Emergency Departments: Preparing for a New War : Journal of Emergencies, Trauma, and Shock

Secondary Logo

Journal Logo

Expert Commentary

Emergency Departments

Preparing for a New War

Chauhan, Vivek; Secor-Jones, Sarah1; Paladino, Lorenzo2; Sardesai, Indrani3; Ratnayake, Amila4; Stawicki, Stanislaw P.5; Papadimos, Thomas J.6; O’Keefe, Kelly7; Galwankar, Sagar C.7

Author Information
Journal of Emergencies, Trauma, and Shock 15(4):p 157-161, Oct–Dec 2022. | DOI: 10.4103/jets.jets_143_22
  • Open

Emergency physicians (EPs) are well-trained to deal with a wide range of acute illnesses and traumatic injuries. However, they are at times confronted with public health emergencies of international concern, such as epidemics, pandemics, natural disasters, large-scale industrial accidents (chemical spills, aircraft crashes), and wars. Under such conditions, the emergency medical system of care delivery becomes the triage epicenter for an exponentially larger number of citizens; the above-mentioned public health threats can occur instantly or may develop gradually over a period of months or even years.

On February 24, 2022, when Russia invaded Ukraine, the emergency departments (EDs) in and around the affected area had to face a new kind of battle.[1] Regional and national emergency medical systems were confronted with all the difficulties of COVID-19 while also dealing with new monumental challenges of refugees, traumatic war injuries, restricted movement, lack of medical supplies, and the threat of food insecurity. At the time of writing this manuscript, the Russia-Ukraine conflict is regionalized, but the threat of escalation looms over the entire planet. The tentacles of war extend far beyond the zone of combat, manifesting as economic, social, and political consequences. While academicians will try to explain the differences between wars, special military operations, and other forms of armed conflict, the civilians affected will tell you there is no difference. What is happening in Ukraine is for all intensive purposes a war, and it has put humanity on the precipice of a third world war with the ongoing threats of nuclear, chemical, and biological weapons use.

What can EDs expect during a war? The EPs “on the ground,” near the war zones, can expect overwhelming patient volumes, horrifying injuries of war, shortage of medical supplies, and destruction of infrastructure in the initial phases. As the war continues, they will face problems with refugee health, placement of the unhoused, food shortages, chronic medical conditions, mental health manifestations in both health-care workers and civilians, and knock-on effects for generations to come [Figure 1].

F1-2
Figure 1:
Impact of war on various domains of health care and well-being

In this article, we outline some of the potential impacts of conflicts and wars on clinics, hospitals, EDs and the health-care delivery in general, focusing on facilities located in and around the conflict zones. We also discuss fundamental aspects of preparing for such events.

HISTORICAL CONTEXT OF WAR, EMERGENCY DEPARTMENTS, AND SURGEONS

Historically, war efforts require active participation of civilian surgeons and EPs due to the large volume of casualties presenting within a short period, challenging the existing system to cope with war injuries and forcing the already deployed medical forces to call upon assistance from parallel health systems. In addition, war provides concentrated experiences in trauma care, traditionally resulting in significant bedside innovation and advances in related clinical approaches and techniques.

The following remarks by Sir George H Makins, renowned World War I surgeon, at the Bradshaw Lecture to The Royal College of Surgeons of England in 1913 vividly convey the facts and realities of war. “At all periods, the opportunities afforded by the field of battle have exercised a strong attraction to the surgeons both from the instinct of patriotism and the fact that in no other branch of surgery can experience be so rapidly gained. One battle can afford more material and that of a more varied nature than many years of experimental work.”[2]

The old adage “He who wishes to be a surgeon should go to war” still applies. It is well known that many medical providers took their grim experiences from the Vietnam war and repurposed them to transform the emergency medical systems, EDs and in-hospital trauma care, thus saving millions of lives in their local communities.[3] Medical breakthroughs and discoveries resulting from surgical experiences during military conflicts have undoubtedly transformed the way we practice medicine and surgery today. Novel programs of triage and health assessment, trauma combat care, and multiple surgical and emergency procedures can be traced directly to the battlefield management of wartime injuries.[4] It is essential that these trauma concepts be taught to the civilian medical force in a standardized manner using a uniform, shared language.

