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Bryce-Alberti M, Bosché M, Benavente R, Chowdhury A, Steel LB, Winslow K, Bain PA, Le T, Hamzah R, Ilkhani S, Pratt M, Carroll M, Nunes Campos L, Anderson GA. Examining nonmilitary and nongovernmental humanitarian surgical capacity and response in armed conflicts: A scoping review of the recent literature. Surgery 2024:S0039-6060(24)00364-7. [PMID: 38955644 DOI: 10.1016/j.surg.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Armed conflicts pose a burden on health care services. We sought to assess the surgical capacity and responses of nonmilitary and nongovernmental humanitarian responders in armed conflicts through proxy indicators to identify strategies to address surgical needs. METHODS We searched 6 databases for articles/studies from January 1, 2013, to March 10, 2023. We included articles detailing the surgical capacity of nonmilitary, nongovernmental organizations operating in armed conflicts. We defined surgical capacity through indicators including the type and number of surgical procedures; number of operating rooms, surgical beds, surgeons, anesthesiologists, and surgical equipment; and type of anesthesia employed. RESULTS We screened 2,187 abstracts and 279 full texts and included 30 articles/studies. Our sample covered 23 countries and 17 surgical specialties. Most publications focused on surgical capacity assessment (63.3%, 19/30) and surgical and clinical outcomes (63.3%, 19/30). Most articles/studies reported surgical capacity indicators at the hospital (56.7%, 17/30) and multinational (26.7%, 8/30) levels. The number (86.7%, 26/30) and type (76.7%, 23/30) of surgical procedures performed were the most commonly reported. More than one half of the articles (53.3%, 16/30) described strategies to meet surgical needs in armed conflicts. Most strategies addressed information management (68.8%, 11/16), health workforce (62.5%, 10/16), and service delivery (62.5%, 10/16). CONCLUSION This review collated common approaches for strengthening health care services in armed conflicts. Several articles emphasized strategies for improving information management, service delivery, and workforce capacity. Hence, we call for standardization of response protocols and multilevel collaborations to maintain or even scale up surgical capacity in armed conflicts.
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Affiliation(s)
- Mayte Bryce-Alberti
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
| | | | | | | | - Lili B Steel
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Kiana Winslow
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, MA
| | - Thalia Le
- Drexel College of Medicine, Philadelphia, PA
| | - Radzi Hamzah
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Saba Ilkhani
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Malerie Pratt
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Madeleine Carroll
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Letícia Nunes Campos
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Faculty of Medical Sciences, Universidade de Pernambuco, Recife, PE, Brazil
| | - Geoffrey A Anderson
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA; US Air Force Reserves, 439th Aeromedical Staging Squadron, Westover Air Reserve Base, Chicopee, MA
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Haverkamp FJC, Van Dongen TTCF, Edwards MJR, Boel T, Pöyhönen A, Tan ECTH, Hoencamp R. European military surgical teams in combat theater: A survey study on deployment preparation and experience. Injury 2024; 55:111320. [PMID: 38238119 DOI: 10.1016/j.injury.2024.111320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/27/2023] [Accepted: 01/08/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Adequate (predeployment) training of the nowadays highly specialized Western military surgical teams is vital to ensure a broad range of surgical skills to treat combat casualties. This survey study aimed to assess the self-perceived preparedness, training needs, deployment experience, and post-deployment impact of surgical teams deployed with the Danish, Dutch, or Finnish Armed Forces. Study findings may facilitate a customized predeployment training. METHODS A questionnaire was distributed among Danish, Dutch, and Finnish military surgical teams deployed between January 2013 and December 2020 (N = 142). The primary endpoint of self-perceived preparedness ratings, and data on the training needs, deployment experiences, and post-deployment impacts were compared between professions and nations. RESULTS The respondents comprised 35 surgeons, 25 anesthesiologists, and 39 supporting staff members, with a response rate of 69.7 % (99/142). Self-perceived deployment preparedness was rated with a median of 4.0 (IQR 4.0-4.0; scale: 1 [very unprepared]-5 [more than sufficient]). No differences were found among professions and nations. Skills that surgeons rated below average (median <6.0; scale: 1 [low]-10 [high]) included tropical disease management and maxillofacial, neurological, gynecological, ophthalmic, and nerve repair surgery. The deployment caseload was most often reported as <1 case per week (41/99, 41.4 %). The need for professional psychological help was rated at a median of 1.0 (IQR 1.0-1.0; scale: 1 [not at all]-5 [very much]). CONCLUSIONS Military surgical teams report overall adequate preparedness for deployment. Challenges remain for establishing broadly skilled teams because of a low deployment caseload and ongoing primary specializations. Additional training and exposure were indicated for several specialism-specific skill areas. The need for specific training should be addressed through customized predeployment programs.
