Wounds of war : surgical care for conflict-related injuries among civilians in resource-limited settings

Abstract: Background: Armed conflicts significantly contribute to the global burden of injury and death. Armed conflicts shocks health systems, deprive its resources and reduce its function, as well as limits access to civilian hospital care. In such resource-limited settings, the evidence on how to optimally manage the injuries sustained by civilians remains scarce. Objectives: To generate knowledge on how wound infection affects outcomes for civilian patients treated for conflict-related injuries, to explore the challenges associated with the treatment of such patients, and to evaluate the safety, effectiveness, and cost-effectiveness of negative pressure wound therapy (NPWT) for conflict-related extremity wounds. Methods: All patients were wounded in armed conflicts in Syria and Iraq. The studies were performed at two civilian hospitals in Jordan and Iraqi Kurdistan. In a cohort study (Paper I), utilising routinely collected clinical data from consecutive patients surgically treated for conflict-related injuries, we compared patients with wound infection to those without, in terms of clinical outcome and resource consumption. Paper II was a qualitative study where treating physicians in Jordan were interviewed to explore the perceived main challenges in conflict wound management. Paper III was a randomised controlled trial on the safety and effectiveness of NPWT compared to standard treatment for conflict-related extremity wounds. In Paper IV we used clinical outcome data from Paper III to perform a health economic evaluation of NPWT in resource-limited settings. Main Findings: Wound infection was associated with poor clinical outcomes and excess resource consumption. In addition, three out of four infected wounds contained multidrug-resistant bacteria. The main challenges in conflict wound management related to protocol adherence. Reasons for protocol deviations included resource scarcity, high patient loads, and limited compliance among patients and caregivers. Neither time to wound closure nor net clinical benefit was improved by NPWT compared to standard treatment for conflict-related extremity wounds. Treatment-related healthcare costs were higher for NPWT compared to standard treatment Conclusions: Wound infection was associated with poor clinical outcomes and an excess resource consumption among patients receiving surgery for conflict-related injuries. Physicians found protocol adherence to be the main challenge in the management of conflict-related wounds. NPWT did not result in superior clinical outcomes compared to standard treatment. In addition, costs were higher, indicating that NPWT is not a cost-effective treatment option.