Combat casualty care is substantially different and uniquely challenging when compared to civilian trauma care. War theatres are characterized by injuries that include complex, multi-cavity, blunt and penetrating, shrapnel, burn, and blast wounds, often presenting as mass casualty scenarios.[56] Exsanguinating torso and limb hemorrhages are common and are among the most common types of preventable deaths in the battlefield.[7] To help address the latter, appropriate damage control assets can be deployed in the form of “forward surgical teams” and other similar implementations, streamlining critical patient flow back to awaiting surgical teams.

Management of battlefield injuries is not taught in civilian ED training, resulting in very limited insight and knowledge which is nonetheless necessary in unforeseen war or disaster situations. War surgery is a specialized skill that needs to be learned and should be taught in medical schools, and reinforced on regular basis thereafter.[8] Targeted medical conferences and seminars helped health-care workers acquire the necessary knowledge and skills to manage COVID-19. Similarly, we feel that all major medical and surgical conferences can have dedicated sessions on war injury management / skills. The international committee of the Red Cross has taken the lead in this specific area by organizing a seminar in Geneva on “The management of patients with war wounds.”[9]

One of the key parameters used to evaluate the overall lethality of a particular battlefield / war theatre, especially in the context of the effectiveness of combat casualty care, is the case fatality rate. It was recorded at 19.1% in World War II, 15.8% in the Vietnam war, and 8.6% at the end of Operation Iraqi Freedom and Operation Enduring freedom.[10] Over the past 150 years, killed-in-action fatalities have increased, primarily due to the increased lethality of newer weapons, while the died-of-wounds fatalities have decreased from 13% to 3% because of improved medical and trauma care.[11] The Joint Theater Trauma System, coupled with purpose-driven research and continuous performance improvement process (focused empiricism), including the deployment of modern tourniquets and hemostatic dressings to control bleeding, far forward surgical capability, advanced combat casualty evacuation with en-route blood product delivery are among the key features of this highly advanced, modern battlefield care delivery process.[12] Forward mobile surgical teams actively incorporate the resuscitation and stabilization skills of EPs and have the ability to perform one major and one minor surgery without resupply at austere locations.[13] Furthermore, highly specialized “damage control” resuscitative teams are capable of caring for several patients in the forward environment depending on location and situation. These forward surgical teams can also create a makeshift blood bank, which is essential in battlefield trauma. It is very important that these military concepts are also taught in the civilian healthcare sector. The adoption of clinical quality management guidelines, especially battlefield clinical practice guidelines, has been shown to improve outcomes on the battlefield as they standardize key aspects of immediate casualty care.[14] Only organizations and professionals with conflict experience, international humanitarian law training, and a strong understanding of the high-risk environments (in which they may find themselves) should be deployed near the frontlines.

DESTRUCTION OF HEALTH-CARE INFRASTRUCTURE

Although protected by international conventions, hospitals continue to be among strategically significant and vulnerable targets of the enemy. Conflicts often devastate essential health services and pose both direct and indirect danger to human life. Health-care workers are often caught in the crossfire. The World Health Organization (WHO) has already listed over 600 verified attacks on medical facilities and workers by Russian forces as of October 14, 2022. A significant number of medical personnel in Syria (847) and Afghanistan (14) have been killed since 2015.[15] There are instances of several doctors being executed in the context of hostile / enemy combatant care scenarios.[16] Because of the inherent danger to life, health-care staff often flee the conflict zones. In Syria, 50% of the health workers and 95% of physicians living in Aleppo have left the country since 2011, and in Iraq, almost half of all the health professionals have emigrated since 2014.[17] In Nigeria, almost all health workers have escaped areas controlled by Boko Haram since 2012, leading to the closure of 450 health facilities.[17] The remaining health-care staff who are ill-equipped to deal with the additional case burden presenting in EDs, and likely lack essential training in acute diseases and combat emergencies, are left to cope during the conflicts.[17] This highlights our earlier point that structured training for war related injuries and associated events should be a required part of medical school and post-graduate medical education curricula. The well-prepared ED will be significantly more resilient when facing the various challenges of war [Figure 2].

