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

Abstract: 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).