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Editorials

Trauma life support in conflict

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7425.1178 (Published 20 November 2003) Cite this as: BMJ 2003;327:1178
  1. Jon Clasper, consultant orthopaedic surgeon,
  2. David Rew, consultant general surgeon
  1. Frimley Park Hospital, Frimley, Surrey GU16 7UJ
  2. Southampton University Hospitals, Southampton SO16 6YD

    Resources must be optimised for the many, rather than dispersed for the few

    War injures and kills combatants and civilians. Medical resources are usually scarce in combat zones, and doctors must plan to make the most of these resources to minimise death and suffering. Planners seek to apply the widely adopted principles of advanced trauma life support to the treatment of penetrating wounds, burns, and other forms of acute physical trauma on the battlefield. This recognises the critical importance of effective early resuscitation after wounding to minimise the consequences of shock and to improve survival.

    Mortality after civilian trauma has been described as having a trimodal distribution.1 The first peak of deaths occurs within minutes of the event from non-survivable injuries, even with the most advanced medical resources immediately to hand. The second peak may account for some 30% of deaths, in the first few hours after injury. Death is most often due to hypoxia and hypovolaemic shock.2 This group stands to benefit the most from excellence in trauma care. The third peak, of up to 20% of trauma deaths, occurs late after the injury, from sepsis, multi-organ failure, and other complications.

    Does this descriptive model help the allocation of resources for trauma care in a war? Much severe civilian trauma is blunt, arising from road traffic accidents rather than from penetrative fragments and bullets, blast, and burns. The circumstances of war also differ from peacetime casualty incidents in that communications are often poor, the environment dangerous, and recovery teams and routes of evacuation unsafe and unreliable. Circumstances differ hugely from one conflict to another and even within individual war zones. Rapid treatment and evacuation of casualties to definitive care undoubtedly improves survival.3 4 However, other than for the lucky few, the evacuation of casualties to hospital usually takes hours,5 even in advancing forces with full and secure helicopter and road transport.6 A delay of several days is often seen by surgeons working for the International Committee of the Red Cross.7 8

    One possible solution to the problem of how to optimise trauma care on the basis of modern principles of advanced trauma life support is to disperse resuscitative surgical teams widely around the war zone to bring care forward to casualties. This has led to the development of the concept of “damage control surgery,” and surgical teams are co-located with mobile stations that receive casualties.

    Unfortunately in such relative isolation such teams cannot work to best effect. The resuscitation and immediate aftercare of patients who may have multiple penetrating, blast, and burn wounds require complex multidisciplinary teamwork. This includes a high standard of resources to support high dependency and intensive care and a holding capability for postoperative patients pending safe and stable evacuation or definitive corrective and revision surgery. Forward trauma teams, which are obliged to undertake ambitious surgery without such support, will face high morbidity and mortality. Conversely, hospitals in conflict zones that are equipped with such facilities will substantially extend their care capabilities and the range and effectiveness of damage control surgery. This in turn substantially increases the demand for specialist resources for the further care of patients who would otherwise die.

    In practical terms, we find that death in war fits a bimodal rather than a trimodal pattern. Casualties with major chest, abdominal, and intracranial trauma will usually die in the first few hours after injury, however good the medical services in place. Longer casualty timelines effectively cause the first and second peaks of the trimodal model to merge. Peripheral injuries to limbs and lucky misses will be disproportionately common among survivors, and the third peak will be small as the patients should generally survive if offered competent care, albeit with incapacities such as amputation.9 10

    Such was our experience during the 2003 Gulf war. Of the 80 patients with surgical trauma treated in a British field hospital during the initial phase of war only one patient with a survivable abdominal injury reached hospital care. Israeli military experience supports this finding even with very short medical communication lines. Ninety six per cent (337) of 351 deaths occurred in the first four hours, usually from blood loss.11 12 For those casualties who reach hospital the death rate is very low, although delays in evacuation increase the rates of serious wound infection and late morbidity.8 13

    In war resources for care of trauma must be optimised for the many, rather than dispersed for the few. Each conflict has its own characteristics.11 14 Medical problems are compounded by the wide dispersal and rapid mobility of forces and by the long range of modern weapon systems. These factors can produce simultaneous civilian and combatant casualties over a wide and insecure area. Current efforts to match resources to peacetime templates and timelines by dispersing the medical effort are unlikely to succeed. They may lead to a serious misallocation of scarce trauma team skills.

    In modern warfare as in the major conflicts of the past century surgical teams are usually best concentrated for the good of the many in well equipped civilian or military hospitals in the field or at base. The wide dissemination of skills in advanced trauma life support and of equipment through war zones,15 supported by commitment to robust casualty evacuation systems, should help minimise early deaths and late morbidity from war trauma. Military and civilian planners must also prepare for a full range of eventualities, with adequate resources for the care of the civilian population at risk, including pregnant women and young children. Tragically we seem to be stuck with war and its consequences, and realism about what is achievable will give the best chance of rehabilitation to those many casualties who receive survivable injuries.

    Acknowledgments

    JC and DR are surgeons to the Defence Medical Services reserve. However, the opinions expressed here are their own and not those of the Ministry of Defence.

    References