F2-2
Figure 2:
Impact of war on facilities, patients, medical personnel, and supplies

MEDICAL SUPPLIES SHORTAGES

The International Federation of Red Cross and Red Crescent Societies has stated, “Health care is most needed where it is most difficult to deliver.”[18] This applies particularly in the context of war and conflict zones, where health-care delivery is inherently significantly disrupted. Under such circumstances, EDs can be overburdened by the cumulative effect of combined civilian and combatant injuries, as well as the acute emergencies in vulnerable populations that include children, pregnant women, the elderly, and patients with chronic diseases.[18] The medical supplies, essential drugs, and facilities in conflict zones face the constant risk of becoming disrupted, leaving frontline personnel with severely limited resources, all while treating the most severely injured patients. Frontline physicians and nurses are often required to work for extended hours, caring for the most acutely sick and gravely wounded victims. They may also need to ration supplies and care, often making extremely difficult life-and-death decisions. Burnout is highly prevalent, frequently extending to (and affecting) providers in the neighboring countries that receive a large number of refugees (most often women, children, and the elderly fleeing the war).

Triage, transfer, and prolonged casualty care of the injured need to be taught to the EPs, who may need to provide initial stabilization and treatment before transferring the injured to a mobile field hospital, then to a regional hospital, then to a tertiary hospital. In a war zone, regional disaster networks need to be established, with shared planning and logistics, including transfer criteria and protocols for the hospitals providing initial care. The personnel with appropriate training should be stationed at each point and “level of care.” Those with the most combat trauma care experience should be proximal to the frontline, taking active leadership roles.

Other important considerations and resources needed during armed conflicts include:

  • Emergency supply stock, including generators, water supplies, blood, and oxygen
  • Assignment and preparation of facilities to receive patients based on geographic location
  • Mapping of safe zones, transfer zones, and protected zones
  • Planning transport modalities and routes, putting in place transfer protocols based on medical situation, number of patients, availability of resources at hospitals involved, etc.
  • Individual tracking of patients throughout the referral pathway and beyond
  • Cross credentialing of providers at facilities based on disaster or emergent needs
  • Consideration of laws to address various critical needs and protect providers working under these dire circumstances
  • Cooperation between what are normally competing facilities through regional networks
  • Ability of government officials to more easily verify core credentials and waive nonapplicable bureaucratic requirements for health-care staff
  • Coordination of overall command and control
  • Ethical considerations for the treatment of combatants
  • Food, water, facilities for sleeping, hygiene for staff
  • Various essential security considerations, including both physical and cyber security
  • Data collection systems strengthening to include clinically appropriate indicators of standard practices to accurately document the quantity and quality of care.

REFUGEE HEALTH, PLACEMENT, AND INTEGRATION

Both the absolute number of refugees as well as the time span over which the influx occurs will have a significant impact on health-care resources of countries providing refuge. For example, Turkey, Lebanon, and Jordan have received over 2 million refugees from Syria in their EDs and hospitals seeking emergency and chronic disease care.[18] At the time of this publication, Poland had recorded over 1.4 million refugees from Ukraine under temporary protection scheme, with a total of more than 7.6 million refugees recorded worldwide.[19] The neighboring countries are allocating health-care resources for both current and anticipated future refugees, most of whom are at the extremes of their ages and may need urgent health-care support upon reaching their intended destinations.[20] It is essential that plans be put in place to adequately prepare for the sheer volume of patients with chronic illnesses that will need to be accommodated. (i.e., dialysis, continuing cancer care, diabetes, etc.) Refugees constitute a vulnerable group due to language barriers, social isolation, financial restrictions, both acute and chronic physical and mental health problems, noncontinuity of previous healthcare plans, and lack of accurate or complete medical records (including immunization history).

