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Humanitarian Trauma Care Delivered by US Military Facilities During Combat Operations in Afghanistan, Iraq, and Syria
Jennifer M. Gurney2, Victoria Graf3, Amanda M. Staudt3, Jennifer D. Trevino3, Christopher A. VanFosson4, Hannah Wild5, Sherry M. Wren1
1Surgery, Stanford University, Palo Alto, California, United States, 2US Army Institute of Surgical Research and the DoD Joint Trauma System, San Antonio, Texas, United States, 3Geneva Foundation, Fort Sam Houston, Texas, United States, 4Brooke Army Medical Center, San Antonio, Texas, United States, 5Surgery, University of Washington, Seattle, Washington, United States

Objective: To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan, Iraq, and Syria.

Background: The Law of Armed Conflict, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949 these standards expanded to include injured civilians. In 2001 the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all coalition forces as well as civilians. A thorough understanding of civilian trauma care during active combat has not been characterized in terms of injury types, resource requirements, and outcomes.

Methods: Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005-2019. Inclusion criteria were civilians and non-NATO coalition forces (NNCF) with traumatic injuries treated at MTFs in Afghanistan, Iraq, and Syria. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized.

Results: A total of 29,963 casualties were abstracted from the registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCF. The majority of patients were age >12 years [11,865 (82.4%)] and male: 14,813 (88.4%) civilians and 13,187 (99.8%) NCCF. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84%) NNCF. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (74%) civilian and 10,029 (76%) NNCF. Median injury severity score (ISS) was 9 in each group with ISS > 25 in civilians 1,624 (9.7%) and 1,009 (8.3%) NNCF. The top 3 mechanisms of injury for both cohorts were explosives (civilians 43.2%; NNCF 49.4%), gunshot wounds (civilians 33.8%; NNCF 35.8%), and motor vehicle crash (civilians 9.0%; NNCF 7.4%). Blood products were transfused to 37% of each population: 6,197 civilians were transfused 12,688 blood products, with 2,242 of them receiving >10 units; 4,916 NNCF were transfused 13,132 blood products with 1,798 receiving > 10 units. MTF mortality rates were: civilians 1,263 (7.5%) and NNCF 776 (5.9%). Interventions, both operative and non-operative, were similar between both groups. (Table 1)

Conclusions: In accordance with International Humanitarian Law, as well as the US military’s medical rules of eligibility, civilians injured in combat zones are provided the same level of care as all other casualties. Injured civilians and NNCFs had similar mechanisms of injury, injury patters, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCF. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.

Non-Operative and Operative Interventions

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