Surgery in Armed Conflicts : Predicting surgical treatment needs and improving resource use in resource-constrained settings

Background  In armed conflicts, civilian health care struggles to cope. Understanding the relationship between demographics, injury mechanism, and injury patterns to predict what surgical resources are needed is therefore vital. In the 1990s the International Committee of the Red Cross (ICRC) implemented the Red Cross Wound Score (RCWS) for the assessment of penetrating injuries. It is unknown to what extent RCWS can be used to predict surgical resource consumption and in-hospital mortality. A substantial portion of surgical resources in conflicts are used in the treatment of infected wounds, which entails antibiotics, debridements, and change of dressings. Many health care providers advocate for the use of honey as an adjunct due to its bactericidal and hyperosmotic properties. However, the scientific evidence to support this notion is insufficient. If efficacy for honey could be demonstrated, the need for repeated debridements and antibiotics could potentially be reduced, subsequently allowing for more efficient use of surgical resources.   Objectives  To increase knowledge regarding the relationship between demographics, injury mechanism, injury patterns, treatment received (Paper I), treatment trends (Paper II), and surgical resources consumption (Paper III). To identify predictive methods (Paper III) and practices (Paper IV) that can improve how surgical resources are used in resource-constrained conflict settings.   Materials and Methods  In Papers I – III routine clinical data from patients treated at three ICRC hospitals were used. The patients had weapon-related injuries from either the conflict around the Afghanistan – Pakistan border or the conflict in the Kivu region in the Democratic Republic of the Congo (DRC). In Paper I, the relationships between gender, injury mechanism, injury patterns, and treatment received were examined with univariate statistics. In Paper II, differences in treatment practices between 1992 – 1995 and 2009 – 2012 for extremity injuries were analysed with univariate statistics and logistic regression to adjust for differences in injury mechanism and severity. In Paper III, univariate statistics, logistic regression, receiver operating characteristics curves, and goodness of fit were used to determine the predictive ability of RCWS and commonly used trauma scores for surgical resource consumption. In Paper IV, 50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topical honey or intramuscular gentamicin to determine if topical honey is non-inferior to systemic gentamicin treatment. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological and immunohistochemical assays, as well as assessment of inflammatory response.   Main findings  In both conflicts, most of the patients were males in their mid-twenties with injuries to the extremities. Injuries from indiscriminate weapons (such as bombs, missiles, and explosives) were more predominant in the Afghanistan – Pakistan border conflict, and gunshot injuries were more frequent in the Kivu conflict. Soft tissue procedures were the most common type of surgery. Less than 20% of the patients were subjected to major surgery, and in-hospital mortality was under 5% (Papers I – III). Females were more frequently injured by indiscriminate weapons, had more severely affected vital parameters, received more blood transfusions, and were subjected to more extensive surgery than the males (Paper I). During the last decades, the risk for amputation remained unchanged, while the use of external fixation and split skin grafts decreased (Paper II). RCWS predicted high surgical resource consumption better than and in-hospital mortality at least equal to commonly used trauma scores (Paper III). Wound size was unchanged with topical honey and decreased with intramuscular gentamicin. However, there was no difference in bacterial count between honey and gentamicin at the end of treatment (Paper IV).  Conclusions  Females were more frequently injured by indiscriminate weapons, had more severe injuries, and had greater surgical treatment needs than the males (Paper I). Even though injuries to the extremities remain common in armed conflicts, the use of limb-preserving treatment techniques seems to have decreased during the last decades (Paper II). RCWS demonstrated a better predictive ability for surgical resource consumption compared to commonly used trauma scores (Paper III). Topical honey may be non-inferior to gentamicin in reducing S. aureus colonization on the wound’s surface, but not in reducing wound size (Paper IV).  