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Affiliation(s)
| | | | | | - Thomas Boel
- Danish Armed Forces, Medical Command, DK-8220 Brabrand, Denmark
| | - Antti Pöyhönen
- Finnish Defence Forces Health Services, Centre For Military Medicine, FI-11311 Riihimäki, Finland
| | - Edward C T H Tan
- Department of Surgery, Radboudumc, 6500 HB Nijmegen, Netherlands; Defence Healthcare Organization, Ministry of Defence, 3584 AB Utrecht, Netherlands
| | - Rigo Hoencamp
- Defence Healthcare Organization, Ministry of Defence, 3584 AB Utrecht, Netherlands; Department of Surgery, Alrijne Hospital, 2353 GA Leiderdorp, Netherlands; Division of Surgery, Leiden University Medical Centre, 2333 ZA Leiden, Netherlands; Department of Surgery, Erasmus MC, 3015 GD Rotterdam, Netherlands
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Benzar I, Levytskyi A, Khrapach V, Unukovych D. Warzone pediatric trauma care: Lessons from civilian medical staff in Kyiv. World J Surg 2024; 48:540-546. [PMID: 38319195 DOI: 10.1002/wjs.12091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/06/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION The article discusses the challenges faced by civilian healthcare providers in Kyiv, Ukraine, during the conflict in treating pediatric trauma resulting from war-related incidents. METHODS The authors share their experiences and insights from managing a series of 12 pediatric patients admitted to the Ohmatdyt children's hospital between February 25 and April 1, 2022. During this period, the hospital was under constant threat due to the military conflict. RESULTS The patients, ranging in age from 3 months to 17 years, suffered injuries from various causes, including vehicle shootings, explosions, and other traumatic events. The interventions and timely management are discussed, and two detailed clinical cases are presented to illustrate the complexities of treating pediatric trauma in a warzone. CONCLUSION In summary, the article sheds light on the unique challenges faced by healthcare providers in a warzone when treating pediatric trauma. It underscores the importance of timely intervention, effective triage, and the utilization of advanced medical techniques to improve patient outcomes in such challenging circumstances.
