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EDITORIALS: Jon Clasper and David Rew Trauma life support in conflict BMJ 2003; 327: 1178-1179 [Full text]

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Who is more effective in war: the Brits or the Yanks?

Richard G Fiddian-Green   (21 November 2003)

Trauma Life Support in Conflict

Ken Millar   (23 November 2003)

Medical support to British soldiers is not a humanitarian operation

Roderick Mackenzie   (23 November 2003)

War related injuries-global perpective

Ediriweera B.R., Desapriya   (25 November 2003)

Trauma life support in conflict: which side are you on?

Hans Husum, Torben Wisborg MD, DEAA.   (3 December 2003)

LOGISTIC COSTS OF DAMAGE CONTROL

Nigel R Tai, Doug Bowley, Ken Boffard   (24 December 2003)

Who is more effective in war: the Brits or the Yanks? 21 November 2003
Richard G Fiddian-Green, None None Send response to journal: Re: Who is more effective in war: the Brits or the Yanks?	The money in managing civilian trauma more effectively is in achieving more effective management of both second and third peaks, those who die within hours from hypovolaemia and hypoxia and those who die in days to weeks from multiple organ dysfunction. The very much higher proportion of deaths (96%) in those Brits who never reached hospital in the 2003 Gulf war (first peak) relative to those who did indicate, however, that the money in the British combat injuries lies in more effective treatment of hypovolaemia and hypoxia in the field. How did the outcome from combat casualties sustained by the Brits in the 2003 war compare with those sustained by the US forces? If not as good as that in the US forces might the evacuation of US casualties have been more efficient? Alternatively might they not have had access to the novel dressing which, according to reports in the lay press, was particularly effective? Was the outcome in those combat injuries sustained by the US forces and who reached hospital any different from that in those amongst the British injured who reached hospital? If so did the difference persist after standardisation for the efficiency of evacuation and severity of injuries received? My only experience with civilian trauma in the UK was as a student some decades ago doing a clerkship at the Birmingham Accident Hospital, widely regarded as the best in the country at the time. As I recall it was staffed by orthopaedic and plastic surgeons. In the US these patients are managed by general or trauma surgeons, who have no training in the management of fractures or exposure to orthopaedic surgery, and the orthopods, who have little or no general surgical experience, and plastic surgeons are consulted if and when necessary. What is more few if any US trained "tramatologists" have any experience with elective urological, thoracic or even paediatric operations. Additionally I suspect that few if any UK or US "traumatologists" have had any exposure to the neurosurgical management of severe head injuries. In other words the UK "traumatologists" are trained to take care of almost all of the injuries sustained by their patients but the US "traumatologists" are not. One wonders how effective they might be relative to general surgeons in lesser developed countries who commonly have a much broader exposure during the course of their training. Competing interests: None declared
Trauma Life Support in Conflict 23 November 2003
Ken Millar, Retired 3 Highmount, Shady Bower, Salisbury SP1 2RE Send response to journal: Re: Trauma Life Support in Conflict	The Editor British Medical Journal (By e-mail) 23rd November 2003 Editor, Trauma Life Support in Conflict I note a clash of logic in your leading article (1) on trauma life support in conflict. The authors accept that deaths from blood loss in abdominal and chest wounds are likely within the first four hours, yet they argue against the provision of forward emergency surgery for the early management of that blood loss. Their implication that ATLS will somehow "fix" the problem misses the point; ATLS on the battlefield can deliver more casualties with survivable injuries, but without early surgery to arrest bleeding this effort is in vain. The validity of damage control surgery is dependent on other factors, not the least of which is the ability to evacuate immediately after forward intervention, specifically by helicopter, to the better equipped hospitals referred to by the authors. I spent a great deal of my professional life involved in medical planning for military operations, and am acutely aware of the problem of resource shortfall. However, the current shortfall in surgical personnel should be viewed neither as permanent nor as a rationale for a plan to abandon casualties (as the authors seem to suggest). Military medicine must have the inherent flexibility to support any operation planned. While damage control surgery may not always be practical, it must remain available as an option. The resources needed to deliver damage control surgery include necessary training and appropriate equipment as well as personnel. If the concept is attacked from within the medical services, the financiers will hardly be likely to allocate the required funds to make the doctrine work. The proposals in the article undermine the efforts of the military medical services to provide the best possible level of care in adverse conflict situations. It is the casualties who will ultimately suffer. (1)Clasper.J, Rew, D. Trauma Life Support In Conflict. BMJ 2003;327:1178-9 (22 November) Competing interests: Senior Medical Adviser MedLogUK Ltd
Medical support to British soldiers is not a humanitarian operation 23 November 2003
Roderick Mackenzie, Clinical Research Fellow in Pre-hospital Imediate Care Addenbrooke's Hospital, Cambridge, CB2 2QQ. Send response to journal: Re: Medical support to British soldiers is not a humanitarian operation	Editor, Mr Clasper and Mr Rew suggest that the provision of a resuscitative surgical or ‘damage control’ capability within a forward military medical facility is wasteful of scarce (medical) resources.1 They remind us that evacuation to hospital may take hours and that a relatively small proportion of patients will survive such delay to surgery. They also remind us that most combat casualties die from uncontrolled haemorrhage. Rather than supporting their argument, I would contend that these facts reinforce the need to make early damage control surgery more readily available. Of course surgeons undertaking such emergency interventions will face high morbidity and mortality. Of course many of these patients will die. But it is precisely because a small but important proportion of these deaths are preventable that damage control surgery is necessary. It is important to understand the role of the Defense Medical Services (DMS) and what is meant by damage control surgery. The reason DMS personnel are deployed is primarily to provide medical support to British troops. In this context, all deployed service personnel should and do expect a very high level of medical care – much higher than is generally expected in the humanitarian and disaster relief setting. Resuscitative or ‘damage control’ surgery is aimed at salvageable patients who are critically unstable, with associated multi-visceral injury and exsanguination.2 The concept is that only the minimum is done to stop bleeding and limit or contain contamination before the wound or cavity is packed and temporarily closed. Efforts are then directed at physiological stabilisation and prevention of the ‘bloody viscious cycle’ of hypothermia, acidosis and coagulopathy before any attempt at definitive surgical repair. 3 Because it has been recognised that few British surgeons have training or experience in major thoracic, abdominal or vascular trauma, damage control surgery is now included in the joint Royal College of Surgeons of England and Royal Defence Medical College Definitive Surgical Trauma Skills course.4 The nature of modern warfare involving British troops is such that live combat casualties are few in number. Clearly it is appropriate that these seriously injured casualties are evacuated as quickly as possible and treated within a sophisticated hospital environment. Severity of injury or delays in evacuation may however prevent this. Resources for these casualties must therefore be available where they are needed. The only possible justification for the argument that “resources must be optimized for the many, rather than dispersed for the few” is the appalling shortage of appropriately trained military medical staff within the DMS. 5 Medical support to British soldiers cannot be considered a humanitarian operation. Roderick Mackenzie Clinical Research Fellow in Pre-hospital Immediate Care Barts and the London School of Medicine, Queen Mary, University of London Honorary Specialist Registrar in Emergency Medicine Addenbrooke’s Hospital, Cambridge References 1. Clasper J, Rew D. Trauma life support in conflict. BMJ 2003;327:1178-9. 2. Bowley DM, Barker P, Boffard KD. Damage control surgery-concepts and practice. J Royal Army Med Corps 2000;146:176-182. 3. Ryan JM, Roberts P. Definitive surgical trauma skills: a new skills course for specialist registrars and consultants in general surgery in the United Kingdom. Trauma 2002;4:184-8. 4. Moore EE, Staged laparotomy for the hypothermia, acidosis and coagulopathy syndrome. Am J Surg 1996;172:405-10. 5. Batty D. 'Chronic' medics shortage at MOD. The Guardian. 18 March 2003. Competing interests: As a member of the Territorial Army Medical Services, I provided close medical support to British troops deployed in the 2003 Gulf War. These opinions are my own and not those of the Ministry of Defence.
War related injuries-global perpective 25 November 2003