Väpnade konflikter leder till kollaps av existerande hälso-och sjukvårdssystem, vilket snabbt begränsar eller omöjliggör kirurgisk vård för patienter med potentiellt livshotande skador. Dessutom är skador i väpnade konflikter ofta mer komplexa och resurskrävande än skador som förekommer i fredstid. För vårdgivare behövs därför kunskap om vad som påverkar det kirurgiska resursbehovet i konflikter, men även metoder för att kunna följa och förutsäga det samma. Internationella Rödakorskommittén (ICRC) har sedan 1990-talet använt ett system för sårklassificering (RCWS) för att hjälpa kirurger att bedöma och prioritera penetrerande sårskador. Det är okänt i vilken utsträckning RCWS eller andra klassificeringssystem som används i civil traumasjukvård kan användas för att förutsäga kirurgiskt resursbehov och dödlighet i resursknappa konfliktmiljöer. En betydande del av kirurgiska resurser i konflikter används för behandling av infekterade sår. Många vårdgivare förespråkar användande av honung som del i denna behandling. Detta på grund av honungs bakteriedödande och uttorkande egenskaper. Det saknas dock vetenskapligt stöd för denna uppfattning. Om honung kan påvisas vara effektivt som behandling för infekterade sår skulle behovet av antibiotika och upprepade kirurgiska behandlingar kunna minskas. Detta skulle möjliggöra mer effektivt användande av kirurgiska resurser. Denna avhandling syftar till att öka kunskapen kring hur kirurgiska resurser används i resursknappa konfliktmiljöer. Detta med målsättningen att identifiera metoder för att förutsäga och mäta det kirurgiska resursbehovet och göra användandet av det samma mera effektivt. I tre av de studier som ingår i avhandlingen har rutinmässigt insamlade journaluppgifter från patienter som behandlats vid tre ICRC sjukhus använts. Patienterna hade vapen-orsakade skador från konflikten vid gränsen mellan Afghanistan och Pakistan eller konflikten i Kivu-regionen i Demokratiska republiken Kongo (DRC). I den första studien undersöktes förhållandet mellan kön, skademekanism, uppkomna skador och erhållen kirurgisk behandling för patienter som behandlats vid ICRC sjukhuset i Peshawar, Pakistan. I den andra studien undersöktes hur behandlingen av vapen-orsakade extremitetsskador skilde sig mellan perioderna 1992 – 1995 och 2009 – 2012 vid ICRC sjukhus i Quetta och Peshawar, Pakistan. I den tredje studien prövades hur väl RCWS samt poängssystem som används i civil traumasjukvård kunde förutsäga det kirurgiska behandlingsbehovet hos patienter vid ICRC sjukhus i Peshawar, Pakistan, och Goma, DRC. I den sista studien jämfördes honung och antibiotika som behandling av infekterade sår i en försöksdjursmodell. De båda behandlingarna utvärderades och jämfördes genom bakterieodlingar, mätningar av såryta, histologiska och immunhistokemiska analyser samt inflammatoriskt svar. På de studerade ICRC sjukhusen var de flesta patienterna män i tjugoårsåldern med skador på armar eller ben. Skador från urskillningslösa vapen, som granater, missiler och bomber, var mer frekvent förekommande i gränskonflikten mellan Afghanistan och Pakistan, medan skottskador var vanligare i Kivu-konflikten. Behandling av mjukdelsskador var den vanligaste typen av kirurgi. Mindre än 20% av patienterna genomgick större operationer och dödligheten under sjukhusvistelsen var mindre än 5%. Kvinnor skadades i större omfattning av urskillningslösa vapen, hade allvarligare skador, fick oftare blodtransfusioner och behandlades med mera omfattande kirurgi än männen. Trots att skador på armar och ben är vanligt förekommande i väpnande konflikter så hade användandet av frakturstabiliserande åtgärder och hudtransplantationer minskat under de senaste årtiondena, medan risken för amputation var oförändrad. RCWS var bättre på att förutsäga kirurgisk resursförbrukning än de poängsystem som används i civil traumasjukvård. Slutligen visade den sista studien i avhandlingen att varken honung eller antibiotika minskar antalet bakterier i sår efter avslutad behandling. Däremot minskade sårens storlek med antibiotika, men var oförändrade med honung. Möjligen skulle därför honung kunna vara effektivt för att förhindra bakterieväxt på sårytan. Det finns därför anledning att undersöka om honung kan vara ett värdefullt tillägg till antibiotika och kirurgisk behandling. Detta skulle kunna förbättra användandet av de begränsade kirurgiska resurser som finns tillgängliga i väpnade konflikter.Funding agencies:• Elsa and Sigurd Golje Foundation• Linköping Society of Medicine• RALF and ALF grants, Region Östergötland• Kamprad Family Foundation</p