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Affiliation(s)
- Iryna Benzar
- Department of Pediatric Surgery, Bogomolets National Medical University, Kyiv, Ukraine
| | - Anatolii Levytskyi
- Department of Pediatric Surgery, Bogomolets National Medical University, Kyiv, Ukraine
| | - Vasyl Khrapach
- Department of Plastic Surgery, Bogomolets National Medical University, Kyiv, Ukraine
| | - Dmytro Unukovych
- Department of Plastic Surgery, Bogomolets National Medical University, Kyiv, Ukraine
- Department of Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
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Hardcastle TC, Gyedu A, Doherty GM, Wren SM. Editorial commentary and call for papers-Humanitarian surgery in conflict zones. World J Surg 2024; 48:507-508. [PMID: 38407321 DOI: 10.1002/wjs.12119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Timothy C Hardcastle
- Department of Health KwaZulu-Natal and Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University if Science and Technology, Kumasi, Ghana
| | | | - Sherry M Wren
- Stanford University School of Medicine, Stanford, California, USA
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McKnight G, Friebel R, Marks I, Almaqadma A, Youssef Seleem M, Tientcheu TF, Saleh R, Ryan-Coker M, Emodi R, Seida M, Barden J, Redmond A, Amirtharajah M, Wren SM, Leather A, Hargest R. Defining humanitarian surgery: international consensus in global surgery. Br J Surg 2024; 111:znae024. [PMID: 38372664 PMCID: PMC10875721 DOI: 10.1093/bjs/znae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Gerard McKnight
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Rocco Friebel
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Isobel Marks
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Urology, Great Ormond Street Hospital for Children, London, UK
| | - Ahmed Almaqadma
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Plastic Surgery Department, Alshifa Medical Complex, Gaza, Palestine
| | - Mohamed Youssef Seleem
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Surgery, Cairo University, Cairo, Egypt
| | - Tim Fabrice Tientcheu
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- General and Digestive Surgical Unit, Central Hospital Yaounde, Yaounde, Cameroon
- Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Raoof Saleh
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Médicins Sans Frontières, Kilo Project, Kilo Hospital, Ibb Governorate, Yemen
| | - Marcella Ryan-Coker
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Surgery, University of Nairobi, Nairobi, Kenya
| | - Rosemary Emodi
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
| | - Mai Seida
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
| | - Jonathan Barden
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
| | - Anthony Redmond
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, University of Manchester, Manchester, UK
| | - Mohana Amirtharajah
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Médicines Sans Frontières Operational Centre Amsterdam, Amsterdam, The Netherlands
| | - Sherry M Wren
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- Department of Surgery and Center for Innovation in Global Health, Stanford University, Stanford, California, USA
| | - Andrew Leather
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King’s College London, London, UK
| | - Rachel Hargest
- Global Surgery Policy Unit, LSE Health, London School of Economics and Political Science, London, UK
- Humanitarian Surgery Initiative, Global Affairs Department, Royal College of Surgeons of England, London, UK
- School of Medicine, Cardiff University, Cardiff, UK
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Sauder M, Kornblith L, Gurney J, Elkbuli A. Trauma care during times of conflict: Strategic targeting of medical resources & operational logistics to save more lives. Injury 2023; 54:271-273. [PMID: 36379738 DOI: 10.1016/j.injury.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Matthew Sauder
- NSU NOVA Southeastern University School of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Lucy Kornblith
- Department of Surgery, Division of Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; University of San Francisco, San Francisco, CA, USA
| | - Jennifer Gurney
- US Army Institute of Surgical Research and the DoD Joint Trauma System, San Antonio, TX, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA, 86 W Underwood St., Orlando, FL 32806, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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Leversedge C, McCullough M, Appiani LMC, Đình MP, Kamal RN, Shapiro LM. Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist. World J Surg 2023; 47:50-60. [PMID: 36210361 PMCID: PMC9726663 DOI: 10.1007/s00268-022-06760-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent. METHODS We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain. RESULTS A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience. CONCLUSION As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.
