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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; 176:748-756. [PMID: 38955644 DOI: 10.1016/j.surg.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Vincent Y, Baltazard C, Pfister G, Pons F, Poichotte A, Goudard Y, Hornez E, Malgras B, Boddaert G, Balandraud P, Avaro JP, de Lesquen H. Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study. Injury 2024; 55:111676. [PMID: 38897902 DOI: 10.1016/j.injury.2024.111676] [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: 01/28/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.
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Affiliation(s)
- Yohann Vincent
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
| | | | - Georges Pfister
- Department of Orthopaedic, Trauma and Reconstructive Surgery, HIA Percy, Clamart, France
| | - François Pons
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Antoine Poichotte
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Yvain Goudard
- Department of Visceral Surgery, Laveran Military Teaching Hospital, French Military Health Service, Marseille, France
| | - Emmanuel Hornez
- Digestive surgery, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France; French Military Health Service Academy, Ecole du Val de Grace, Paris, France
| | | | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
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Muhrbeck M, Egelko A, Haweizy RM, von Schreeb J, Älgå A. Exploratory laparotomy during the battle of Mosul, 2016-2017: results from a tertiary civilian hospital in Erbil, Iraqi Kurdistan. BMC Emerg Med 2023; 23:113. [PMID: 37741988 PMCID: PMC10518085 DOI: 10.1186/s12873-023-00882-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND The Battle of Mosul (2016-2017) was an urban conflict resulting in over 9000 civilian deaths. Emergency Management Centre (EMC), located 90 km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating exploratory laparotomy (ex-lap) provide a unique window into the system of care delivery in conflicts, given the importance of timely, resource-intensive care. However, there is insufficient knowledge regarding the presentation and outcomes for conflict-related ex-lap in civilian institutions. METHODS This is a descriptive study retrospectively analyzing routinely collected data for all patients who underwent ex-lap at EMC for injuries sustained during the battle of Mosul. Differences in demographics, pre-hospital/hospital course, and New Injury Severity Scores (NISS) were analysed using student t-test, Hotelling T-squared, and linear regression. RESULTS During the battle, 1832 patients with conflict-related injuries were admitted to EMC. Some 73/1832 (4.0%) underwent ex-lap, of whom 22/73 (30.1%) were children and 40/73 (54.8%) were non-combatant adults. Men constituted 51/73 (69%) patients. Gunshot wounds caused 19/73 (26.0%) injuries, while ordnances caused 52/73 (71.2%). Information regarding hospital course was available for 47/73 (64.4%) patients. Children had prolonged time from injury to first laparotomy compared to adults (600 vs 208 min, p < 0.05). Median LOS was 6 days (IQR 4-9.5); however, 11/47 (23%) patients left against medical advice. Post-operative complications occurred in 11/47 (23.4%) patients; 6/11 (54.5%) were surgical site infections. There were 12 (25.5%) patients who underwent relaparotomies after index surgery elsewhere; 10/12 (83.3%) were for failed repairs or missed injuries. Median NISS was 18 (IQR 12-27). NISS were significantly higher for women (vs men; 28.5 vs 19.8), children (vs adults; 28.8 vs 20), and relaparotomy patients (vs primary laparotomy patients; 32.0 vs 19.0). Some 3 patients died, 2 of whom were relaparotomies. CONCLUSION At this civilian tertiary trauma centre, conflict-related exploratory laparotomies were associated with low morbidity and mortality. Long transport times, high rates of repeat laparotomies, and high numbers of patients leaving against medical advice raise questions regarding continuity of care along the Mosul Trauma Pathway. TRIAL REGISTRATION The study protocol was registered at Clinicaltrails.gov, ID NCT03490305, prior to collection of data.