Clostridium septicum myonecrosis following gardening: A case report

Introduction and importance Clostridial myonecrosis (CM), or gas gangrene, is a rare necrotizing muscle infection caused most often by Clostridium perfringens or C. septicum. Inoculation can occur either traumatically or spontaneously. CM has a high mortality rate if not treated promptly. Case presentation A 64-year-old male presented to the emergency department (ED) with sudden onset left flank pain and fever. Repeated CT scans demonstrated progressive edema around the left iliopsoas muscle with gas formation and bleeding. The patient received intravenous fluids, meropenem, and clindamycin. Emergency laparotomy was performed on suspicion of necrotizing fasciitis and revealed a necrotic left iliopsoas muscle which was partially excised. Blood cultures were positive at 12 h with growth of C. septicum. Prolonged stay in the intensive care unit, and six additional surgical interventions to the abdomen, left thigh, and flank were needed. The patient was discharged after four months to a nursing home. Clinical discussion C. septicum CM more often occurs spontaneously and is associated with colorectal malignancy. However, for our patient, CT colonography and proctoscopy did not reveal any pathology. Therefore, we believe the CM resulted from an injury the patient sustained while working in his backyard, either a cut from barbed wire on his arm or from soil contaminating his psoriatic lesions. Successful outcomes for patients with CM require a high index of suspicion, timely treatment with antibiotics, and repeated surgical debridements. Conclusion This case report describes the presentation and management of a presumably injury-related CM caused by C. septicum

Efficacy of topical honey compared to systemic gentamicin for treatment of infected war wounds in a porcine model : A non-inferiority experimental pilot study

Background: In armed conflicts, infected wounds constitute a large portion of the surgical workload. Treatment consists of debridements, change of dressings, and antibiotics. Many surgeons advocate for the use of honey as an adjunct with the rationale that honey has bactericidal and hyperosmotic properties. However, according to a Cochrane review from 2015 there is insufficient data to draw any conclusions regarding the efficacy of honey in treatment of wounds. We, therefore, decided to evaluate if honey is non-inferior to gentamicin in the treatment of infected wounds in a highly translatable porcine wound model. Material and methods: 50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topically applied Manuka honey or intramuscular gentamicin for eight days. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological, immunohistochemical assays, and inflammatory response. Results: Topically applied Manuka honey did not reduce bacterial count or wound area for the duration of treatment. Intramuscular gentamicin initially reduced bacterial count (geometric mean 5.59*,0.37 - 4.27 *,0.80 log10 (GSD) CFU/g), but this was not sustained for the duration of the treatment. However, wound area was significantly reduced with intramuscular gentamicin at the end of treatment (mean 112.8 +/- 30.0-67.7 +/- 13.2 (SD) mm(2)). ANOVA-analysis demonstrated no variation in bacterial count for the two treatments but significant variation in wound area (p = 0.0001). The inflammatory response was more persistent in the pig with wounds treated with topically applied Manuka honey than in the pig treated with intramuscular gentamicin. Conclusion: At the end of treatment S. aureus count was the same with topically applied Manuka honey and intramuscular gentamicin. The wound area was unchanged with topically applied Manuka honey and decreased with intramuscular gentamicin. Topically applied Manuka honey could consequently be non inferior to intramuscular gentamicin in reducing S. aureus colonization on the wounds surface, but not in reducing wound size. The use of Manuka honey dressings to prevent further progression of a wound infection may therefore be of value in armed conflicts, where definite care is not immediately available.Funding agencies: Kamprad Family Foundation [20170287]; Swedish government [LIO-700121]; county councils, the ALF-agreement [LIO-700121]</p

Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study

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 ICRCs hospitals in Peshawar, 2009-2012 and Goma, 2012-2014. High resource consumption was defined as &amp;gt;= 3 surgical procedures or &amp;gt;= 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.Funding Agencies|Linkoping University</p

Hospital Workload for Weapon-Wounded Females Treated by the International Committee of the Red Cross: More Work Needed than for Males

Civilians constitute 33-51% of victims in armed conflicts. Several reports on civilian injuries exist, but few have focused on injuries afflicting females. We analyzed routinely collected data on weapon-related injuries from the International Committee of the Red Cross (ICRC) hospital in northwestern Pakistan in order to define injury patterns and types of surgical treatment for females. A total of 3028 patient files (376 females) from consecutively admitted patients to the ICRC-hospital in Peshawar from February 2009 to May 2012 were included. Information regarding injury-mechanism, time since injury, vital parameters at admission, type of injury, treatment and basic outcome was extracted from the files and analyzed. Comparisons between gender and age-groups were done by cross-table analyses or nonparametric tests. Females were younger than males (20 vs. 25 years), arrived sooner after injury (24 vs. 48 h) (p amp;lt; 0.001 for both) and were victims of bombs and missiles more frequently (64.4 vs. 54.6%) (p amp;lt; 0.001). Vital parameters such as systolic blood pressure (110 vs. 113 mmHg) and pulse rate (100 vs. 86) were more affected at admission (p amp;lt; 0.001 for both). Females were subjected to surgery (83.0 vs. 77.4%) (p amp;lt; 0.05) and were given blood transfusions more often (18.8 vs. 13.6%) (p amp;lt; 0.01). No differences in amputations or in-hospital mortality were found. Females treated at the ICRC-hospital in northwestern Pakistan are markedly affected by indiscriminate weapons such as bombs and missiles. Their average consumption of surgery is greater than for males, and this might be relevant in planning for staffing and facility needs in similar contexts.Funding Agencies|Elsa and Sigurd Golje Foundation; Linkoping Society of Medicine</p