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Affiliation(s)
- Chelsea Leversedge
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA USA
| | - Meghan McCullough
- Department of Plastic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA USA
| | - Luis Miguel Castro Appiani
- Department of Orthopaedic Surgery, Hospital Clinica Biblica, Aveinda 14 Calle 1 Y Central, San José, Costa Rica
| | - Mùng Phan Đình
- Orthropaedic Institute, 175 Military Hospital, Ho Chi Minh City, Vietnam
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street MC: 6342, Redwood City, CA USA
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, University of California, 1500 Owens St., San Francisco, CA USA
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Sandhu A, Herron JBT, Martin NA. Burns management in the military and humanitarian setting. BMJ Mil Health 2022; 168:467-472. [PMID: 33361439 DOI: 10.1136/bmjmilitary-2020-001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/04/2022]
Abstract
Burns are an unpredictable element of the modern battlespace and humanitarian operations. Most military burns are small and may not be a significant challenge for deployed healthcare assets but usually render the individual combat ineffective until healed. However, larger burns represent a more significant challenge because of the demand for fluid resuscitation therapy, early surgical intervention and regular wound management that can rapidly deplete surgical capabilities. Beyond the initial injury, longer-term consequences, such as psychological morbidity and loss of functional independence, are rarely considered as part of an ongoing care plan. Globally, most of the morbidity and mortality associated with burns are seen in less economically developed countries and are frequently associated with conflicts and natural disasters, but with simple interventions and resources, outcomes in these environments can be markedly improved. Prehospital providers should be confident to manage the initial assessment of a burn, including triaging for evacuation and packaging for safe transfer. This article provides an overview for prehospital providers on the management of thermal burns in military and humanitarian settings, with additional considerations for the management of chemical and electrical injuries.
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Affiliation(s)
| | | | - N A Martin
- Joint Hospital Group South East, Aldershot, UK
- St Andrew's Burns Service, Chelmsford, UK
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Salio F, Pirisi A, Bruni E, Court M, Peleg K, Reaiche S, Redmond A, Weinstein E, Hubloue I, Corte FD, Ragazzoni L. Provision of trauma care in asymmetric warfare: a conceptual framework to support the decision to implement frontline care services. Confl Health 2022; 16:55. [PMID: 36309683 PMCID: PMC9618202 DOI: 10.1186/s13031-022-00490-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The emerging trends of asymmetric and urban warfare call for a revision of the needs and the way in which frontline trauma care is provided to affected population. However, there is no consensus on the process to decide when and how to provide such lifesaving interventions in form of Trauma Stabilization Point (TSP). METHODS A three-step Delphi method was used to establish consensus. A focus group discussion was convened to propose a framework and develop the list of twenty-one (21) statements for validation of a group of experts. RESULTS A panel of twenty-eight (28) experts reviewed the statements and participated to both first and second rounds. Comments and recommendations provided by the FGD and during round 1 were used to analyze the findings of the study. The proposed framework includes five main categories identified as interconnected components that facilitate the decision to implement or not the TSP. A total of sixteen (16) elements distributed across the five categories have been considered as being able to guide the decision to utilize such capability in high-risk security and resource constrained settings. CONCLUSION The TSP has the potential to prevent death and disability. The proposed framework and categories add a structure to the decision-making process and represents an important step to support emergency and trauma care planning and implementation efforts.
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Affiliation(s)
- F Salio
- World Health Organization (WHO), Geneva, Switzerland.
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Vrije Universiteit Brussel (VUB), Humanitarian Aid and Global Health Università del Piemonte Orientale Via Lanino, 1, 28100, Novara, Italy.
| | - A Pirisi
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Vrije Universiteit Brussel (VUB), Humanitarian Aid and Global Health Università del Piemonte Orientale Via Lanino, 1, 28100, Novara, Italy
| | - E Bruni
- World Health Organization, Ukraine Country Office, Kyiv, Ukraine
| | - M Court
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - K Peleg
- Department of Emergency and Disaster Management, Tel Aviv University, Tel Aviv, Israel
| | | | - A Redmond
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - E Weinstein
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Vrije Universiteit Brussel (VUB), Humanitarian Aid and Global Health Università del Piemonte Orientale Via Lanino, 1, 28100, Novara, Italy
| | - I Hubloue
- Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - F Della Corte
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Vrije Universiteit Brussel (VUB), Humanitarian Aid and Global Health Università del Piemonte Orientale Via Lanino, 1, 28100, Novara, Italy
| | - L Ragazzoni
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Vrije Universiteit Brussel (VUB), Humanitarian Aid and Global Health Università del Piemonte Orientale Via Lanino, 1, 28100, Novara, Italy
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Wild H, Reavley P, Mayhew E, Ameh EA, Celikkaya ME, Stewart B. Strengthening the emergency health response to children wounded by explosive weapons in conflict. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000443. [DOI: 10.1136/wjps-2022-000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/07/2022] [Indexed: 11/04/2022] Open
Abstract
The 2022 war in Ukraine has highlighted the unacceptable consequences wrought on civilians and health infrastructure by conflict. Children are among the most vulnerable of those affected and constitute an increasing percentage of non-combatants injured in conflicts globally. A disproportionate number of these injuries are caused by blast mechanisms from munitions including ‘conventional’ landmines and indiscriminate explosive weapons such as barrel bombs and improvised explosive devices. In 21st century conflict, children are no longer only accidental casualties of war, but are increasingly targeted by parties through acts such as bombing of school buses and playgrounds, conscription as child soldiers, and use as human shields. In the present viewpoint article, we review the state of pediatric blast injury studies, synthesizing current understandings of injury epidemiology and identifying gaps in research to advance the field towards a concrete agenda to improve care for this vulnerable population.
