Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway

Beginning in October 2016, the Iraqi army, supported by the Kurdish Peshmerga and a U.S.-led international coalition, launched an intensive campaign to retake Mosul, once Iraq’s second largest city, from the militant group the Islamic State, which had captured the city and much of northern Iraq and western Syria in 2014. The campaign lasted nearly nine months and became arguably the largest urban siege since World War II. Nearly one million people were displaced, and thousands killed, by the time the battle ended in July 2017 [1, 2].

As fighting unfolded, severe gaps in trauma care for wounded civilians emerged. Humanitarian planners, led by the World Health Organization (WHO), responded by coordinating what became a novel trauma response pathway designed to improve access to trauma and surgical care. This pathway drew upon the concept of “echelons of care” used by the North Atlantic Treaty Organization (NATO) and other military evacuation systems, in which war-wounded are stabilized near the frontlines and, when necessary, transferred “up the chain” to higher levels of care [3]. In Mosul, three levels, or echelons, of care were ultimately implemented for civilians: Trauma stabilization points (TSPs), run by medical non-governmental organizations (NGOs), were situated within 10–15 min of the frontline; field hospitals were established within roughly an hour of the point of the injury; and referral hospitals for more complex injuries were designated further away from the theatre (Fig. 1).

In many ways, this pathway represented a marked departure from “business as usual” for humanitarian trauma care in wartime. Although echelons of care are well-described in war surgery literature, they are most commonly associated with western militaries, having been deployed in military responses in Vietnam, Israel, and the Falkland Islands in the 1970s and 1980s through Afghanistan and Iraq more recently [4, 5]. These military evacuation chains provided first aid near the point of injury, transport of the critically wounded, and surgical care for combatants and, to varying degrees, injured civilians. Humanitarian actors, by contrast, have historically been constrained by resource, security, and logistical challenges and have not organized formal, military-style trauma evacuation pathways [6‐10]. As the International Committee for the Red Cross (ICRC) noted, “echelons for the management of war wounded do not always exist in a civilian or humanitarian context”; rather humanitarians often work at a single site, at variable distances from the frontlines, and have been dependent upon the war-wounded getting to them by whatever means possible [11]. Even when echelons do exist, they are often rudimentary: In the 1980s, for example, the ICRC supported a series of “first aid posts” and field hospitals in Afghanistan and along the Afghanistan-Pakistan border, but it took patients 6–7 h, and at times more than a day, to reach one of the hospitals [7, 8]. Moreover, on principle, many humanitarian organizations feel strongly that care at or near the frontlines is -- and should remain -- the responsibility of professional militaries, not humanitarians, in accordance with the Geneva Conventions [12, 13].

Yet recent experiences in Iraq and elsewhere have shown that humanitarian agencies are actively reassessing, and seeking to improve, how they deliver trauma and surgical care [14, 15]. These efforts began with natural disaster responses, reflecting the fallout from the 2011 Haiti earthquake response that was widely criticized as slow, fragmented, and poorly coordinated [16]. Agencies are now re-examining trauma care in war, spurred in part by growing lessons from military battlefield trauma systems over the past two decades. In the 2000s, the U.S.-led international coalition in Iraq and Afghanistan made massive investments in battlefield trauma systems that have been credited with a marked reduction in servicemember fatality rates compared to previous armed conflicts [17, 18]. Critically, these systems feature not only multiple echelons of care (from point of injury to complex rehabilitative care), but also integrative components such as communication, transportation, data collection, and clinical practice guidelines that enabled a continuum of timely, quality care for the gravely injured [3, 5]. Many of these elements have been credited with saving lives, including reduced times between injury and definitive care (often through the use of air evacuation to limit the time between injury and definitive care to less than one hour); better tactical pre-hospital care that prioritized hemorrhage control including tourniquet use, resuscitation with blood products, and hypothermia management; sustained en-route care during transportation; and real-time use of data to improve care delivery [5, 19, 20]. In sum, the combination of improved data collection and analysis, clinical practice guidelines, and real-time clinical governance have enabled such achievements.

Given the novel application of military-style echelons of care to the Mosul humanitarian trauma response, as well as the growing interest from humanitarians to strengthen trauma care in conflict settings, there is a need to better understand what was done in Mosul and to examine how trauma systems insights were manifest in this approach and how they might be improved in the future. Accordingly, the purpose of this study is to analyze the Mosul trauma response through a trauma systems lens, drawing upon a published framework for civilian battlefield trauma systems [21]. This framework outlined a schema featuring multiple levels of care, with providers and activities designated at each level (Table 1); it also specifies six supportive or integrative components: coordination, communication, transportation, health information systems, education and training, and research. Applying this framework, the study aims to assess whether the Mosul trauma pathway functioned as an integrated system and to identify areas that could be strengthened, context-permitting, in future responses.

The Mosul civilian trauma response represented a novel effort by humanitarian actors to apply aspects of military battlefield trauma systems to improve access to care for severely injured civilians and avert an even greater humanitarian catastrophe in Mosul. This approach, implemented in real-time and under great pressure as gaps in trauma care became apparent, may have helped save up to 1500–1800 lives, according to a recent case study on the response [20, 21]. As a first-of-its-kind approach, it has attracted significant attention and debate within the humanitarian community and raised important questions about the extent to which trauma systems advances can be adapted by humanitarians in conflict settings.

