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ORIGINAL ARTICLE
Ahead of print publication  

The changing paradigm of injuries and their outcome in an international conflict zone


1 Department of Surgery, Command Hospital, Northern Command, Udhampur, Jammu and Kashmir, India
2 Department of Surgery, INHS Asvini, Mumbai, Maharashtra, India
3 Department of Surgery, MH, Secunderabad, Telangana, India

Date of Submission06-Aug-2019
Date of Acceptance12-Jan-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Pawan Sharma,
Department of Surgery, Trauma and Surgical Critical Care, Surgical Division, Command Hospital, Northern Command, Udhampur - 182 101, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_44_19

  Abstract 


Background: The characteristics of combat injuries differ from those encountered in civilian practice in terms of epidemiology, mechanism of wounding, pathophysiology, trajectory after injury and outcome. Furthermore, the nature of combat injuries is likely to change because of changes in the ways wars will be fought; such changes may influence therapeutic tactics and techniques, and military medical planning and logistics. Proper medical deployment at various peacekeeping missions requires projecting injuries. For this reason, the injury patterns and mechanism of injury were reviewed over a five year period, and injury rates and mechanisms were extracted for review. Methods: An observational study of 2942 trauma cases attending trauma Out Patient Department and emergency centre of United Nations Peacekeeping Mission Hospital in eastern DRC (Democratic Republic of Congo), was carried out from Jan 2009 to Dec 2013. The study includes age profile of patients along with the distribution and mechanism of injuries. Results: Penetrating injuries and blunt injuries accounted for 4.65% and 95.35% respectively of the total injuries sustained. The majority of the patients sustained injuries like mixed burns and inhalation injuries, assaults and contusions (84.33%). The most common age group affected was 22- 29 years (60.74%). Conclusions: The data clearly demonstrate that humanitarian and peacekeeping missions require preparation for a wide variety of mechanisms of injuries including non-combat trauma beyond the expected penetrating missile and blast injuries of a typical war scenario.

Keywords: Trauma, Peacekeeping mission, Combat injuries



How to cite this URL:
Sharma P, Sharma A, Rao K R. The changing paradigm of injuries and their outcome in an international conflict zone. J Mar Med Soc [Epub ahead of print] [cited 2021 Apr 23]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=312889




  Introduction Top


The United Nations (UN) undertakes peacekeeping missions in various countries to promote nation-building ideology. Epidemiological analysis of mechanism of injury and other variables affecting the pattern of injuries sustained helps to generate data that aid the policymakers to effectively utilize the available workforce and infrastructure.[1]

The medical response team must be versatile and adapt itself to various conflicts and the likely type of fatalities. Modern warfare has seen a drastic transformation in the distribution of various type of injuries.[2] Nonbattle injury was ranked the fourth leading cause of admissions in World War I trailing by respiratory, infectious, and digestive disorders. It jumped to the third leading cause during World War II and Korean war.[3]

In contrast to war scenario, peacekeeping mission entails management of a broader spectrum of diseases.[4] Availability of right equipment at the right time depends on the knowledge of the spectrum of diseases dealt at a particular place in a specific circumstance.[5],[6],[7] This study highlights the variety of cases dealt in Trauma Outpatient Department (OPD) in a UN peacekeeping mission hospital over a 5-year period.


  Materials and Methods Top


The study was carried out at a Level III hospital in an Eastern town of a central African nation which was catering for nearly 80,000 personnel of forces comprising of different nations. It was a fifty-bedded hospital with a four-bedded intensive care unit, two operation theaters (OT), blood bank, and basic radiological and laboratory facilities. The surgical team comprised of three surgeons including one trauma surgeon, OT-trained matrons, and paramedical staff. It received patients either directly from the place of incident or from a Level II hospital. The hospital had a well-trained casualty evacuation team capable of evacuation of patients by air and road. Difficult patients were transferred to Level IV hospital at Southern African Nation for further management.

The study is an observational study carried out among military personnel of various nations from all across the globe deployed in UN mission. The injured soldiers presented with various injuries despite wearing protective military gears at the above Level III hospital situated in eastern region of central African nation. The records of serving personnel of any nation attending trauma OPD and trauma center (emergency setting) from 2009 to 2013 were maintained meticulously. The data collected included age, mechanism of injury, distribution of injuries, and their severity. The information thus obtained was analyzed, compared, and tabulated. The results were compared to the existing studies on nature and pattern of injuries observed during various international conflicts since First World War.