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Affiliation(s)
- Måns Muhrbeck
- Department of Surgery in Norrköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Aron Egelko
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Johan von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Älgå
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Hanafi I, Alzamel L, Alnabelsi O, Sallam S, Almousa S. Lessons learnt from the first wave of COVID-19 in Damascus, Syria: a multicentre retrospective cohort study. BMJ Open 2023; 13:e065280. [PMID: 37474170 PMCID: PMC10360434 DOI: 10.1136/bmjopen-2022-065280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVES The decade-long Syrian war led to fragile health infrastructures lacking in personal and physical resources. The public health of the Syrian population was, therefore, vulnerable to the COVID-19 pandemic, which devastated even well-resourced healthcare systems. Nevertheless, the officially reported incidence and fatality rates were significantly lower than the forecasted numbers. DESIGN A retrospective cohort study. SETTING The four main responding hospitals in Damascus, which received most of the cases during the first pandemic wave in Syria (i.e., June-August 2020). PARTICIPANTS One thousand one hundred eighty-four patients who were managed as inpatient COVID-19 cases. PRIMARY AND SECONDARY OUTCOME MEASURES The records of hospitalised patients were screened for clinical history, vital signs, diagnosis modality, major interventions and status at discharge. RESULTS The diagnostic and therapeutic preparedness for COVID-19 was significantly heterogeneous among the different centres and depleted rapidly after the arrival of the first wave. Only 32% of the patients were diagnosed based on positive reverse transcription-PCR tests. Five hundred twenty-six patients had an indication for intensive care unit admission, but only 82% of them received it. Two hundred fifty-seven patients needed mechanical ventilation, but ventilators were not available to 14% of them, all of whom died. Overall mortality during hospitalisation reached 46% and no significant difference was found in fatality between those who received and did not receive these care options. CONCLUSIONS The Syrian healthcare system expressed minor resilience in facing the COVID-19 pandemic, as its assets vanished swiftly with a limited number of cases. This forced physicians to reserve resources (e.g., ventilators) for the most severe cases, which led to poor outcomes of in-hospital management and limited the admission capacity for milder cases. The overwhelmed system additionally suffered from constrained coordination, suboptimal allocation of the accessible resources and a severe inability to informatively report on the catastrophic pandemic course in Syria.
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Affiliation(s)
- Ibrahem Hanafi
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Lyana Alzamel
- Division of Pulmonology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Ola Alnabelsi
- Division of Pulmonology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Sondos Sallam
- Division of Pulmonology, Department of Internal Medicine, Damascus Hospital, Damascus, Syrian Arab Republic
| | - Samaher Almousa
- Division of Rheumatology, Department of Internal Medicine, Tishreen Military Hospital, Damascus, Syrian Arab Republic
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Hanafi I, Munder E, Ahmad S, Arabhamo I, Alziab S, Badin N, Omarain A, Jawish MK, Saleh M, Nickl V, Wipplinger T, Wipplinger C, Nickl R. War-related traumatic brain injuries during the Syrian armed conflict in Damascus 2014-2017: a cohort study and a literature review. BMC Emerg Med 2023; 23:35. [PMID: 36977988 PMCID: PMC10053936 DOI: 10.1186/s12873-023-00799-6] [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: 06/08/2022] [Accepted: 02/24/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND The decade-long Syrian armed conflict killed or injured more than 11% of the Syrian population. Head and neck injuries are the most frequent cause of war-related trauma, about half of which are brain injuries. Reports about Syrian brain trauma victims were published from neighboring countries; However, none are available from Syrian hospitals. This study aims to report war-related traumatic brain injuries from the Syrian capital. METHODS We conducted a retrospective cohort study between 2014 and 2017 at Damascus Hospital, the largest public hospital in Damascus, Syria. Target patients were the victims of combat-related traumatic brain injuries who arrived alive and were admitted to the neurosurgery department or to another department but followed by the neurosurgery team. The collected data included the mechanism, type, and site of injury based on imaging findings; types of invasive interventions; intensive-care unit (ICU) admissions; as well as neurological status at admission and discharge including several severity scales. RESULTS Our sample consisted of 195 patients; Ninety-six of them were male young adults, in addition to 40 females and 61 children. Injuries were caused by shrapnel in 127 (65%) cases, and by gunshots in the rest, and most of them (91%) were penetrating. Sixty-eight patients (35%) were admitted to the ICU, and 56 (29%) underwent surgery. Neurological impairment was reported in 49 patients (25%) at discharge, and the mortality rate during hospitalization was 33%. Mortality and neurological impairment associated significantly with higher values on clinical and imaging severity scores. CONCLUSIONS This study captured the full spectrum of war-related brain injuries of civilians and armed personnel in Syria without the delay required to transport patients to neighboring countries. Although the clinical presentation of injuries at admission was not as severe as that in previous reports, the inadequate resources (i.e., ventilators and operation rooms) and the lack of previous experience with similar injuries might have resulted in the higher mortality rate. Clinical and imaging severity scales can provide a handy tool in identifying cases with low probability of survival especially with the shortage of personal and physical resources.
