Triage of mass casualties in war conditions: realities and lessons learned (original) (raw)
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A Clinical Review on Basic Management of War Injuries / Mass Casualties
Journal of Bangladesh College of Physicians and Surgeons, 2010
Managing war injury is no longer the exclusive preserve of military surgeons. All surgeons require a sound grasp of the subject. Increasing numbers of non-combatants are injured in modern conflicts, and peacetime surgical facilities with expertise may not be available 1-2. One of the hallmarks of war injury is the early lethality of wounds to the head, chest, and abdomen; therefore, limb injuries form a high proportion of the wounds that present at hospitals during conflicts 3. However, it is still appropriate to be aware of the "Gold standard" of management 4. Aim The aim of this clinical review article is to describe the sequence of events of managing war injuries including mass casualties with triage, resuscitation and initial wound surgery by non-specialist surgeons with limited resources and expertise. Objectives 1. To understand the epidemiology of warfare injuries / mass casualties. 2. To know the fundamentals of wound ballistics and injury mechanisms. 3. To understand the principles of wound management. 4. To have a sound grasp of initial management principles when dealing with mass casualties .
Collegium antropologicum, 2008
This report presents experience in treatment of war injuries in Franciscan hospital "dr. fra Mato Nikolić" in Nova Bila, during the war in Central Bosnia from 1993 to 1994, in conditions of encirclement and typhoid fever outbreak. Descriptive-retrospective analysis of organization, implementation and outcomes of surgical care for patients treated from January 1, 1993 till August 20, 1994. In this period, the hospital took care of 2500 wounded persons, 2286 (91.4%) of them male and 214 (8.6%) female, their the average age being 31.5 +/- 12.8. There were 1412 gunshot injuries (56.5%), 1022 explosive injuries (40.9%), and 66 blunt injuries (2.6%). There were 1250 injuries to extremities (50.0%), 349 injuries to head and neck (14%), 233 chest injuries (9.3%) and 193 injuries to abdomen (7.7%). There were also 475 multiple injuries (19%). Surgical operations were performed in 1498 patients (60%), with surgical mortality rate of 4.5%. Total hospital mortality rate was 11.4 perce...
Conflict and Health, 2010
Background: The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict.
Surgery, 2015
Operative trauma in low-resource settings: The experience of Médecins Sans Frontières in environments of conflict, postconflict, and disaster. 2015, 157 (5):850-6 Surgery Democratic Republic of the Congo, Tabarre, Port-au-Prince, Ha€ ıti, Timurgara, Lower Dir, Pakistan, Jabal-Akkrad, Syria, and Baltimore, MD Background. Conflicts and disasters remain prevalent in low-and middle-income countries, and injury remains a leading cause of death worldwide. The objective of this study was to describe the operative procedures performed for injury-related pathologies at facilities supported by M edecins Sans Fronti eres (MSF) to guide the planning of future responses. Methods. A retrospective review of a prospectively collected database of all MSF procedures performed between July 2008 and June 2014 for injury-related indications was completed. Individual data points included country of project and date of procedure; age, patient sex, and the American Society of Anesthesiologists' score of each patient; indication for surgery, including mechanism of injury; operative procedure; operative urgency; operative order; type of anesthesia; and intraoperative mortality. Injury severity was stratified according to operative order and urgency. Results. A total of 79,715 procedures were performed in MSF projects that met the inclusion criteria. Of these, 35,756 (44.9%) were performed specifically for traumatic indications across 17 countries. Even after excluding trauma centers, 29.4% (18,329/62,288) of operative cases were for injuries. Operative trauma procedures were performed most commonly for road traffic injuries (29.9%; 10,686/35,756). The most common procedure for acute trauma was extensive wound debridement (31.6%; 3,165/ 10,022) whereas burn dressings were the most frequent planned reoperation (27.1%; 4,361/16,078). Conclusion. Trauma remains an important component of the operative care provided in humanitarian assistance. This review of procedures performed by MSF in a variety of settings provides valuable insight into demographics of trauma patients, mechanisms of injury, and surgical capabilities required in planning resource allocation for future humanitarian missions in low-and middle-income countries. (Surgery 2015;157:850-6.)