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Applying the Haddon Matrix to Frontline Care Preparedness and Response in Asymmetric Warfare. Prehosp Disaster Med 2022; 37:577-583. [PMID: 35875999 PMCID: PMC9470527 DOI: 10.1017/s1049023x22001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction: Asymmetric warfare and the reaction to its threats have implications in the way far-forward medical assistance is provided in such settings. Investments in far-forward emergency resuscitation and stabilization can contribute to saving lives and increase the resilience of health systems. Thus, it is proposed to extend the use of the Haddon Matrix to determine a set of strategies to better understand and prioritize activities to prepare for and set-up frontline care in the form of Trauma Stabilization Points (TSPs). Methods: An expert consensus methodology was used to achieve the research aim. A small subject matter experts’ group was convened to create and validate the content of the Haddon Matrix. Results: The result of the expert group consultations presented an overview of TSP Preparedness and Operational Readiness activities within a Haddon Matrix framework. Main strategies to be adopted within the cycle from pre- to post-event had been identified and presented considering the identified opportunities in the context of the possibility of implementation. Of particular importance was the revision of a curriculum that fits the civilian medical system and facilitates its adaptation to the context and available resources. Conclusion: The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.
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Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq. Ann Surg 2022; 276:732-742. [PMID: 35837945 DOI: 10.1097/sla.0000000000005592] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations. BACKGROUND International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949 these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements and outcomes of civilian trauma in combat zones has not been previously characterized. METHODS Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005-2019. Inclusion criteria were civilians and non-NATO coalition personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized. RESULTS A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age >13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median injury severity score (ISS) was 9 in each cohort with ISS scores ≥ 25 in 2,236 (13.4%) civilians and 1,398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5,850 civilians received a transfusion with 2,118 (12.6%) of them receiving ≥10 units; 4,590 NNCPs received a transfusion with 1,669 (12.6%) receiving ≥ 10 units. MTF mortality rates were civilians 1,263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and non-operative, were similar between both groups. CONCLUSIONS In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as non-NATO Coalition Personnel. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.