We identified several areas where trauma systems concepts were effectively incorporated into the Mosul response. The organization of medical capacities into echelons of care, starting at the TSP level near the frontlines and continuing through field and referral hospitals, created a pathway that allowed civilians to receive care in a highly challenging, insecure environment where frontline services were otherwise lacking. The placement of TSPs near the frontlines clearly pushed care closer to the point of injury, as most civilian casualties were being evacuated by military vehicles and would not have had the means to reach care farther away. From a clinical perspective, efforts were made to define appropriate activities at each level of care; for example, WHO developed TSP guidelines for evidence-based pre-hospital care interventions, such as tourniquet placement and fluid resuscitation. Coordination among actors was encouraged and supported through a variety of mechanisms, including trauma working group meetings as well as intelligence and logistical support from the UN system.

However, the study found that important components that link echelons of care and have underpinned achievements of military battlefield trauma systems were difficult to implement in the Mosul context [11‐13]. En-route medical care was limited by a lack of stocked ambulances and trained medical personnel, meaning that some patients likely suffered disruptions in care during transport, and air evacuation was not available. Capacity for post-operative care and rehabilitation was scarce, leading to patients being discharged without follow-up or rehabilitative care. Data collection was impacted by inconsistent reporting and lack of patient tracking, limiting conclusions about the response’s overall effectiveness. Field coordination was under-resourced, often relying upon a single individual to make decisions about where to send patients. Understandably, these challenges must be viewed within the context of planners needing to adapt quickly in a highly insecure environment and attempting such an ambitious response for the first time. But identifying such gaps may inform and help strengthen future responses.

Several limitations of this study should be acknowledged. The study was retrospective, as the authors did not directly observe the trauma response in real-time. Although efforts were made to interview as many direct participants as possible, some viewpoints may have been missed. Because interviews were limited to the organizations participating in the UN response, important perspectives, including those of Iraqi beneficiaries, local health authorities and providers, and other NGOs providing medical care during the response, were not included. Interview responses may have been affected by recall bias. The framework used to guide this study, although offering a systematic approach for conceptualizing trauma systems, has its own limitations, including being agnostic on the logistical and ethical complexities of implementation in other contexts. Finally, this analysis does not include quantitative data. Although quantitative data were collected by WHO and implementing partners, these data have limitations, discussed elsewhere [24, 25] and were excluded for this analysis. The lack of patient tracking in particular limits conclusions on continuity of care and patient outcomes.

The applicability of the Mosul approach to future conflicts is now being widely debated. In the Mosul response, donor interest, resource availability, and strong intelligence and security support from parties to the conflict (e.g. U.S. and European countries) were important, even essential, enabling factors. Whether these resources will be present in other humanitarian responses is an open question – and may well not be when high-income countries are less invested. Moreover, the recent achievements of military trauma systems in reducing battlefield mortality have drawn upon many technological advances, including the use of blood products in far forward positions, the reliance on airpower for rapid evacuation of casualties, and the development of sophisticated trauma registries that have allowed for the identification of suboptimal care and real-time improvements. A recent analysis by Howell et al. (2019), reviewing U.S. servicemember casualties in Iraq and Afghanistan, found that improvements in blood product availability, tourniquet use, and reduction in pre-hospital transport times accounted for nearly half of the reduction in case fatality in those conflicts [5]. Some observers have raised concerns that, in the absence of such advances, echeloning care may be counterproductive or even harmful if such echelons delay rather than expedite access to appropriate care.

Nonetheless, many humanitarian groups are now exploring ways to bring trauma care closer to the point of injury and improve civilian access to treatment. In recent years, MSF and ICRC have invested in mobile surgical units in conflict settings, and referrals from NGO-run field hospitals to facilities offering a higher level of care have been documented in various contexts [9, 10, 14, 15]. Given this interest, there is clearly a need to better understand how advances from military trauma systems can be adapted by humanitarians given the resource limitations and logistical challenges they face. A consensus framework for humanitarian responses for conflict was recently published which advances this agenda even further with greater detail [23].

There is also the contentious question of who should provide such care. During the Mosul response, many humanitarian organizations raised concerns that frontline trauma care is and should remain the responsibility of the warring parties under the Geneva Conventions and its Protocols, and that the willingness of the UN and humanitarian NGOs to “step in” and fill this void created a worrisome precedent, such that militaries may feel more comfortable outsourcing their responsibilities to humanitarians in future conflicts. These concerns deserve further consideration but are outside the scope of this article. Nonetheless, it is highly likely that in future conflicts, NGOs will continue to face questions about how to apply insights from military trauma systems to their actions, and what to do when professional militaries cannot, or will not, provide such care.

Although every conflict is unique and requires a contextually appropriate response, some generalizable opportunities may already exist. Guidelines could be developed to identify evidence-based interventions at different echelons, and specify the resources needed to support them. Opportunities for improving the availability of blood transfusions for civilians could be explored. Field coordination could be improved through basic investments in communication technology and software. En-route care could be strengthened by examining existing global procurement options for ambulances, supporting early assessments of transportation infrastructure, and funding basic training programs for local paramedics, as the ICRC has done in many previous conflicts. Data collection could be improved by identifying appropriate indicators and methodologies in advance, supporting the hiring of monitoring and evaluation specialists, and by making modest investments in patient tracking systems, modelled after the UK or US trauma registries and establishing guidelines for data ownership and access in advance. Many of these efforts would have the greatest impact if they begin now, before another international emergency trauma response is required. A good starting point would be to convene humanitarian, civilian, and trauma experts to discuss these points, develop guidelines, and endorse a research agenda for the future.

The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarians closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult for humanitarians to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.