Pathway and education
Although the Lashkar Gah hospital has very limited equipment, a high patient inflow can be managed. This NGO hospital cannot be compared with a military facility, as both the financial means and the training of the medical staff working there are completely different. In addition, it is extremely difficult to transfer severely injured patients to a larger trauma centre. Nevertheless, with these resources on one day (21.03.2016), 22 Patients (21 BI) were treated by four surgeons within 24 h without enabling mass casualty protocol. In this 92-beds-hospital, this amount equals 23.91% of the overall capacity. This becomes even more impressive, regarding the fact that with exception of the surgeons, the medical personnel was trained in the hospital only, with no pre-existing medical education. It seems that standardized pathways can compensate the lack of medical education and are crucial in the treatment of high patient’s inflow.
According to Lesaffre et al., who analyzed the terror attacks in Paris 2015, a “…simpler and more robust organization…” is one of the most significant factors to deal with a mass casualty incident [
9]. During the Paris Terror in 2015, 495 wounded and 130 dead victims were counted. One hundred twenty-four before reaching a hospital. This day, about 1800 firefighters trained in first aid were on call. Many of the 7900 Parisian firefighters are accommodated in 80 fire stations and thus quickly accessible. In case of a terror attack, the severely injured patient may not reach a level 1 trauma centre, but a primary health care institution. This was the case in 22% of the absolute emergencies in Paris 2015. This fact underlines the need of a profound training in life-saving skills of every doctor in charge [
9]. In those cases, necessary diagnostic procedures should be kept simple and focused on life-threatening injuries to assure a quick life-saving treatment. They include a fast but thorough clinical examination of the undressed patient, measurement of heart rate, blood pressure, and oxygen saturation, insertion of two large bore intravenous lines, taking blood samples, and radiography only if necessary. All these steps stick to a well-defined simple pathway.
After diagnosing, a fast treatment without delay is essential. Besides fast and thorough wound debridement, this means mostly performing laparotomies, inserting chest tubes and amputations. These skills are crucial to save the patient’s life [
9,
13]. They are also providing the basis for western surgeons dealing with an enormous number of casualties by a terror attack or a mass catastrophe [
14,
15]. The speed factor is essential, not only for the patient treated momentarily, but for the next severely injured patients waiting for treatment.
Surgical skills needed include vessel repairs, craniotomies, and thoracotomies.
The war surgeon needs to combine techniques from different surgical fields such as maxilla-facial, plastic, abdominal, orthopedic, and neurosurgery [
4,
16]. In Lashkar Gah, specialist surgical care was needed for eye related procedures. These patients were sent to Kabul.
Although war surgery’s spectrum is broad, surgeons have to deal with two main trauma mechanisms. Most of the injuries are caused by penetrating high velocity projectiles of any sort (BI and SI) or by blasts and burns from explosives like bombs or mines (SI and MI) [
2].
Even though resources in western countries might be superior to NGO hospitals in LIC, critical incidents like terror attacks will overwhelm local resources [
17]. As a solution, mass casualty protocols have been created to assure a proper medical health care even in situations with more than 500 severely injured [
9,
18].
Skills
Besides these in-hospital pathways, surgical skills need to be trained as well. Teaching of life-saving procedures, compulsory for every surgeon in training might be helpful [
19,
20], but they hardly match the surgeons expertise gained through high patient turnover. But not every patient is “in extremis.” Wound debridements, simple laparotomies, insertion of chest tubes, and vessel repairs are probably the majority of cases and need to be achieved as fast as possible.
Treatment pathways and surgical skills are the main characteristics of the Lashkar Gah hospital for civilian war victims. Although medical education was not available for most of the personnel and the hospital is very basic, it could cope with a high number of patients. Training, surgical skills, and clear pathways did lead to reliable, appropriate, and rapid treatment of the seriously injured, even with a large proportion of staff who have not received any official medical training.
Limitations
The mission period was restricted to three months, and the data collected only reflect this period. Due to the limited documentation in a war zone, a further evaluation of long-term follow-up was not possible. However, the necessity to prepare for an extremely seldom incident, such as a terror attack, can be discussed. Although medial impact is increasing, death due to terrorism has decreased over the last 40 years [
21]. Further, the data published from these incidents showed good coping strategies of the treating hospitals, even without specific preparation [
22]. Nevertheless, the determined characteristics could be useful for polytraumatized patients. In these cases, fast treating algorithms and surgical manoeuvres are essential [
9].
Summarizing, the knowledge of any anatomic region and the ability to perform fast surgery make the war surgeon unique. Speed is essential in surgery and treatment pathways. Those special abilities can provide a basis for surgeons working in HIC who are confronted with a mass casualty incident like a terror attack.
The lesson learned from Lashkar Gah for terror surgery in Europe:
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Surgeons must be trained in war surgery performing thorough debridements, laparotomies, chest tube insertions, vessel repair, and craniotomies.
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Treatment pathways must be trained by the hospitals’ staff.
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The hospitals´ resources are of minor importance.