Trends in Demographics and Surgical Treatment of Weapon-Related Limb Injuries Over Two Decades in a Resource-Scarce Setting

Background In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. Methods Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. Results Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p amp;lt; 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p amp;lt; 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p amp;lt; 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. Conclusion In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.Funding Agencies|Sigurd and Elsa Goljes Memorial Foundation; ALF grants, Region Ostergotland, Sweden [LIO-799621, LA2016-0457]</p

Using the Red Cross wound classification to predict treatment needs in children with conflict-related limb injuries: a retrospective database study

Background The International Committee of the Red Cross (ICRC) implemented the Red Cross wound classification (RCWC) to quickly assess the severity of a wound in conflict settings. A subdivision into wound grades derived from the RCWC consists of grades 1, 2, and 3, and represents low, major, and massive energy transfer, respectively, to the injured tissue. The aim of this observational study is to assess whether the Red Cross wound grade of a pediatric patients wound correlates with patient outcomes. Methods All pediatric patients (age &amp;lt; 15 years) treated in an ICRC hospital between 1988 and 2014 for conflict-related penetrating extremity injuries were retroactively included. Correlations were assessed between wound grades and number of surgeries, blood transfusions, days hospitalized, and mortality. Stratification analyses were performed to evaluate potential effect modifiers. Results The study included 2463 pediatric patients. Pediatric patients with a higher wound grade received significantly more surgeries (grade 1 median 2; grade 3 median 3), more blood transfusions (grades 1 and 3 received 33.9 and 72.2 units per 100 patients, respectively), and were hospitalized longer (grade 1 median 15; grade 3 median 40 days). Mortality rates did not significantly differ. Stratification analyses did not reveal effect modifiers for the association between wound grades and patient outcomes. Conclusion The Red Cross wound grade of a pediatric patients extremity wound correlates independently with treatment needs. This simple wound grading system could support clinical decision-making and should be integrated into the clinical assessment of weapon-wounded pediatric patients in conflict settings

Self-perceived preparedness and training needs of healthcare personnel on humanitarian mission: a pre- and post-deployment survey

Background: Humanitarian healthcare workers are indispensable for treating weapon-wounded patients in armed conflict, and the international humanitarian community should ensure adequate preparedness for this task. This study aims to assess deployed humanitarian healthcare workers’ self-perceived preparedness, training requirements and mental support needs. Methods: Medical professionals deployed with the International Committee of the Red Cross (ICRC) between October 2018 and June 2020 were invited to participate in this longitudinal questionnaire. Two separate questionnaires were conducted pre- and post-deployment to assess respondents’ self-perceived preparedness, preparation efforts, deployment experiences and deployment influence on personal and professional development. Results: Response rates for the pre- and post-deployment questionnaires were 52.5% (114/217) and 26.7% (58/217), respectively. Eighty-five respondents (85/114; 74.6%) reported feeling sufficiently prepared to treat adult trauma patients, reflected by predeployment ratings of 3 or higher on a scale from 1 (low) to 5 (high). Significantly lower ratings were found among nurses compared to physicians. Work experience in a high-volume trauma centre before deployment was associated with a greater feeling of preparedness (mean rank 46.98 vs. 36.89; p = 0.045). Topics most frequently requested to be included in future training were neurosurgery, maxillofacial surgery, reconstructive surgery, ultrasound, tropical diseases, triage, burns and newborn noncommunicable disease management. Moreover, 51.7% (30/58) of the respondents regarded the availability of a mental health professional during deployment as helpful to deal with stress. Conclusion: Overall, deployed ICRC medical personnel felt sufficiently prepared for their missions, although nurses reported lower preparedness levels than physicians. Recommendations were made concerning topics to be covered in future training and additional preparation strategies to gain relevant clinical experience. Future preparatory efforts should focus on all medical professions, and their training needs should be continuously monitored to ensure the alignment of preparation strategies with preparation needs

Additional file 1 of Exploratory laparotomy during the battle of Mosul, 2016–2017: results from a tertiary civilian hospital in Erbil, Iraqi Kurdistan

Additional file 1

Global surgery for paediatric casualties in armed conflict

Background: Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones. Methods: Characteristics of children (age &lt; 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years). Results: Of the patients listed in the database, 15% (5843/38,088) were aged &lt; 15 years. The median age was 10 years (IQR 6-12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1-3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates. Conclusions: Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts