PERSPECTIVES

Drs. Ahmad and Bhandari talked about traumatic injuries in mass casualty situations, specifically the casualties in the war zone of the West Bank and Gaza Strip, how patients are managed, challenges in patient care and the needs from healthcare teams in the region. Our discussion uncovered 4 core themes. These themes and their supporting insights are highlighted below.

1. Number and Types of Injuries

Dr. Ahmad shared that in the war in 2018, there were about 600 patients arriving at the emergency room (ER) in hospital with 200 patients being admitted to hospital requiring urgent surgery on a typical day. The situation these days is worse than before. For example, there may be 600 people with casualties (mainly bullet-related injuries) in one day in the West Bank, and there are more casualties in the Gaza Strip, with 2,000 people needing management of their injuries mainly caused by missiles in a day. Dr. Ahmad pointed out that the majority of injuries are open fractures and complicated fractures of extremities, with or without vascular injury.

2. Patient Management in the Warzone

Dr. Ahmad talked about the importance of first aid and the primary life-saving procedures for patients. In the West Bank, the field hospital is around 300 meters away from the site of clashes, where patients can be transported to if necessary. Two healthcare workers, one of them having received four to five months’ basic training and the other an intermediate professional, are responsible for the primary management of patients in the ambulance before the patients arrive at the hospital for injury management. An intermediate-trained professional is able to put a cannula (to give intravenous fluids to a patient) as soon as possible.

In the hospital in the West Bank, an officer who had relevant training for nearly one month will play the role of the first responder to provide basic care to the patients. For example, they can put a tourniquet on a patient’s wound if there is severe bleeding. A general surgeon will assess the severity of injuries and triage a patient within 3 minutes. If needed, the patient will be sent to the ER, where three professionals (a senior surgeon, an ER specialist and a nurse) for each bed can perform the needed procedures to manage patients’ injuries, or transfer the patient to the operating room (OR) for a surgery.

In the hospital in the Gaza Strip, because numbers and injury severity of patients are greater than those in the West Bank, patients will usually be transferred to the ward after they receive the minimal care of cannulas and life-saving management, without going to the ER. In the ward, senior orthopaedic surgeons will review all the patients every 2 hours and triage patients to receive surgery according to the level of life-threatening injuries.

3. Early Management of Open Fractures is Crucial

Dr. Ahmad shared that in the case of mass casualties, although temporary management like posterior slabs and antibiotics are given to patients, surgery for open fractures may be delayed for 1 or 2 days. These delays may increase risk of complications among patients.

Drs. Bhandari and Ahmad regard that it is crucial to do early management for patients with open fractures. Delayed repair and wound closure are associated with higher risk of non-unions, infections and worse functional outcomes.

4. Challenges

Dr. Ahmad mentioned that there is a lack in the experienced healthcare personnel, especially those who work at graduate level of paramedic, ER specialty, plastic surgeons, and vascular surgeons. There is not an intensive care unit (ICU) in the West Bank. There is a paucity of resources that include some necessary facilities to build a good connection between the ER doctors and the medical team officers working in an ambulance, as well as orthopaedic surgery equipment and supplies such as interlocking instrument sets. Dr. Ahmad also addressed that remote skill coaching in plastic surgery and vascular surgery in the West Bank is also greatly needed and appreciated.

SENSE-MAKING

Drs. Ahmad and Bhandari addressed the importance of early management of open fractures in order to prevent various complications in patients. Dr. Ahmad shared that the number and severity of injuries are great in a war zone. The most commonly seen injuries are open fractures of the upper and lower extremities. Most cases are severe and there may be a one-to-two-day delay for these patients to receive appropriate orthopaedic surgeries. There is a lack in experienced healthcare personnel, especially ER specialists, plastic surgeons, and vascular surgeons, as well as some orthopaedic instruments.