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Abstract
Objectives The Seventh Airborne Forward Surgical Team (FST) has been deployed in Gao, Mali, and in Bangui, Central African Republic (CAR), for two 3-month periods in 2014. The initial role of the FST was to provide emergent care to French and coalition soldiers but it was expanded to include humanitarian assistance. The aim of the present study was to describe and compare injuries and surgical activity of the Seventh Airborne FST during these two conflicts.
Methods All surgical patients treated by the FST between January and December 2014 have been included. Patient demographics, mechanisms of injury, surgical management including triage categories and types of surgery performed and evacuation modalities were recorded.
Results During the 6-month deployment period in 2014, the FST performed 129 operations on 134 patients, 61 of which were trauma patients (45 battle injuries (BI)). The remaining 73 patients were treated as part of the humanitarian mission. Thirty of the BI were managed during the Malian conflict and 15 in CAR; 29 patients (64%) were military. The median Injury Severity Score (range) was 20 (10–34) in Mali and 8 (5–21) in CAR with median (range) evacuation time of 390 min (240–947) in Mali and 120 min (60–120) in CAR (p<0.0001). The most frequent mechanisms of injury were gunshot wounds in Mali (15/30) and road traffic accident in CAR (7/15). Extremity injuries were most common (58%) with head, face and neck injuries and thoracic injuries in 15% of cases each and 12% had suffered abdominopelvic injuries. Ten patients were categorised as T1 and underwent urgent surgery, five had damage control surgery and four received transfusion. The average length of stay was 2 days (1–2), with most patients being transferred to another hospital.
Conclusions Casualties from Mali and CAR presented with a wide variety of injury patterns, and there were some instances where damage control surgery and whole blood transfusion were necessary. Surgical equipment scales must allow treatment of a large variety of injuries including all body regions and extreme emergency procedures. These two conflicts differ in terms of scope, one being an urban guerrilla and the other an open conflict in a large desertic area. Long distances in the Malian desert increase significantly the evacuation time. It has to be taken into account in the FST location when coalition forces are deployed in such places.
- SURGERY
- TRAUMA MANAGEMENT
- PUBLIC HEALTH
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Key messages
Information about the ongoing conflicts in Africa is scarce.
Treatment of casualties in remote environments requires specific materials and capabilities.
Humanitarian assistance provided the team with good trauma experience and had positive impacts.
Performing surgery in a desert in a tented hospital is challenging and needs specific training.
Knowing the precise epidemiology of likely casualties is crucial to ensuring appropriate training for upcoming missions in austere environments.
Introduction
Improving the survival rate of casualties from the battlefield is a primary goal for all military doctors.1 The type of injuries suffered varies according to the nature of the conflict and the weaponry available; identifying the likely injury mechanisms enables adaptations and improvements in care.2 Numerous medical challenges exist in the remote and contested environment of the battlefield where the clinical evidence base is sparse, particularly in the pre-hospital arena, and yet significant improvements in mortality and morbidity can be made.3–6 French forces are currently deployed in two theatres of operations: Mali since early 2013 and the Central African Republic (CAR) from late 2013.
These two contemporary conflicts differ significantly. In North Mali, the paramilitary groups operate in the wide desert area where they are difficult to locate and can receive training; since 2012, they have been expanding with the goal of imposing Sharia rule throughout the whole country. The CAR has a long history of political turbulence, with a succession of weak governments attempting to assert their authority beyond the capital city of Bangui. Few studies have reported and compared the wounding patterns and mechanisms of injury from these two conflicts.7 ,8
La 7è Antenne Chirurgicale Parachutiste (translated as the Seventh Airborne Forward Surgical Team (FST)) was deployed in 2014 to provide medical support to the troops deployed in these two theatres of operation and in contrast to many nations, the French Military policy is to place healthcare providers reasonably far forward in the battle space.9–11 Based on the North Atlantic Treaty Organization (NATO) recommendations,12 the French Military Health Service has been organised into four levels: Role 1 are the medical teams deployed with the combatants, Role 2 is a small field hospital (where the FST is deployed), Role 3 represents the combat support hospital and Role 4 are the Military Hospitals in France.13 The French Military Health Service includes eight FSTs, which are normally deployed for 3-month periods twice annually.
The aim of this study is to describe the surgical activity of the Seventh Airborne FST during 2014, including descriptions and comparison of the epidemiological profiles of casualties from the two current conflicts in Mali and CAR and some of the humanitarian care provided to the local populations.
