have investigated remains of the victims of alleged mass violence in the former Yugoslavia in 1996 under the mandate of the United Nations, and in 1998 and 1999 under the mandate of the European Union. The investigative documents later were surrendered to the International Criminal Tribunal for the former Yugoslavia (ICTY). The indictments issued by the ICTY include charges even against the highest authorities of the Federal Republic of Yugoslavia. This study describes the experience gained in organising forensic expert team operations in a foreign state by the Finnish team. The establishment and operation of a forensic expert team in a foreign state involve, among other things, legal issues, often related to differing legal systems. From an independent forensic expert team, great objectivity and self-constraint are expected. Moreover, a clear and sufficiently detailed agreement on the mandate of the team and on the possibility for unhindered and safe access of the experts to the alleged mass graves, as well as the assembling and briefing of the team members and provision of the necessary equipment should be completed before the beginning of the mission. Furthermore, the application of adequate and internationally recognised methods for processing and documenting the examination is essential for team's credibility.

Fatal missile injury from the rotating knife of an agricultural mower

The first case of a lethal injury inflicted by a projectile-wise shot piece of the rotating knife of an agricultural mower (gyro mower) is presented. The knife had travelled approximately 100 m through the air before hitting the victim's body. It transected most organs of the ventral neck including both carotids, the trachea and the esophagus and led to death from exsanguination. The type of the knife which was recovered from the body led to the identification of the mower whose operator had not noticed the accident. Legal action against the user or against the producer of the mower were considered but dismissed as no safety regulations had been violated.

Wartime civilian injuries: epidemiology and intervention strategies

BACKGROUND

Trauma is the most important public health risk in wartime. Most preventive effort have addressed the political etiology of armed conflicts and the secondary effects of war (food, water, shelter, sanitation, and vector control). Little to no efforts have addressed the direct prevention and control of war trauma.

METHODS

An extensive review of the literature, with compilation of the most important data.

RESULTS

Civilians are the major wartime targets in recent wars, and account for most of the killed and wounded. The trend has been toward a greater proportion of injuries from powerful explosive devices such as artillery shells and mines. Lessons learned from Bosnia and Lebanon show that the most effective way to achieve successful surveillance and injury prevention is to enhance the local skills and resources.

CONCLUSIONS

New approaches are needed to minimize trauma to civilians. Both political advocacy and local efforts (including modifying firearms and ammunition, bullet proof helmets for children, anti-sniper shields) are needed.

Clinical course in 52 severely wounded patients treated in the intensive care unit during the war in Croatia

Fifty-two severely wounded patients, admitted directly from a battlefield or after surgical treatment in a war hospital, were treated in the Surgical Intensive Care Unit of the 'Sisters of Mercy' University Hospital in Zagreb during the 1991 war in Croatia. Considering the severity of the wounds, blood loss was not as severe as expected. This can be attributed to the nature of the injuries as most of the patients were wounded by fragments of explosive devices which cause less tissue destruction than military bullets. Low serum potassium levels, metabolic acidosis, low total protein levels and consequently low serum calcium levels correlated with wound severity. Low serum potassium levels were caused by its redistribution. Reperfusion liver injury was also present. Consumption coagulopathy was one of the characteristic disturbances in this type of injury. There was a relatively big difference between fluid input and output caused by fluid loss through drain sites and large open wound surfaces. The low mortality of the severely wounded was due to their young age and the well-organized military medical service which was developed from the civilian medical service in a short time.

The incidence and outcome of penetrating and blunt trauma in central Bosnia: the Nova Bila Hospital for War Wounded

OBJECTIVES

Since February 1992, the civil war in the former Yugoslavia has left over 140,000 people dead. This study describes the injuries and outcome of patients treated at a provisional war hospital in Bosnia and compares mortality rates with war hospitals from prior armed conflicts.

DESIGN

This is a retrospective review of 1,703 trauma patients treated between March 1993 and October 1993 at the Nova Bila War Hospital.

RESULTS

In Bosnia, the overall mortality was 10.3% (5.0% dead on arrival and 5.3% inhospital deaths). Head injuries, seen in 19.2% of patients, had a mortality of 23.8%. The odds of sustaining a gunshot wound were 2.8 times greater in Bosnia than in Vietnam (p < 0.05). The odds of sustaining a head injury were 1.1 to 1.6 times greater in Bosnia than in Lebanon and Afghanistan (p < 0.05). The overall mortality odds in Bosnia were 3.1 times greater than in Vietnam (p < 0.001), but were equal to those in Lebanon and Afghanistan.

CONCLUSIONS

Despite limited personnel and supplies, the inhospital mortality rate was comparable with those found in other war hospitals. The Nova Bila Hospital represents a unique response to the great medical need brought about by the continued fighting in the former Yugoslavia.