Ediriweera B.R., Desapriya, Department of Pediatrics BC injury Research and Prevention Unit, Centre for community Child health Research, BC, V6H 3V4 Send response to journal: Re: War related injuries-global perpective	War related injuries-global perspective Armed conflict between warring states and groups within states have been major causes of ill health and mortality for most of human history. Conflict obviously causes deaths and injuries on the battlefield, but also health consequences from the displacement of populations, the breakdown of health and social services, and the heightened risk of disease transmission (1). War injures and kills combatants and civilians (2). The article highlights the valuable information on much neglected area of study in Medicine. It is better that further we should see the magnitude of the problem by looking at numbers as appended below. Worldwide in 2000 more then 300,000 people died from war-related injuries. In 25 conflicts during the 20th century, 72 million deaths were conflict- related and nearly half of these deaths were civilians. Table 1- Injury related mortality Type of Injury Deaths due to Injuries, 2000 Road traffic Incidents 1 260 000 Suicide 815 000 Interpersonal violence 520 000 Drowning 450 000 Poisoning 315 000 War and conflict 310 000 Falls 283 000 Burns 238 000 Source: WHO-Injury related mortality-Geneva Switzerland- 2002 (3) Two new WHO (2002) publications highlight that injuries kill more than five million people worldwide each year, accounting for nearly 1 of every 10 deaths globally. In addition, tens of millions of people visit emergency departments annually due to injury. Whether they are unintentional - resulting from incidents such as road traffic collisions, drowning or falls - or intentional - following an assault, suicide or war- related violence - injuries affect people of all ages and economic groups. In fact 7 of the 15 leading causes of deaths for people aged 5-29 years are injury-related; these are road traffic injuries, suicide, homicide, war, drowning, poisoning and burns. References: (1). Murray, C.J.L., King, G., Lopez, A.D., Tomijima, N., Krug, E.G., Armed conflict as a public health problem. BMJ 2002; 324:346-349 (2). Clasper, J., Rew, D., Trauma life support in conflict. BMJ 2003; 327:1178-1179 (3). WHO-Injury related mortality-Geneva Switzerland- 2002 Competing interests: None declared
Trauma life support in conflict: which side are you on? 3 December 2003
Hans Husum, MD, PhD. Head, Tromsoe Mine Victim Resource Center. University Hospital of Northern Norway, N-9038 Norway., Torben Wisborg MD, DEAA. Send response to journal: Re: Trauma life support in conflict: which side are you on?	In a recent editorial Clasper and Rew recommend that resources under wartime conditions “… must be optimised for the many, rather than dispersed for the few”.(1) According to the authors this seemly objective should be achieved by battlefield trauma systems in which in-field advanced trauma life support teams, robust casualty evacuation systems, and well equipped hospitals constitute the main elements. However, universalistic epidemiological descriptions and strategies do not yield meaningful accounts of reality in modern war scenarios in the South. At the receiver side of cruise missiles we find peasant communities stuck in poverty and infested by endemic diseases, that is patients whose pre- injury physiological capacity is poor. In the Black Hawk-target areas local medical infrastructures are devastated by years of war and/or embargo; casualty evacuation to surgical centres takes several hours, and many patients will be admitted with full-blown post-injury stress syndromes. Clasper and Rew draw on data from the British mission during the late war on Iraq, and experiences gained by the Israeli army in the occupied territories. These are data taken from quite another laboratory where you find well fed and healthy study patients, short prehospital transit times, and surgical centres of high performance. Our experiences – and recommendations – are quite different from those of Clasper and Rew. Having run rural trauma systems in Northern Iraq and Cambodia since 1997, we learned that the simple things are most important when it comes to life-saving trauma care. Our study patients (n = 1,061) are mainly poor peasants injured by land mines and conventional weapons, mean evacuation times being six hours. A prehospital trauma system of 5,000 lay first responders at village level and a second tier consisting of 120 ATLS paramedics reduced the mortality rate from 40% (preintervention) to 9% (five years after initiation of the project).(2) A small number of patients were managed by advanced procedures (1.6%). However, the major benefit from the program included broad application of simple manoeuvres for airway control, external bleeding control, efficient painkilling, hypotensive fluid resuscitation, and hypothermia prevention. The main take-home message from our study is thus the efficacy of basic life support measures applied rapidly by the people to have early access to the injured person. The editorial claims that “in practical terms” most casualties with major critical area injuries die on the way “however good the medical services in place”, especially so when casualty timelines are long. We fear that such blunt statements may advocate a defeatist attitude. When we established the trauma systems in Northern Iraq and Cambodia, we found that 31% of fatalities occurred during transport or