FST methods
An FST comprised one general surgeon, one orthopaedic surgeon, one anaesthetist, two nurse anaesthetists, one operating room nurse, two critical care nurses, one executive officer and three emergency medical technicians. Diagnostic support was provided by a mobile X-ray system (Movix, Stephanix, La Ricamarie, France), a portable ultrasound unit (SonoSite, Bothell, Washington, USA) and a field laboratory. The laboratory tests available were arterial blood gases, blood grouping, full blood count, prothrombin time, activated clotting time, liver function tests, a point-of-care test for malaria and Quick Stick (InGen, Chilly-Mazarin, France) test for tetanus. FSTs are deployed under canvas and include one operating room (Figure 1A), two intensive beds (Figure 1B) and eight general beds with a capability to operate as a Role 2 facility anywhere in the world. Currently, there is no deployed French Role 3 but the Role 2 in Mali was enhanced to increase treatment capacity. The 12-member basic FST was reinforced with an emergency physician, a psychiatrist, two more critical care nurses, a laboratory technician, a small mobile X-ray unit and three more emergency medical technicians. When necessary, triage was performed using standard NATO criteria.14 When only limited diagnostic imaging is available, surgical exploration is systematically performed for all penetrating trauma to evaluate the extent of injury and define, which important structures are involved. Damage control surgery (DCS) was performed when the patient physiological status was considered critical. Wounds were mainly treated with extensive debridement with delayed primary closure and external fixation applied to bone fractures. For the local population, the whole surgical management until hospital discharge was performed by the FST within Role 2, whereas military patients received either definitive or temporising DCS prior to onward evacuation.
(A) Operating room, when Forward Surgical Team (FST) is deployed under canvas. (B) One of two ICU beds. Beside the head of the bed is the ventilator and monitor; there is a blood fridge on the lefthand side.
The FSTs benefited from the logistic chain of the camps in which they were based and there was never any supply issue with regard to the likes of packed red cells, oxygen, drug resupply or power.
In the humanitarian mission, surgeons selected local patients suitable for elective surgery and the policy was to select patients with a clear cut benefit to risk ratio. Performance of humanitarian assistance is part of FST missions when abroad and has been clarified by military administration.15 The procedures commonly performed in the context of the humanitarian mission were inguinal hernia repair, thyroidectomy, hysterectomy, oophorectomy, hydrocele surgery and the treatment of old fractures (both non-unions and malunions).
French patients were evacuated rapidly to France via early strategic medical evacuation; casualties from the United Nations (UN) were evacuated by their own organisations using a variety of platforms, with the majority being evacuated by air to the regional UN hospital in Nairobi, Kenya. Local military patients were evacuated mainly by local means often after a prolonged stay in Role 2 and were discharged mainly to local hospitals, both civilian and military. In accordance with the Geneva conventions, every patient referred to our facility who needed emergency care received treatment regardless of their origin or status.
Methods
Patient data were collected prospectively of all the surgical patients treated by the enhanced Role 2 (Role 2E) in Gao, Mali, from 20 February to 28 May 2014 and the Role 2 in Bangui, CAR, from 2 September to 19 November 2014 and reviewed retrospectively. The study was approved by the institutional review board of the head of the French Military Health Service Academy, Ecole du Val-de-Grâce, Paris. All patients had the following data recorded: demographics, clinical presentation, injury mechanism, description of injuries sustained, initial triage category, biological test results, nature of surgery, length of hospital stay and details about subsequent evacuation; Injury Severity Scores and Shock Index were calculated.
Statistical analysis
Due to the sample size, the data were considered to have a non-normal distribution and thus a non-parametric, two-tailed test was used (Mann–Whitney U test). Continuous data were described using the median and 25–75 percentiles (IQR 25–75). Statistical significance was defined as values of p<0.05 and statistical analyses were performed using Prism V.4.00 for Mac (GraphPad Software, San Diego, California, USA).
Results
The team performed 129 surgical procedures on 134 patients during the course of 6 months of deployment. Overall, 90 (67%) patients were civilians, including one French, five Nigerians, 63 Malians and 21 Central Africans; 42 patients (31%) were from military: 13 (10%) were French soldiers, 14 (10%) were from Malian military and 15 (11%) were from other UN coalition forces (mainly Cameroonian). Only two patients (2%) were clearly identified as insurgents.