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Stucky CH, Brown WJ, Knight AR, Hover AJ, De Jong MJ. Operation Allies Refuge and Operation Allies Welcome: Military Perioperative and Perianesthesia Nursing Support to the Afghan Evacuation Mission. J Perianesth Nurs 2022; 37:298-307. [PMID: 35339386 DOI: 10.1016/j.jopan.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/01/2021] [Accepted: 12/26/2021] [Indexed: 10/18/2022]
Abstract
Nursing has a long and celebrated history of providing life-saving care during crises and periods of great need. Following the government collapse in Afghanistan and the withdrawal of US troops, a severe humanitarian and human rights crisis emerged. The US military participated in one of the largest and most complex humanitarian missions in history to aid Afghan relief efforts. US and coalition forces evacuated more than 130,000 people in the chaotic Allied airlift from the Kabul Airport. The overarching missions, Operation Allies Refuge and Operation Allies Welcome, provided humanitarian support to at-risk Afghan nationals who contributed to the Global War on Terrorism efforts, as well as US citizens living in Afghanistan. Landstuhl Regional Medical Center (LRMC), an overseas military treatment facility located in Germany, supported the healthcare needs of Afghan evacuees and injured US service members during the humanitarian crisis. LRMC clinicians provided emergent, urgent, and specialty care while advocating for evacuee health, wellness, and living conditions. Perioperative and perianesthesia nurses were essential to the humanitarian response, as many evacuees and injured US service members arrived in Germany requiring immediate surgical interventions. In this article, we describe the vital contributions of military perioperative and perianesthesia nurses to the Operation Allies Refuge and Operation Allies Welcome missions, and share our experiences providing humanitarian relief. Military and civilian healthcare planners can learn from our humanitarian relief contributions, experiences, and lessons to strategically prepare their health systems to respond to future crises.
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Affiliation(s)
- Christopher H Stucky
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center. Rheinland-Pfalz, Germany.
| | - William J Brown
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center. Rheinland-Pfalz, Germany
| | - Albert R Knight
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center. Rheinland-Pfalz, Germany
| | - Andrew J Hover
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center. Rheinland-Pfalz, Germany
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15
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Nerlander MP, Pini A, Trelles M, Majanen H, Al-Abbasi O, Maroof M, Ragazzoni L, von Schreeb J. Epidemiology of Patients Treated at the Emergency Department of a Medcins Sans Frontieres Field Hospital During the Mosul Offensive: Iraq, 2017e. J Emerg Med 2021; 61:774-781. [PMID: 34538676 DOI: 10.1016/j.jemermed.2021.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/17/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts. OBJECTIVE This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict. METHODS During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant. RESULTS The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately one-third of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED. CONCLUSIONS The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflict-related injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.
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Affiliation(s)
- Maximilian P Nerlander
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Alessandro Pini
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Miguel Trelles
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Hanna Majanen
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Omar Al-Abbasi
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Mansour Maroof
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Luca Ragazzoni
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Johan von Schreeb
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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16
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Muhrbeck M, Osman Z, von Schreeb J, Wladis A, Andersson P. Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study. BMC Emerg Med 2021; 21:94. [PMID: 34380419 PMCID: PMC8359038 DOI: 10.1186/s12873-021-00488-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/30/2021] [Indexed: 11/14/2022] Open
Abstract
Background In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings. Methods A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC’s hospitals in Peshawar, 2009–2012 and Goma, 2012–2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC). Results A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74–0.78) than for KTS (0.53, 95% CI 0.50–0.56) and RTS (0.51, 95% CI 0.48–0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79–0.88) than for KTS (0.71, 95% CI 0.65–0.76) and RTS (0.70, 95% CI 0.63–0.76) for all patients, but not for patients with complete data. Conclusion RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00488-2.
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Affiliation(s)
- Måns Muhrbeck
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden.