UNANTICIPATED DISEASE TRANSMISSION

Data from 16 countries with the highest number of refugees, representing 12% of the global population, demonstrated a significant attributable burden of newly identified polio and measles cases between 2010 and 2015.[21] Furthermore, the immunization coverage for diphtheria, pertussis, and tetanus was below 85% coverage in many among the studied countries.[21] The sudden increase in the burden of infectious diseases may lead to significant outbreaks in the countries providing refuge to the fleeing citizens. Consequently, a robust public health system needs to be in place to mitigate these dangers.

The ongoing humanitarian work by Medecins Sans Frontiers in Ukraine in the areas of tuberculosis (TB), HIV, and mental health had come to a halt in Ukraine when the war started.[17] Public health experts have expressed concerns that the ongoing conflict between Russia and Ukraine could represent a significant setback for TB control in Eastern Europe, especially since Ukraine as a country that reported approximately 30,000 new TB cases annually. Of concern, it has the fourth-highest reported incidence of multidrug resistant (MDR) TB rates out of 53 countries of WHO European region.[22] The outflux of Ukrainians is statistically likely to disseminate MDR TB, and the surrounding nations in Eastern Europe need to scale up the TB screening and treatment programs to effectively safeguard against outbreaks of MDR TB in their population. Ukrainian refugees are also at increased risk of experiencing moderate-to-severe COVID-19 as just 35% of the country’s population received vaccinations against COVID-19. Consequently, the EDs will most likely have to bear the brunt of the resulting increase in more severe COVID-19 presentations.[22]

FOOD SHORTAGES, FAMINE, AND NUTRITIONAL DEFICIENCIES

The Global Food Security report states that 46% of the population in the developing world lives in countries affected by civil conflicts.[23] The impact of conflicts on food security and nutritional deficiencies is evident from the fact that over the past two decades, the number of provably affected children in countries experiencing armed conflict has increased from 97.5 million to 112.1 million.[23] Child malnutrition can therefore be considered a surrogate marker for food shortages in affected geographic areas. Wars and conflicts affect food security through the destruction of infrastructure, roads, storage facilities, lack of governance, inflation of prices, corruption, and overall shortage of food supplies. The adverse weather and climate-related events in the countries that are already grappling with wars and conflicts have the potential to create an insurmountable burden on the already depleted food supplies.

The impact of conflicts on food security can also spiral into a more extensive worldwide food crisis, as is currently the case with the ongoing Russia and Ukraine conflict.[24] These two countries are responsible for a approximately 25% of the global wheat exports.[24] Forty percent of wheat and corn from Ukraine is shipped to the Middle East and Africa, where many countries are already finding it difficult to deal with hunger issues and their own ongoing civil conflicts.[24] This latest conflict between Russia and Ukraine has, therefore, endangered the food security of tens of millions of people in the Middle East, Africa, and likely beyond.

Armed conflicts are known to result in food security issues; however, the reverse may also occur. As an example, the developing economic and food security issue in Sri Lanka over the past few months has resulted in civil unrest leading to violent protests and can potentially escalate into a larger conflict.[25]

