War Injuries, Trauma, and Disaster Relief

Damage control packing: How long can it stay?

Damage control (DC) packing is used selectively in patients in shock with extensive abdominal, thoracic, perineal/genital/perirectal, neck/axillae/groin (junctional), and extremity injury to stop bleeding. In multiple casualty scenarios, DC packing may be used to facilitate an abbreviated surgery and thus "buy time". The packing is by guideline or military doctrine removed or exchanged 1-3 days later in a planned reoperation. In remote environments, however, where timely evacuation cannot occur and resources are limited, it may be necessary for packing to be left in place longer than 3 days. Also, in Large Scale Combat Operations, Multi-Domain Operations, and Distributed Maritime Operations, evacuation will be accomplished by nonsurgeons and may last several days. Prolonged retention of packing is associated with complications, but significant rebleeding may occur upon removal. This article reviews the benefits and hazards of DC packing removal to inform decision making by both surgeons and nonsurgeons. We conclude that except for Dismounted Complex Blast Injury most DC gauze packing does not mandatorily need to be removed or exchanged within a three-day window.

Surgical frontiers in war zones: perspectives and challenges of a humanitarian surgeon in conflict environments

This opinion article delves into the complexities of surgical care in conflict zones, highlighting the challenges and ethical considerations faced by humanitarian surgeons. It emphasizes the importance of collaboration with local healthcare professionals and specialized training programs in preparing surgeons for the unique demands of conflict trauma and war surgery.

Reconstruction of firearm and blast injuries in Syrian war refugees

BACKGROUND

War injuries differ from other injuries owing to the large tissue defects they cause and their high risk of contamination. As fragments scattered by high-energy firearms and explosives cause serious composite tissue damage, repair of such injuries is difficult and requires a long treatment period. We discuss the treatment methods used for injured Syrian War refugees admitted to our clinic and present the most effective repair methods for war-related tissue defects for each region of the body.

METHODS

A total of 61 patients treated between June 2012 and April 2015 were retrospectively evaluated in terms of age, gender, duration of hospitalisation, injury site and repair method employed. The patients were grouped by region injured (head/neck, extremities and trunk).

RESULTS

The female-to-male ratio of the patients was 16/45, and their mean age was 25.2 (range, 3-51) years. Twenty-two patients were under the age of 18. The mean duration of hospitalisation was 28.5 days. A total of 130 operations were performed on the patients, including debridement and revisions. Repairs were conducted with free flaps in 17 patients (6 on the head/neck region, 11 on extremities) and with pedicle flaps in 28 patients (11 on the head/neck region, 12 on extremities, 5 on the trunk). Two patients experienced flap loss without other complications, and other patients experienced complications including bleeding, infection, flap detachment, hematoma and seroma.

CONCLUSIONS

War injuries cause tissue damage of a composite and extensive nature. Most affect the extremities, followed by the head/neck and trunk regions. They are primarily sustained by the young population, not usually easy to treat, and require long hospitalisation periods. A variety of methods may be preferred to treat these injuries.

Dealing With Burn Patients in War Zones

OBJECTIVE

Treating burn patients in the battlefield is one of the biggest challenges that military doctors and medical personnel can face. Wound patterns have been changed over time due to the introduction of new weapons, and many different aspects play a major role in the management of those burns nowadays. There is a potential gap in care of burn patients in war zones.

METHODS

A thorough literature search in PubMed, scientific journals, and Internet sites was conducted in regard to burn patients and trauma in war zones.

RESULTS

It is crucial for military surgeons to be able to stabilize burn patients during wartime conflicts, especially those patients who suffer from extreme burn injuries, as specialized treatment should be given. Medical personnel should be aware of all medication types used, the ways to minimize the risk of bacterial infection, and the ways to keep the injured safe.

CONCLUSIONS

Injured civilians with burn trauma in the field of battle are deserving care, and special recognition should be given to the non-governmental organizations (NGOs) that strive to ease human suffering in war zones. Proper management of burn patients in war zones is crucial, and military medical staff and NGOs can play a key role in that purpose.