Twenty patients (15%) were women, 12 (9%) were children (<16 years) and 71 were non-traumatic patients scheduled for elective surgery in the context of humanitarian mission. Trauma accounted for 61 cases (46%), 45 of which were battle injuries (BI) and 16 were non-BI with the main cause being either domestic or civilian road traffic accidents (RTA); those RTA that occurred during combat were counted with the BI as opposed to civilian RTA.
Table 1 describes the battlefield injuries from the two conflicts in Mali and CAR.
Epidemiology of the two different battlefields
Two thirds of the BI (29/45) were soldiers from coalition forces, 14 were civilians and 2 were rebels—there were 2 French and 1 Spanish soldier meaning that 41 patients (91%) were civilians, rebels or soldiers from African nations. The most frequent mechanism of injury was gunshot wound (GSW) followed by blast from Improvised Explosive Devices, grenades and military RTA; 18% of the patients presented with multiple fragmentation injuries.
The frequencies of injuries to the various body regions are displayed in Figure 2, with the extremities of the body accounting for 51% of the cases. Overall, 80% of the patients with BI were operated emergently requiring 72 procedures (Table 2).
Types of procedures undertaken
Body regions injured.
The initial triage categorisation of patients is shown in Figure 3, with 10 patients deemed to be T1 category (Table 3).
Summary of the T1 category critical patients
Triage categorisation.
Of the 10 T1 casualties, six had suffered GSW and the remaining four blast injury, with DCS necessary in five with four receiving transfusions; three of these T1 patients had head or facial injuries and two of them died within the first 48 h.
The median length of stay was 2 days; 34/45 (76%) battle-injured patients were transferred to another hospital, 16 patients (36%) went to a local hospital (Gao and Bangui civilian hospitals) and 18 patients (40%) went to a higher level of care (French military hospital, Spanish hospital, Nairobi ONU hospital in Kenya, Malian civilian hospital in Bamako and Lybian hospital). Two thirds of cases (24/34) were discharged by car, the remaining 10 by plane; 8 (18%) were discharged directly, one French military patient (2%) returned to duty and two patients died (4%).
Comparison between casualties from the two theatres of operation revealed some significant differences. Median ISS, number of patients categorised as T1 or T2 (Figure 3) and the proportion of GSW's were higher in Mali than in CAR (p<0.05, Table 1). In contrast, multiple fragmentation injuries were more frequent in CAR than in Mali and were related to the more frequent use of grenades. The median duration of evacuation between point of injury (POI) and Role 2 was significantly higher in Mali than in CAR (390 vs 120 min, p<0.0001).
One third of the BI patients (15/45) occurred in the context of mass casualties, including five injured during the battle of Kidal at the end of May 2014. Seventy-two patients were wounded with 14 being evacuated to Gao airport, triage was done by our team directly at the airport in coordination with local medical providers; five of the injured patients (4 T2 and 1 as T3) were referred to our facility for emergency surgery.
On the 134 patients included, two required Fresh Whole Blood (FWB) transfusion (case 9, Table 3) and a non-surgical patient with severe malaria who presented with impaired consciousness leading to a fear of intracranial bleeding—the FWB use was aimed at correcting the severe coagulopathy and low-platelet count in the absence of apheresis platelets.
Discussion
During the 6-month deployment period in 2014, this FST managed 61 trauma patients which represented half of the surgical activity of the FST, two thirds of which were BI (mainly from coalition military forces); the remaining patients were civilians and were treated as part of the humanitarian mission. Only two patients were clearly identified as insurgent in Mali, but in CAR as in Mali, the distinction among collateral damage on civil population and insurgents was sometimes difficult.