ABC of conflict and disaster : principles of war surgery
Bmj British Medical Journal, 2005
Managing war injury is no longer the exclusive preserve of military surgeons. Increasing numbers of non-combatants are injured in modern conflicts, and peacetime surgical facilities and expertise may not be available. This article addresses the management of war wounds by non-specialist surgeons with limited resources and expertise. One of the hallmarks of war injury is the early lethality of wounds to the head, chest, and abdomen; therefore, limb injuries form a high proportion of the wounds that present at hospitals during conflicts. Wounding patterns Gunshot wounds The incidence of gunshot wounds in conflict depends on the type and intensity of the fighting. In full scale war the proportion of casualties injured by gunshot is generally less than in low intensity or asymmetric warfare. Bullets cause injury by: x Direct laceration of vital structures x Stretching of tissue (cavitation), causing fracturing of blood vessels and devitalisation of tissue
Triage of American Combat Casualties: The Need for Change
Military Medicine, 1994
United States military medical planning must reevaluate the practices of combat casualty resuscitation, transportation, and triage to secondary echelon care. Analysis of the experiences of other medical commands, such as that of the Israeli Defense Force, offers insight into improvements in equipment and training that are achievable with minimal cost. Training programs must involve formal instruction in Advanced Trauma Life Support for the combat corpsman, and ongoing experience in trauma surgery for personnel who are placed in the role of military surgeons. Today in military medicine there exists a major deficiency of expertise in trauma care, arising through a near total lack of involvement in active trauma surgery on the part of military medical training facilities. Civilian trauma centers offer an abundance of opportunity for military-like casualty management, and successful efforts at our command have integrated active duty personnel into this experience.
BMJ Global Health
Trauma/stroke centres optimise acute 24/7/365 surgical/critical care in high-income countries (HICs). Concepts from low-income and middle-income countries (LMICs) offer additional cost-effective healthcare strategies for limited-resource settings when combined with the trauma/stroke centre concept. Mass casualty centres (MCCs) integrate resources for both routine and emergency care—from prevention to acute care to rehabilitation. Integration of the various healthcare systems—governmental, non-governmental and military—is key to avoid both duplication and gaps. With input from LMIC and HIC personnel of various backgrounds—trauma and subspecialty surgery, nursing, information technology and telemedicine, and healthcare administration—creative solutions to the challenges of expanding care (both daily and disaster) are developed. MCCs are evolving initially in Chile and Pakistan. Technologies for cost-effective healthcare in LMICs include smartphone apps (enhance prehospital care) to el...
Military Medicine, 2015
Paris cedex 05, France keywords:!forward surgical team, medical support to the population, humanitarian medicine, advance course for deployment surgery, surgical skill set, military deployment ! 3! Abstract INTRODUCTION: The aims of this study were as follows: first, to quantify and review the types of surgical procedures performed by military surgeons assigned to a Forward Surgical Team (FST) providing medical support to the population (MSP) in the Ivory Coast (IC); and second, to analyze how this MSP was achieved. METHODS: Between 2002 and 2012, all of the local nationals operated on by the different FSTs deployed in the IC were included in the study. The surgical activity was analyzed and divided into surgical specialties, war wounds (WWs), non-war emergency trauma (NWET), non-trauma emergencies (NTEs) and elective surgery (ES). Demographics, circumstances of healthcare management, wounded organs and types of surgical procedures were described. RESULTS: Over this period, surgeons operated on 2315 patients and performed 2556 procedures. ES accounted for 78.7% of the surgical activity, NTEs accounted for 12.7%, NWET accounted for 8%, and WWs accounted for 0.6%. The main surgical activities were visceral (43.8%) and orthopedic (including soft tissues) surgeries (38.5%). CONCLUSION: The FSTs contributed widely to MSP in the IC. This MSP required limited resources, standardization of the procedures and specific skills beyond the original surgical specialties of military surgeons to fulfill the needs of the local population. Key Words: forward surgical team, medical support to the population, humanitarian medicine, advance course for deployment surgery, surgical skill set, military deployment ! 4!
IMPORTANCE Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. OBJECTIVE To describe a consensus framework for surgical care designed to respond to this emerging need. DESIGN, SETTING, AND PARTICIPANTS An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. MAIN OUTCOMES AND MEASURES The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. RESULTS Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. CONCLUSIONS AND RELEVANCE Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.