Improving Management of Limb Injuries in Disasters and Conflicts

It has become clear that disaster relief needs to transition from good intentions or a charity-based approach to a professional, outcome-oriented response. The practice of medicine in disaster and conflict is a profession practiced in environments where lack of resources, chaos, and unpredictability are the norm rather than the exception. With this consideration in mind, the World Health Organization (WHO; Geneva, Switzerland) and its partners set out to improve the disaster response systems. The resulting Emergency Medical Team (EMT) classification system requires that teams planning on engaging in disaster response follow common standards for the delivery of care in resource-constraint environments. In order to clarify these standards, the WHO EMT Secretariat collaborated with the International Committee of the Red Cross (ICRC; Geneva, Switzerland) and leading experts from other stakeholder non-governmental organizations (NGOs) to produce a guide to the management of limb injuries in disaster and conflict.The resulting text is a free and open-access resource to provide guidance for national and international EMTs caring for patients in disasters and conflicts. The content is a result of expert consensus, literature review, and an iterative process designed to encourage debate and resolution of existing open questions within the field of disaster and conflict medical response.The end result of this process is a text providing guidance to providers seeking to deliver safe, effective care within the EMT framework that is now part of the EMT training and verification system and is being distributed to ICRC teams deploying to the field.This work seeks to encourage professionalization of the field of disaster and conflict response, and to contribute to the existing EMT framework, in order to provide for better care for future victims of disaster and conflict.Jensen G, Bar-On E, Wiedler JT, Hautz SC, Veen H, Kay AR, Norton I, Gosselin RA, von Schreeb J. Improving management of limb injuries in disasters and conflicts. Prehosp Disaster Med. 2019;34(3):330-334.

The burden of war-injury in the Palestinian health care sector in Gaza Strip

Background

War-related injury is a major public health concern, and a leading cause of mortality, morbidity, and disability globally, particularly in low and middle-income countries such as Palestine. Little is known about the burden of war-related injury in the Palestinian context. The objective of this study was to characterize the incidence and pattern of injuries, associated with war in Gaza Strip, from July 8 to August 26, 2014.

Methods

This was a descriptive study based on an injury registry at hospital facilities in the Gaza Strip. A total of 420 victims records from 2014 Gaza war injuries were randomly selected, proportionate to the size of the study population estimated across five Gaza governorates. Simple descriptive statistics were calculated to explore the frequency and percentage distribution of study variables and injury data. A chi-square test (X²) was used. The significance level was derived at p < 0.05. The data were analyzed by IBM SPSS software, version 23.

Results

Males (75.5%) have experienced more war-related injuries than females (24.5%), constituting a male: female ratio of 3.1:1. Almost half (49.5%) of the injured victims were of the age group 20–39, followed by children and adolescents (< 20 years), accounting for 31.4%. More than half of victims were single (53.6%), 44.3% were married and the rest were widowed or divorced. The overall number of injuries was 6.4 per 1000 population, though it varied among regions. North Gaza reported the highest number of injuries (9.0) and Rafah the lowest (4.7) per 1000 population. Blast and explosion were found to be the most common causes of war injuries (72.9%). The highest proportion of injuries were reported in the upper body. Multiple body shrapnel wounds and burns (39.3%) were most frequent. Other types of injuries were multiple organ injury (24.3%), fractures (13.6%), internal organ injury and bleeding (9.8%), amputation (4.5%), abrasions/lacerations and contusions (4.8%), vision or hearing loss or both (1.9%) and respiratory problems (1.9%). The highest percentage of injuries were classified as mild (46.9%), and the rest ranged from moderate-to-severe. Almost 26% of individuals had sustained disability, and most of them had physical/motor impairment.

Conclusion

War-related injuries constitute a major problem to public health discipline and clinical medicine as well. A better surveillance system using ICD codes, and development of a comprehensive electronic data network are necessary to make future research easier and more timely.

Assessment of orthotic needs in Iranian veterans with ankle and foot disorders

BACKGROUND

War-related traumas can lead to orthopedic and neurological disorders in victims. However, the scope of such disorders may expand months or even years after the trauma. Orthotic treatment as a rehabilitation process aims to enable people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels. This study aimed to investigate the rate of using orthoses among Iranian veterans with neuromuscular and skeletal disorders of the ankle and foot. Furthermore, the priorities of orthotic treatment in those veterans were explored.

METHODS

This qualitative study was a national health needs assessment conducted in 11 provinces of Iran during 2011-2016. A stakeholder research group was established to survey the veterans in respect to their demographic variables, activities of daily living, current health conditions, and rate of using orthoses.

RESULTS

Overall, 907 of the 1124 veteran participants completed the survey (response rate: 80.7%). Most of the veterans were men (97.7%), and their age and disability rate were 52.07 ± 8.13 years and 31.92% ± 14.93%, respectively. Nearly 42% of the veterans had experience in using orthoses on a daily and weekly basis. As physical ambulation was the main problematic activity in veterans, most of them were using medical shoes and foot orthoses. Nearly 37% of veterans were in need of some type of lower limb orthoses on the contralateral side to compensate for their hip inequality. In sequential order, the most in need orthoses for veterans were foot orthoses (n = 538), medical shoes (n = 447), lower limb orthoses on the contralateral side (n = 320), spinal orthoses (n = 273), and upper limb orthoses (n = 86).