MENTAL HEALTH CHALLENGES AMONG HEALTH-CARE WORKERS

Disasters, wars, and pandemics have the potential to affect health-care providers both emotionally and psychologically. Provider burnout was both highly prevalent and widely reported during the COVID-19 pandemic, regardless of the reporting geographic location, and appeared to be universally highly prevalent around the planet.[26] Although all staff members may be affected, EPs and nurses are the most severely affected during such scenarios, with burnout levels in excess of 60% when compared to physicians in general.[27] During the civil war in Libya, 45% of physicians reported depression and anxiety, 65% experienced verbal violence, and 25% were subject to physical violence by militias.[28] Health-care workers are also susceptible to developing posttraumatic stress disorder (PTSD) after serving in war zones. Up to 90% of health-care workers developed severe PTSD in government hospitals of the Gaza strip after experiencing a high-intensity military confrontation. The effects were slightly more pronounced among females compared to males and among nurses compared to physicians.[29] Witnessing acts of warfare, including killing, torture, and widespread devastation, is dehumanizing and inherently leads to severe emotional trauma. In addition, affected health-care providers suffer from separation from loved ones due to prolonged work hours combined with the uncertainty regarding family member safety. Cumulatively, all of the above factors can result in significant lasting mental health consequences for health-care personnel.[30] Although the wartime experience is stressful for medical students and resident physicians, and no student or resident should ever be intentionally exposed to the tragedy of war, experiences reported by those who were unable to escape the conflict were described as both highly unique and valuable. More specifically, trainees were able to more readily adapt to difficult conditions, become more resourceful, empathize emotionally with their patients, and show more compassion. They reported feeling pride in their chosen profession and exhibited higher levels of motivation. Practical skills associated with the treatment of wartime injuries are also learned, as are more personal lessons and coping mechanisms.[31]