in hospital, the rate coming down to 12.5% when the network of some thousands of village first helpers was fully developed (95% confidence interval for difference 4% to 33%). Our data does not confirm that “most major intracranial trauma die in the first few hours” as claimed by Clasper and Rew. Out of 21 penetrating head injuries with ISS >15, eight patients died during transport or in hospital – five of them from failed airway control. We do not claim that our experiences are universally valid, but at least on the poor peasant-side of missiles there are avoidable deaths, and it is our duty and well within reach to minimise the numbers. Lessons from civilian urban trauma systems are not directly applicable in the rural setting. Also in conflict it probably makes a lot of difference which side you are on. (1) Clasper J, Rew D. Trauma life support in conflict. BMJ 2003; 327: 1178 - 79. (2) Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prespective study from North Iraq and Cambodia. J Trauma 2003; 54: 1188 - 96. Competing interests: None declared
LOGISTIC COSTS OF DAMAGE CONTROL 24 December 2003
Nigel R Tai, Hon Lecturer in Surgery, Dept of Surgery, Johannesburg Hospital, University of the Witwatersrand University of the Witwatersrand, Private Bag X39, Johannesburg 2000, Doug Bowley, Ken Boffard Send response to journal: Re: LOGISTIC COSTS OF DAMAGE CONTROL	Sir, The deployment of surgical facilities, capable of damage control surgery (DCS) to forward locations is aimed at saving the lives of combat casualties who would otherwise die. In their editorial Clasper and Rew suggest that dispersing resources in this manner threatens the overall provision of surgical services to the battle-space, diminishing the ability of doctors to do “the most for the most” (1). This debate is not new. In 2000, Eisemann and co-workers argued that the substantial logistic burden associated with forward DCS made its incorporation into military surgical doctrine “unwise” (2). In a spirited rebuttal, Holcomb and Champion maintained that forward surgical facilities were exactly where DCS would be most effective (3). The experience of urban trauma centres provides an insight in to the scale of resources required in managing these critically injured but potentially salvageable patients. We reviewed a prospectively maintained registry to find patients who had survived damage control or resuscitative laparotomy and were admitted to the trauma intensive care unit of the Johannesburg Hospital. During the first 6 months of 2003, 24 patients were identified; 20 sustained gunshot injuries with the remainder suffering a blunt mechanism of trauma. Initial surgery lasted 109 (75-205) minutes with patients consuming 6 (0-11) units of blood, 2350 (500-6500) cc of colloid, and 6000 (2000-13000) cc of crystalloid. Following their surgery, patients required a further 2 (1-10) re-look laparotomies, spent 12 (1-42) days in ICU, 7 (1-37) days aided by mechanical ventilation, and were infused with 14 (0-34) units of blood. Nine of the 24 (38%) died 8 (1-29) days in to their admission. The needs of such patients cannot be met by far-forward surgical facilities working in the austere environment in time of war. Indeed, given that 9% of soldiers killed in action bleed to death from extremity wounds and 5% die from untreated tension pneumothorax (4), more lives could be salvaged through better education of troops in the use of tourniquets, field dressings impregnated with haemostatic agents, needle thoracentesis and other simple treatments administered at the point of wounding. Casualties requiring surgery should be evacuated swiftly to properly sustained surgical centres staffed by Defence Medical Service surgeons and anaesthetists trained in all the modern techniques of trauma surgery and intensive care, including DCS. Other than when special circumstances dictate, we agree with Clasper and Rew that the enthusiasm for dispersal of surgical resources into far-forward locations is misplaced. Nigel Tai Hon Lecturer in Surgery, Dept of Surgery, Johannesburg Hospital, University of the Witwatersrand and Surgical Registrar, The Royal London Hospital, London Doug Bowley Hon Lecturer in Surgery, Dept of Surgery, Johannesburg Hospital, University of the Witwatersrand and Surgical Registrar, St Marks Hospital, London Ken Boffard Professor Chief Surgeon and Clinical Head, Dept of Surgery Johannesburg Hospital and the University of the Witwatersrand References: 1.Clasper J, Rew D. Trauma life support in conflict. BMJ 2003;327:1178-1179 2.Eiseman B, Moore EE, Meldrum DR, Raeburn C. Feasibility of damage control surgery in the management of military combat casualties. Arch Surg 2000; 135(11):1323-1327. 3.Holcomb JB, Champion HR. Military damage control. Arch Surg 2001; 136(8):965-967. 4.Champion HR, Bellamy RF, Roberts P, Leppaniemi A. A profile of combat injury. J Trauma 2003;54:S13-S19. Competing interests: NT is a medical officer in the Territorial Army. DB is a regular Army surgical registrar. The views expressed are their own and do not reflect official UK Defence Medical Services policy.