CONCLUSIONS

In spite of the high demands for orthoses among Iranian veterans with ankle and foot disorders, the use of orthoses is insufficient. Hence, there is a discrepancy between the current rate of orthoses use and its ideal situation, and more resources should be provided for service providers to be able to serve veterans. Moreover, veterans should be educated regarding orthoses, their use, and their impacts on the user's health status. The findings of a needs assessment of orthoses can be used in strategic planning and decision making to improve health care services for Iranian veterans.

Military nurse deployments: Similarities, differences, and resulting issues

BACKGROUND

Military nurses have a long history of deploying to combat and disaster. Much can be gleaned from their experiences.

PURPOSE

The purpose of this secondary analysis was to explore military nurses' perceptions of similarities, differences, and resulting issues of military deployments from narratives of three previous studies.

METHODS

Secondary analysis of interviews from 65 U.S. military nurses (Air Force, Army, Navy) was conducted. Line-by-line readings and Nvivo8 qualitative software were used.

DISCUSSION

Seven themes emerged. Similarities: We Have Suffered, Support Really Matters, The Chaos Is Real, and I'm a Different Person Now; Differences: We Didn't Know, The Structure Is Missing, and Disasters and War Are Not Equal.

CONCLUSION

Findings indicated potential areas for improvement in behavioral health, support, and preparedness. Nurses noted they had changed; that they were a different person, and were having difficulty fitting into postdeployment roles. Positive experiences included personal growth and pride.

The pattern of the Syrian refugee's injuries managed in King Abdullah University Hospital (Jordan)

OBJECTIVE

This study was conducted to assess the pattern, the magnitude, the severity, the distribution, and the results of the management of the injured Syrian refugees at King Abdullah University Hospital (KAUH).

METHODS

The medical records of 90 consecutive injured Syrian patients admitted to KAUH at the beginning of the Syrian conflict in 2012-2013 were reviewed. Information regarding the age, the sex, the antomical regions, the organs injured, the operations performed, the complications, and the weapons used were recorded.

RESULTS

Of the 90 cases, 86 (95.6%) were males and 4 (4.4%) were females. The age of patients ranged between 6 and 64 years with: 8 children (6-18) years old, 81 young adults (18-48) years old, and only 1elderly patient (64) years old. The distributions of the injuries were: 54.5% in extremities, 47.8% head and neck, 15.5% chest, and 14.4% abdomen with involvement of more than one injured region in several patients. The injuries were inflected by explosives in 49 cases, bullets in 45 cases, and both in 4 cases. The most frequently performed operations were: fractures fixations, fasciotomies, laparotomies, and craniotomies. Musculoskeletal and neurological deficits occurred in 11.1 and 8.8% of cases, respectively. The mortality rate was 2.2%. The average hospital stay was 19 days. The overall management costs were more than half million US Dollars.

CONCLUSIONS

Extremities and head and neck were the most injured regions. The referral from the forward centers and the procedures performed in our hospital improved the management outcomes. The management required long hospital stay and was costly.

Injuries and surgical needs of children in conflict and disaster: From Boston to Haiti and beyond

Comprehensive care of patients in conflict and disaster requires coordination of medical, social, and public health agencies. Pediatric patients in these settings comprise a particularly vulnerable group subject to disruption of social networks and separation from family, inadequate surgical care due to lack of surgeon, anesthetist, and nursing specialization, and a general lack of advocacy within the global public health agenda. In the recent upswell of attention to the global surgical burden of disease and deficiencies in necessary infrastructure, the needs of pediatric surgical patients remain underappreciated and underemphasized amid calls for improvement in global surgical health. Experience in recent natural and man-made disasters has demonstrated that pediatric patients makeup a significant proportion of those injured, and has perhaps refocused our need to better characterize the surgical needs of children in conflict and disaster. In addition to treat such patients, we recognize the unmet challenges of improving pediatric emergency and surgical infrastructures in the low- and middle-income country settings where conflict and disaster occur most often, and continuing to advocate for vulnerable children worldwide and keep them out of harm's way.

Assessment of the perioperative period in civilians injured in the Syrian Civil War

BACKGROUND

wars and its challenges have historically afflicted humanity. In Syria, severe injuries occurred due to firearms and explosives used in the war between government forces and civilians for a period of over 2 years.

MATERIALS AND METHODS

the study included 364 cases, who were admitted to Mustafa Kemal University Hospital, Medicine School (Hatay, Turkey), and underwent surgery. Survivors and non-survivors were compared regarding injury site, injury type and number of transfusions given. The mortality rate found in this study was also compared to those reported in other civil wars.