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Affiliation(s)
- Ibrahem Hanafi
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Mazzah, Damascus, Syria.
| | - Eskander Munder
- Faculty of Medicine, Syrian Private University, Mazzah, Damascus, Syria
| | - Sulafa Ahmad
- Faculty of Medicine, Damascus University, Mazzah, Damascus, Syria
| | - Iman Arabhamo
- Faculty of Medicine, Syrian Private University, Mazzah, Damascus, Syria
| | - Suzan Alziab
- Faculty of Medicine, Damascus University, Mazzah, Damascus, Syria
| | - Noor Badin
- Faculty of Medicine, Damascus University, Mazzah, Damascus, Syria
| | - Ahmad Omarain
- Faculty of Medicine, Damascus University, Mazzah, Damascus, Syria
| | | | - Muhannad Saleh
- Division of Neurosurgery, Department of Surgery, Damascus Hospital, Damascus, Syria
| | - Vera Nickl
- Department of Neurosurgery, Würzburg University, Würzburg, Germany
| | - Tamara Wipplinger
- Department of Neurosurgery, Würzburg University, Würzburg, Germany
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, USA
| | | | - Robert Nickl
- Department of Neurosurgery, Würzburg University, Würzburg, Germany
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Anatoliyovych IL, Yuriyovych OU, Valentynovych OH. Surgical treatment features of liver gunshot wound with a dumdum bullet (expanding bullet). Int J Emerg Med 2022; 15:57. [PMID: 36217126 PMCID: PMC9549613 DOI: 10.1186/s12245-022-00460-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Liver injury is one of the most common abdominal traumas. The causes of military activity related injuries are gunshot wounds (up to 60–70%), while in peacetime—closed blunt abdominal trauma (up to 45–55%). The overall mortality is up to 40–60% and has higher rates in the group of wartime injury, among the male population over 65 years old and of low social status. Presentation of the case We report the management of a clinical case of a 34-year-old man with thoracoabdominal dumdum’s bullet trauma in the case of which damage control tactics were applied in cooperation between two clinics in conditions of active hostilities. Discussions Treatment of patients with abdominal injuries should be guided by the principles of damage control. This tactic requires stabilization of the patient's condition at the initial stage, followed by the completion of the final volume of surgical treatment in a compensated state of the patient. Liver injuries represent an ideal model for the application of damage control surgery in wartime settings and require close coordination between clinics that perform primary and delayed surgical interventions. Minimizing the volume of surgical intervention at the stage of primary control of bleeding due to liver damage provides the most optimal immediate results in conditions of a hemodynamically unstable patients, simultaneous admission of a large number of wounded, and a limited clinic resource. Conclusion This surgical history research is an example of the effectively organized and coordinated work of two clinics such as National Military Medical Clinical Center “Main Military Clinical Hospital” and Shalimov National Institute of Surgery and Transplantation, based on the principle of damage control in conditions of active hostilities.
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Affiliation(s)
| | | | - Oleksandr Hrynenko Valentynovych
- National Institute of Surgery and Transplantation named after O.O. Shalimov NAMS of Ukraine, Kyiv, Ukraine. .,Department of Liver Transplantation and Surgery, Shalimov National Institute of Surgery and Transplantation, 30 Heroiv Sevastopolya Str., Kyiv, 03680, Ukraine.
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COMPARATIVE EVALUATION OF HISTOLOGICAL RESULTS OF MODERN FIRE INFLAMMATORY INJURIES OF THE COLUMN BY DIFFERENT TYPES OF BULLETS IN THE EXPERIMENT. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-1-79-244-248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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