  Results Top


During the 5 years' study period, 2942 trauma cases were attended to and managed at our hospital. The age distribution of the patients is as per [Table 1]. The age group 20–29 years was most commonly injured (60.74%) and those more than 50 years were least commonly affected (0.37%). The number of cases was unevenly distributed during the study period ranging from a minimum of 212 per year to a maximum of 949 per year [Figure 1].
Table 1: Age distribution

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Figure 1: Yearwise distribution

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Penetrating injuries occurred due to missile injuries which comprised of blast injuries (61.3%) and gunshot wounds (38.7%). These accounted for 4.65% of total injuries. Shrapnel from grenade and mine blast and assault rifles used by both UN troops and the rebels caused maximum penetrating injuries [Figure 2] and [Figure 3]. Blunt trauma included all other nonpenetrating injuries. These injuries (95.35%) were sustained consequent to motor vehicle accidents (MVAs), falls, and assaults including other nonpenetrating trauma like inhalation injuries and burns.
Figure 2: Penetrating missile injuries

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Figure 3: Blast injuries

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Fall from height was observed in 6% patients whereas MVAs resulted in 2% of all blunt injuries [Figure 4]. Majority of the blunt injuries occurred due to significant vehicular movements, frequent clashes with the local population, inhospitable terrain, fire hazards, and aircraft crashes.
Figure 4: Mechanism of injury

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Ninety-five (3.23%) patients presented with injuries consequent to assaults. Majority of the injured patients brought to our center had sustained mixed burns, contusions, large laceration, and other external injuries (84.33%). The anatomical distributions of the penetrating injuries are depicted in [Table 2].
Table 2: Penetrating injuries - anatomical distribution

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  Discussion Top


Of 2942 cases during the 5 years' study period from 2009 to 2013, majority of patients (84.33%) were treated in Emergency Department (ED) without need to admit them for more than a day. This finding highlights the need of a well-equipped dressing station/minor OT with well-trained paramedical staff. A significant number of patients (3.23%) suffered disabling musculoskeletal injuries during their active combat deployment which resulted in significant drop in the fighting strength and loss of man hours.

Of blunt injuries, fall from height contributed to 6% of total injuries. Majority of falls were accidental while climbing difficult terrains in different missions. Motor vehicular accidents comprised of 1.9% of total injuries. These injuries were seen in those areas where the roads were poorly maintained added with lack of traffic control. Adequate maintenance of the roadways could have reduced this number significantly.[8]

Penetrating injuries which are traditionally classified as combat-type injuries accounted for 4.65% of total injuries. Majority of this category of patients underwent emergency operative procedures and subsequently were deported back to their parent nations. The time interval between injury scene and arrival at the hospital was 20–30 min, and air evacuation facilities were effective. These factors were responsible for providing right service at the right time and helped to reduce mortality and morbidity. The emergency surgeries were usually in a cohort of two to ten patients at a time. Well-equipped trauma center and adequate training of paramedical staff were of paramount importance in handling multiple emergencies effectively.

Although combat injuries are the most evident and glaring, from a medical administrative standpoint, these injuries constitute only a single dimension in the multifaceted military medical care.[9] Injuries not attributable to combat scenario can also hamper fighting force strength. Combat casualties constitute a small proportion of the total disabilities in the conflict zone.[10] As compared to other wars, 37.44% of injuries were due to noncombat in World War II. Similarly, 43.66% and 34.81% of total injuries were contributed by noncombat mechanism in Korean and Vietnam War, respectively.[11] In our study, it was as high as 95%.

The anatomical distribution of penetrating injuries observed at our center was comparable with studies of other war scenarios (P = 0.042) [Table 3].[12] Similar was the observation while studying injuries to thorax, abdomen, and limbs. Head and neck region injuries seen at our center (8%) were significantly less. The strict enforcement of wearing a protective war head gear as well as wearing a good-quality helmets while riding a two-wheeler played a significant role in preventing head injuries both in conflict zone as well as on roads.
Table 3: Anatomical distribution of penetrating injuries

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In a study by Wolf et al., massive blood transfusion protocol was activated in 7% of the combat casualties. Acute traumatic coagulopathy was seen in 65% of them with mortality exceeding 50%.[13] Ivey et al. observed that the mortality attributed to chest injuries during the American Civil War, World War I, World War II, the Korean War, and the Vietnam War was 62.6%, 27.0%, 11.0%, 1.5%, and 2.9%, respectively. Fascinatingly, during operation enduring freedom (Iraq), the mortality of chest injuries “unexpectedly” increased to 10.5%. This was due to the better reporting of cases due to prevalent use of protective equipment and better evacuation facilities.[14]

Berg R et al. in a series of 984 patients in 2014 observed that surgical intervention was required in 86% of the patients alive (638 of 671). Sixty-eight percent of total casualties underwent laparotomy alone, 4% underwent thoracotomy alone, and 14% (104 of 741) underwent both the surgeries. 75% of the patients had either diaphragmatic injury or hollow viscus injury. Cardiac injury was present in 33% of the patients arriving alive.[15]

In a study by Morrison et al. of 27 trauma patients, 11 required laparotomy and tube thoracostomy and 9 required thoracolaparotomy. There were nine fatalities, all within 2 weeks of being wounded. Four patients died from hemorrhagic shock, solitary mortality from a traumatic brain injury, and four from multiorgan dysfunction syndrome.[16]