RESULTS

the mean age was 29 (3-68) years. Major sites of injury included extremities (56.0%), head (20.1%), abdomen (16.2%), vascular structures (4.4%) and thorax (3.3%). Injury types included firearm injury (64.4%), blast injury (34.4%) and miscellaneous injuries (1.2%). Survival rate was 89.6% while mortality rate was 10.4%. A significant difference was observed between mortality rates in this study and those reported for the Bosnia and Lebanon civil wars; and the difference became extremely prominent when compared to mortality rates reported for Vietnam and Afghanistan civil wars.

CONCLUSION

among injuries related to war, the highest rate of mortality was observed in head-neck, abdomen and vascular injuries. We believe that the higher mortality rate in the Syrian Civil War, compared to the Bosnia, Vietnam, Lebanon and Afghanistan wars, is due to seeing civilians as a direct target during war.

Extremity amputation: how to face challenging problems in a precarious environment

PURPOSE

Indications for amputation in natural disasters are not the same compared to our daily practice. They must be determined by those with great surgical experience and good knowledge of military or disaster surgical doctrine. Unfortunately, nowadays few surgeons have this experience. In fact, some volunteer surgeons may be interested in providing care for civilian victims of war or disaster in developing countries. However, there are significant differences between the type and the management of cases seen in this context versus those seen at home. The problems of amputations cannot be solved schematically. Amputation will depend on several factors: the form of warfare or disaster, the conditions for surgery, the skill of the surgical team and the experience of the surgeon, and the length or duration of the mission.

METHODS

Here is a schematic showing the three main situations: civilian practice, war practice and disaster context. These three different situations require different strategies for treating the wounded and for making amputation decisions.

RESULTS

In the case of a natural disaster, there are many wounded civilians, they arrive at the medical facility late and there is usually only one surgeon and a single, limited medical facility to provide all treatment. He must make quick, wise choices, economising limited blood supplies and the use of surgical procedures. The decision to proceed with limb salvage or amputation for patients with severely injured limbs will be a source of continued debate. Amputation, radical and irreversible intervention, is a frequent and essential procedure in the disaster context and one of the standard means to successful treatment of limb wounds.

CONCLUSIONS

We propose to reflect on the following questions: why to amputate, how to perform amputation under these conditions and how to pass on a doctrine to the voluntary surgeons who lack experience in a disaster context.

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.

[Trauma care - a global challenge. Experience gathered in a (trauma) center managing urban violence in Nigeria]

Internal fixation of fractures is an integral part of health care. However this is a privilege of the developed world. For humanitarian aid internal fixation has always been considered as too prone to infection given the poor hygienic conditions, too specialized, too costly and the infrastructure of so-called developing countries too weak to perform internal fixation successfully. Due to the globally increasing density of road traffic an alarming increase in victims of road traffic accidents can be observed. The World Health Organization (WHO) estimates that in 2030 road traffic accidents will be responsible for twice as many deaths as caused by HIV/AIDS.Road traffic accidents are considered to be the new global epidemic. Since the victims are generally young, their rehabilitation has not only a humanitarian, but also an economic impact for low-income countries. The organization Doctors Without Borders (Médecins Sans Frontières; MSF) is not only providing surgical care for victims of violence in war and conflict regions, but has expanded its portfolio to include victims of road traffic accidents and started to perform internal fixation under good hygienic circumstances in closed fractures. The following is a report about the work in a hospital for surgical trauma care in Port Harcourt, Nigeria where victims of road traffic accidents are treated besides victims of urban violence.

[Trauma surgery catastrophe aid following the earthquake in Haiti 2010--a report on experiences: injury patterns, special challenges, prospects]

The earthquake in Haiti in January 2010 resulted in more than 220,000 deaths and over 300,000 injured and was one of the greatest mass casualties in recent history. "Doctors Without Borders" started a medical relief response immediately after the earthquake, building up to the biggest disaster relief activity in the organization's history. Roughly 173,000 medical consultations and more than 11,700 surgical interventions were performed in 26 medical facilities during the first 4 months. A particular challenge was the sheer number of patients in a situation with a completely destroyed medical infrastructure. While the initial phase mainly focused on life saving surgery, the second phase concentrated on reconstructive surgery of the extremities. Crucial for effective patient care is an ability to act early and employ surgical techniques which are adapted to the overall situation. The following article is a personal report of the early emergency response from the viewpoint of two orthopedic trauma surgeons, who have surgical careers in Germany and also frequently volunteer for "Doctors Without Borders".