The battle-injury mechanisms in this study differ from those in recently published articles, where explosion was the most frequent cause of injury in Afghanistan and Iraq,16 ,17 representing 55–70% of cases, compared with a preponderance of GSW in our data from Mali (Table 1). The anatomical distribution also differs with lower rates of injury to the head and neck and a relatively higher incidence of extremity injuries.16 Comparison with the literature reveals that our results correlate more closely with published data about general population injuries rather than military casualties,17 ,18 which can be explained by the wide range (91%) of care provided by our team, treating coalition armed forces and also civilians and rebels. Indeed, the lack of difference in personal protective equipment among local population, rebels and African soldiers who comprised 91% of the battle-injured casualties compared with Western soldiers may leave them more vulnerable to thoracic, abdominal and head injuries.17 ,19 This is consistent with the higher rate of thoracic injury reported in our study (15%), compared with the 10.5% rate published in a recent review of thoracic injury in the UK military experience.20
In comparing the casualties from the two theatres, we found some significant differences. The conflict in Mali involved well-prepared combatants sometimes equipped with heavy weapons such as mortars, whereas the conflict in CAR involved non-professional urban guerrillas armed with guns and grenades. These differences have a direct impact on the nature of the casualties. Although the patients were more severely injured in Mali than in CAR, the frequency of T1 patients was slightly higher in CAR (27%) than in Mali (20%), which is likely to be related to the longer evacuation timelines from POI to Role 2 in Mali, as it is probable that a fair number of foreign patients died before reaching the FST. Similarly, injured patients would have reached the medical facility alive in CAR; the long distances in the Malian desert render NATO recommendations for evacuation unrealistic despite air transport capacity.21 Another explanation for those long delays is that the transportation of foreign patients was made by road due to the means available for local nationals. The median duration of evacuation was 60 min for French patients, who were always stabilised on-scene by an emergency doctor, which was not the case for other nationalities. This is important for the planning of future military operations, as it has been the case for the French Army, deploying several highly mobile FSTs is mandatory during expeditionary operations.
The severe nature of our T1 triaged patients is borne out by their high ISS (44 (31–49)), high rates of damage control (50%) and need for transfusion (40%). Damage control with exploration and debridement was the principle operating paradigm for treating patients injured during both conflicts; however, other urgent procedures were performed (Table 2). The team performed four vascular operations when the need to save a limb necessitated a venous graft which underlines the importance of vascular training for general and orthopaedic surgeons, which may not be part of their routine practice in France. The limited availability of radiological imaging reinforces the necessity for practitioners to be skilled in ultrasonography. Ultrasonography was helpful for a variety of procedures such as Focus Assessment Sonography for Trauma, lung and cardiac exams, transcranial Doppler, optic nerve sheath diameter measurement to evaluate intracranial pressure, vascular Doppler of the extremities and to check bone fracture reduction during surgery in the absence of fluoroscopy, as in CAR. We required FWB transfusion for two patients. The benefits of whole blood transfusion have gained acceptance during the last few years with the emergence of the walking blood bank concept, which is particularly useful in a remote conflict environment.22 ,23 Explanation of the goals of such a method was given to every soldier by their military chief upon arrival in the theatre of operations and each time when we required FWB, we closely observed the military donors with no adverse reaction.
We undertook humanitarian assistance for local populations during both missions. After contact with local doctors in the immediate neighbourhood, patients were selected in accordance with local care providers for surgery during specific clinics. Advertisement of the surgical capabilities was made only by local doctors after careful definition of the types of surgery that could be provided. After discharge from the FST, patients were followed-up by their local doctors. All the medical staff and the military headquarters felt that this humanitarian help has a beneficial political and social impact, helping to win hearts and minds and encouraging acceptance of the French military forces.24 Moreover, during periods of low medical activity, this humanitarian aid provided the FST with essential trauma experience.25
This work presents some limitations; first of all the number of patients is small, however, the data collection was thorough and extensive and encompassed all the patients treated by one FST during 6 months in 2014, but we were not able to collect data about the final outcomes following discharge. The patient cohort included a wide variety of nationalities, and the on-scene treatments received were heterogeneous, with POI care being delivered by a range of providers from emergency physicians to the ordinary soldier with limited first-aid training.
But to the best of our knowledge, this is the first series presenting and comparing results about patients injured during the two ongoing conflicts in Mali and CAR. Thus, it provides useful information for surgical teams before their deployment in remote environments and particularly in desert areas.
Conclusion
During its two deployments in 2014, our FST performed 129 interventions on 134 patients, including 61 trauma patients (45 BI). The results differ slightly from recently published data concerning the conflicts in Afghanistan and Iraq in terms of mechanism and site of injury. Of interest is the wide variety of care provided by our team, which strongly suggests that surgeons should be trained and able to perform a wide range of surgical techniques within many anatomical areas. For the anaesthetist, the remote conditions and limited imaging necessitate the ability to use ultrasonography as the primary imaging modality and also highlight the importance of whole blood transfusion.
In Mali, long desert distances prolong air-evacuation times, necessitating the placement of several FSTs. The environmental constraints should be taken into account when deciding where and which medical facilities should be used because they have direct impacts on the delays of evacuation.
References
Footnotes
Clément Dubost and Yvain Goudard contributed equally to this manuscript.
Funding Begin Military Hospital.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.