| | - Zaher Osman
- International Committee of the Red Cross, Geneva, Switzerland
| | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Wladis
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
| | - Peter Andersson
- Department of Surgery in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,International Medical Programme, Center for Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden
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17
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Counting the costs of trauma: the need for a new paediatric injury severity score. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:391-392. [PMID: 34019790 PMCID: PMC9764975 DOI: 10.1016/s2352-4642(21)00132-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/24/2022]
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Samuel N, Epstein D, Oren A, Shapira S, Hoffmann Y, Friedman N, Shavit I. Severe pediatric war trauma: A military-civilian collaboration from retrieval to repatriation. J Trauma Acute Care Surg 2021; 90:e1-e6. [PMID: 33021604 DOI: 10.1097/ta.0000000000002974] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Modern conflicts take a disproportionate and increasing toll on civilians and children. Since 2013, hundreds of Syrian children have fled to the Israeli border. Severely injured children were triaged for military airborne transport and brought to civilian trauma centers in Israel. After recovery, these patients returned to their homes in Syria.We sought to describe a unique model of a coordinated military-civilian response for the stabilization, transport, and in-hospital management of severe pediatric warzone trauma. METHODS Prehospital and in-hospital data of all severe pediatric trauma casualties transported by military helicopters from the Syrian border were extracted. Data were abstracted from the electronic medical records of military and civilian medical centers' trauma registries. RESULTS Sixteen critically injured children with a median age of 9.5 years (interquartile range [IQR], 6.5-11.5) were transported from the Syrian border to Level I and Level II trauma centers within Israel. All patients were admitted to intensive care units. Eight patients underwent lifesaving procedures during flight, 7 required airway management, and 5 required thoracostomy. The median injury severity score was 35 (IQR, 13-49). Seven laparotomies, 5 craniotomies, 3 orthopedic surgeries, and 1 skin graft surgery were performed. The median intensive care unit and hospital length of stay were 6 days (IQR, 3-16) and 34 days (IQR, 14-46), respectively. Fifteen patients survived to hospital discharge and returned to their families. CONCLUSION The findings of this small cohort suggest the benefits of a coordinated military-civilian retrieval of severe pediatric warzone trauma. LEVEL OF EVIDENCE Therapeutic, Level V.
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Affiliation(s)
- Nir Samuel
- From the Pediatric Emergency Department (N.S., I.S.), Rambam Health Care Campus, Haifa; Department of Neurobiology (N.S.), Weizmann Institute of Science, Rehovot; Medical Corps (D.E., S.S.), Israel Defense Forces, Tel-Hashomer; Department of Internal Medicine "B" (D.E.), Rambam Health Care Campus, Haifa; Sackler School of Medicine (A.O., N.F.), Tel Aviv University, Tel Aviv; Department of Military Medicine (S.S.), Hebrew University Hadassah School of Medicine, Jerusalem; Pediatric Intensive Care Unit (Y.H.), Galilee Medical Center, Nahariya; and Pediatric Emergency Department (N.F.), Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
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19
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Wild H, Stewart BT, LeBoa C, Stave CD, Wren SM. Epidemiology of Injuries Sustained by Civilians and Local Combatants in Contemporary Armed Conflict: An Appeal for a Shared Trauma Registry Among Humanitarian Actors. World J Surg 2020; 44:1863-1873. [PMID: 32100067 PMCID: PMC7223167 DOI: 10.1007/s00268-020-05428-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. METHODS We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. RESULTS The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. CONCLUSIONS Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements.
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Affiliation(s)
- Hannah Wild
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Research and Prevention Center, Seattle, WA, USA
| | | | - Christopher D Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
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Garber K, Kushner AL, Wren SM, Wise PH, Spiegel PB. Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway. Confl Health 2020; 14:5. [PMID: 32042308 PMCID: PMC7001520 DOI: 10.1186/s13031-019-0249-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016-July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts. METHODOLOGY A qualitative study design was used to examine the Mosul civilian trauma response. From August-December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified. RESULTS The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system. CONCLUSIONS The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.
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Affiliation(s)
- Kent Garber
- 0000 0000 9632 6718grid.19006.3eDepartment of Surgery, University of California, Los Angeles, CA USA ,0000 0001 2171 9311grid.21107.35Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Adam L. Kushner
- 0000 0001 2171 9311grid.21107.35Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA ,Surgeons OverSeas, New York, NY USA
| | - Sherry M. Wren
- 0000000419368956grid.168010.eDepartment of Surgery, Stanford University, Palo Alto, CA USA
| | - Paul H. Wise
- 0000000419368956grid.168010.eDepartment of Pediatrics, School of Medicine, Stanford University, Stanford, CA USA
| | - Paul B. Spiegel
- 0000 0001 2171 9311grid.21107.35Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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