In another study by Schoenfeld et al., explosions were the most common mode of injury (70%), while 18% of wounds occurred due to gunshot. Extremity wounds and injuries to the head and neck represented 34% of casualty burden. Thoracic trauma and abdominal injuries occurred in 16% and 17%, respectively.[17]

A review by Du Bose et al. in their study of 604 patients revealed shock as initial presentation in 5.5%. Blast injuries (61.9%) and gunshot wound (19.5%) mechanisms accounted for the majority of combat injuries. Mortality was less among military casualties overall (7.7% vs. 21.0%; P < 0.001; odds ratio, 0.32 [0.16–0.61]) as compared to civilian counterparts.[18]


  Conclusion Top


In our study, the pattern of injuries is different from those seen in any other conflict or conventional war scenario. In any case, the receiving hospital must be adequately equipped for handling a large number of injuries with varying mechanisms involving multiple body regions in addition to having a robust emergency operating room and ED. Significant reduction of avoidable injuries (MVAs and thermal injuries) can be ensured by strict enforcement of preventive measures such as wearing good-quality helmets and following traffic discipline. Adequate trauma and emergency training of all the personnels involved in providing combat care must be stressed on which goes a long way in effective and simultaneous management of both combat and noncombat injuries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bellamy RF. Combat trauma overview. In: Zajtchuk R, Grande CM, editors. Textbook of Military Medicine, Anesthesia and Perioperative Care of the Combat Casualty. Falls Church, VA: Office of the Surgeon General, United States Army; 1995. p. 1-42.  Back to cited text no. 1
    
2.
Assessing the effectiveness of conventional weapons. Bellamy RF, Zajtchuk R, editors. Textbook of Military Medicine, Conventional Warfare. Falls Church, VA: Office of the Surgeon General, United States Army; 1991. p. 55-69.  Back to cited text no. 2
    
3.
Murray CK, Reynolds JC, Schroeder JM, Harrison MB, Evans OM, Hospenthal DR. Spectrum of care provided at an echelon II Medical Unit during Operation Iraqi Freedom. Mil Med 2005;170:516-20.  Back to cited text no. 3
    
4.
Dupuy TN. Attrition: Forecasting Battle Casualties and Equipment Losses in Modern War. In: Falls Church: VA: Nova Publications; 1995.  Back to cited text no. 4
    
5.
Appenzeller GN. Injury patterns in peacekeeping missions: The Kosovo experience. Mil Med 2004;169:187-91.  Back to cited text no. 5
    
6.
Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE, et al. United States Army Rangers in Somalia: An analysis of combat casualties on an urban battlefield. J Trauma 2000;49:515-28.  Back to cited text no. 6
    
7.
Meade P, Mirocha J. Civilian landmine injuries in Sri Lanka. J Trauma 2000;48:735-9.  Back to cited text no. 7
    
8.
Original data are in the Possession of the Uniformed Services University of the Health Sciences. Wound data, and munitions effectiveness team: The WDMET study. Bethesda, MD: Original data are in the Possession of the Uniformed Services University of the Health Sciences; 1970.  Back to cited text no. 8
    
9.
Bellamy RF. The causes of death in conventional land warfare: Implications for combat casualty care research. Mil Med 1984;149:55-62.  Back to cited text no. 9
    
10.
Arnold K, Cutting RT. Causes of death in United States Military personnel hospitalized in Vietnam. Mil Med 1978;143:161-4.  Back to cited text no. 10
    
11.
Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB. Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006;61:1366-72.  Back to cited text no. 11
    
12.
Champion CC, Howard R, Bellamy BB, Ronald F, Roberts RR, Colonel P, et al. A Profile of Combat Injury. Journal of Trauma and Acute Care Surgery 2003;54:S13-19.  Back to cited text no. 12
    
13.
Wolf SE, Kauvar DS, Wade CE, Cancio LC, Renz EP, Horvath EE, et al. Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom. Ann Surg 2006;243:786-92.  Back to cited text no. 13
    
14.
Ivey KM, White CE, Wallum TE, Aden JK, Cannon JW, Chung KK, et al. Thoracic injuries in US combat casualties: A 10-year review of Operation Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg 2012;73:S514-9.  Back to cited text no. 14
    
15.
Berg RJ, Inaba K, Okoye O, Karamanos E, Strumwasser A, Chouliaras K, et al. The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg 2014;77:684-91.  Back to cited text no. 15
    
16.
Morrison JJ, Midwinter MJ, Jansen JO. Ballistic thoracoabdominal injury: Analysis of recent military experience in Afghanistan. World J Surg 2011;35:1396-401.  Back to cited text no. 16
    
17.
Schoenfeld AJ, Dunn JC, Bader JO, Belmont PJ Jr. The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003-2011. J Trauma Acute Care Surg 2013;75:287-91.  Back to cited text no. 17
    
18.
Du Bose JJ, Barmparas G, Inaba K, Stein DM, Scalea T, Cancio LC, et al. Isolated severe traumatic brain injuries sustained during combat operations: Demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. J Trauma 2011;70:11-6.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

 
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