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Wren SM, Wild HB, Gurney J, Amirtharajah M, Brown ZW, Bulger EM, Burkle FM, Elster EA, Forrester JD, Garber K, Gosselin RA, Groen RS, Hsin G, Joshipura M, Kushner AL, Norton I, Osmers I, Pagano H, Razek T, Sáenz-Terrazas JM, Schussler L, Stewart BT, Traboulsi AAR, Trelles M, Troke J, VanFosson CA, Wise PH. A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare. JAMA Surg 2020; 155:114-121. [PMID: 31722004 PMCID: PMC6865259 DOI: 10.1001/jamasurg.2019.4547] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Question What are consensus components of a framework for humanitarian surgical response in modern conflict zones? Findings This survey study using responses from 35 participants in the Stanford Humanitarian Surgical Response in Conflict Working Group suggests that humanitarian responses include both care of traumatic injury and emergency surgical needs of the population. Lessons from civilian and military trauma systems as well as humanitarian settings were translated into a tiered continuum of response from patient presentation through rehabilitation. Meaning Evidence suggests that modern trauma systems save lives but providing this standard of care in insecure conflict settings places new burdens on humanitarian systems; the framework presented herein integrates advances in surgical care to these environments. 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.
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Affiliation(s)
- Sherry M Wren
- Stanford University School of Medicine, Stanford, California
| | - Hannah B Wild
- Stanford University School of Medicine, Stanford, California
| | - Jennifer Gurney
- US Army Institute of Surgical Research/Joint Trauma System, San Antonio, Texas
| | | | - Zachary W Brown
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle.,Committee on Trauma, American College of Surgeons, Chicago, Illinois
| | - Frederick M Burkle
- Harvard T. H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | | | - Kent Garber
- Department of Surgery, University of California, Los Angeles
| | | | - Reinou S Groen
- Department of Obstetrics and Gynecology, Alaska Native Medical Center, Anchorage
| | - Gary Hsin
- Stanford University School of Medicine, Stanford, California
| | | | - Adam L Kushner
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public health, Baltimore, Maryland
| | - Ian Norton
- Emergency Operations and Partnerships, Emergency Operations, World Health Organization, Geneva, Switzerland
| | - Inga Osmers
- Médecins Sans Frontières, Amsterdam, the Netherlands
| | | | - Tarek Razek
- Centre for Global Surgery, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | | - John Troke
- Samaritan's Purse, Boone, North Carolina
| | | | - Paul H Wise
- Stanford University School of Medicine, Stanford, California
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Schussler L, Burkle FM, Wren SM. Protecting Surgeons and Patients During Wars and Armed Conflicts: Importance of Predeployment Training on the Geneva Conventions and International Humanitarian Law. JAMA Surg 2020; 154:683-684. [PMID: 31141147 DOI: 10.1001/jamasurg.2019.0041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Lilli Schussler
- Medical student, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frederick M Burkle
- Harvard Humanitarian Initiative, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts.,Woodrow Wilson International Center for Scholars, Washington, DC
| | - Sherry M Wren
- Department of Surgery, Stanford University, Palo Alto, California
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Wren SM, Schussler L, Burkle FM. Global Action Needed to Protect Humanitarian Surgeons and Patients During Wars and Armed Conflicts-Reply. JAMA Surg 2020; 155:90-91. [PMID: 31532473 DOI: 10.1001/jamasurg.2019.3501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sherry M Wren
- Department of Surgery and Center for Global Health and Innovation, Stanford University, Stanford, California.,Palo Alto Veterans Hospital, Palo Alto, California
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