CONCLUSION

Medical training should include the management of acute and chronic conditions associated with war and armed conflict, specifically to foster the development of a highly skilled and cognitively proficient medical workforce. Battlefield trauma care, management of wide array of blunt, penetrating, thermal, and combined injuries, triage in war, the deployment and operations of a make-shift blood bank, identification and management of the effects of human rights violations, acute stress response, and PTSD, as well as any pertinent coping strategies constitute just a few of the multiple facets of such a training. Given the state of the world, it is imperative that EM physicians be trained to face the colossal toils of war.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Russia Declares War on Ukraine |All you Need to Know 2022 Available from: https://www.indiatoday.in/world/story/ukraine-russia-war-news-crisis-explained-latest-vladimir-putin-donetsk-luhansk-1917202-2022-02-24 Last accessed on 2022 Nov 01
2. Makins GH The Bradshaw lecture on gunshot injuries of the arteries:Delivered before the royal college of surgeons of England. Br Med J 1913;2:1569–77.
3. Brian Zink J How War Shaped a Specialty Available from: https://epmonthly.com/article/war-shaped-specialty Last accessed on 2022 Nov 01
4. Goniewicz M Effect of military conflicts on the formation of emergency medical services systems worldwide. Acad Emerg Med 2013;20:507–13.
5. Gawande A Casualties of war –Military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004;351:2471–5.
6. Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM Jr Extremity vascular injuries on the battlefield:Tips for surgeons deploying to war. J Trauma 2006;60:432–42.
7. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al Death on the battlefield (2001-2011):Implications for the future of combat casualty care. J Trauma Acute Care Surg 2012;73:S431–7.
8. Giannou C, Baldan M War surgery. Ann R Coll Surg Engl 2010;92:179–80.
9. Rd Surgical Seminar “The Management of Patients with War Wounds” International Committee of the Red Cross 2019 Available from: https://www.icrc.org/en/event/war-surgery-seminar-the-management-of-patients-with-war-wounds Last accessed on 2022 Nov 01
10. Kotwal RS, Howard JT, Orman JA, Tarpey BW, Bailey JA, Champion HR, et al The effect of a golden hour policy on the morbidity and mortality of combat casualties. JAMA Surg 2016;151:15–24.
11. Carr ME Jr Monitoring of hemostasis in combat trauma patients. Mil Med 2004;169 12:11 5–4.
12. Rasmussen TE, Baer DG, Cap AP, Lein BC Ahead of the curve:Sustained innovation for future combat casualty care. J Trauma Acute Care Surg 2015;79:61–4.
13. D'Angelo M, Losch J, Smith B, Geslak M, Compton S, Wofford K, et al Expeditionary resuscitation surgical team:The US Army's initiative to provide damage control resuscitation and surgery to forces in austere settings. J Spec Oper Med Wint 2017;17:76–9.
14. De Lorenzo RA, Pfaff JA Clinical quality management in the combat zone:The good, the bad, and the unintended consequences. Mil Med 2011;176:375–80.
15. Bou-Karroum L, El-Harakeh A, Kassamany I, Ismail H, El Arnaout N, Charide R, et al Health care workers in conflict and post-conflict settings:Systematic mapping of the evidence. PLoS One 2020;15:e0233757
16. Arie S Islamic state executes 10 doctors for refusing to treat its wounded fighters. BMJ 2015;350:h1963
17. War and Conflict 2022 Available from: https://www.msf.org/war-and-conflict Last accessed on 2022 Nov 01
18. Jenny T Making a Difference in Conflict Zones 2018 Available from: https://blogs.bmj.com/case-reports/2018/02/26/making-a-difference-in-conflict-zones Last accessed on 2022 Nov 01
19. UNHCR Ukraine Refugee Situation UNHCR The UN Refugee Agency Available from: https://data.unhcr.org/en/situations/ukraine Last accessed on 2022 Nov 01
20. Reuters EU says expects millions of displaced Ukrainians 2022 2022 ] Available from: https://www.reuters.com/world/europe/eu-says-expects-more-than-7-million-displaced-ukrainians-2022-02-27/ Last accessed on 2022 Nov 01
21. Grundy J, Biggs BA The impact of conflict on immunisation coverage in 16 countries. Int J Health Policy Manag 2019;8:211–21.
22. Barber H War in Ukraine Could Lead to 'Devastating'Tuberculosis Problem, Warns Anthony Fauci 2022 Available from: https://www.telegraph.co.uk/global-health/science-and-disease/war-ukraine-could-lead-devastating-tuberculosis-problem-warns Last accessed on 2022 Nov 01
23. Breisinger EO C, Tan JF Chapter 7:Conflict and Food Insecurity 2015 Available from: https://www.ifpri.org/sites/default/files/gfpr/2015/feature_3086.html Last accessed on 2022 Nov 01
24. JL Impacts of Ukraine Conflict on Food Security Already Being Felt in the Near East North Africa region and will Quickly Spread, Warns IFAD International Fund for Agricultural Development 2022 Available fro m: https://www.ifad.org/en/web/latest/-/impacts-of-ukraine-conflict-on-food-security-already-being-felt-in-the-near-east-north-africa-region-and-will-quickly-spread-warns-ifad?p_l_back_url=/en/web/latest/news Last accessed on 2022 Nov 01
25. Crisis-Hit Sri Lanka Hikes Rates as Protests Intensify NDTV 2022 Available from: https://www.ndtv.com/world-news/crisis-hit-sri-lanka-hikes-rates-as-protests-intensify-2872667 Last accessed on 2022 Apr 10, Last updated on 2022 Apr 09
26. Sasangohar F, Jones SL, Masud FN, Vahidy FS, Kash BA Provider burnout and fatigue during the COVID-19 pandemic:Lessons learned from a high-volume intensive care unit. Anesth Analg 2020;131:106–11.
27. Arora M, Asha S, Chinnappa J, Diwan AD Review article:Burnout in emergency medicine physicians. Emerg Med Australas 2013;25:491–5.
28. Elhadi M, Khaled A, Malek AB, El-Azhari AE, Gwea AZ, Zaid A, et al Prevalence of anxiety and depressive symptoms among emergency physicians in Libya after civil war:A cross-sectional study. BMJ Open 2020;10:e039382
29. Abu-El-Noor NI, Aljeesh YI, Radwan AS, Abu-El-Noor MK, Qddura IA, Khadoura KJ, et al Post-traumatic stress disorder among health care providers following the israeli attacks against Gaza strip in 2014:A call for immediate policy actions. Arch Psychiatr Nurs 2016;30:185–91.
30. Pols H, Oak S War &military mental health:The US psychiatric response in the 20th century. Am J Public Health 2007;97:2132–42.
31. Batley NJ, Makhoul J, Latif SA War as a positive medical educational experience. Med Educ 2008;42:1166–71.
© 2022 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer – Medknow