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The Golden Hour After Injury Among Civilians Caught in Conflict Zones

Published online by Cambridge University Press:  17 June 2019

Joseph D. Forrester ,
Auriel August ,
Lawrence Z. Cai ,
Adam L. Kushner  and
Sherry M. Wren
Joseph D. Forrester*
Affiliation:
Department of Surgery, Stanford University Medical Center, Stanford, California
Auriel August
Affiliation:
Department of Surgery, Stanford University Medical Center, Stanford, California
Lawrence Z. Cai
Affiliation:
Stanford University School of Medicine, Stanford, California
Adam L. Kushner
Affiliation:
Surgeons OverSeas, New York, New York Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Department of Surgery, Columbia University, New York, New York
Sherry M. Wren
Affiliation:
Department of Surgery, Stanford University Medical Center, Stanford, California Palo Alto Veterans Affairs Health Care System, Palo Alto, California.
*
Correspondence and reprint requests to Joseph D. Forrester, Department of Surgery, 300 Pasteur Drive H3591, Stanford, CA 94305 (e-mail: jdf1@stanford.edu).
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Abstract

Introduction:

The term “golden hour” describes the first 60 minutes after patients sustain injury. In resource-available settings, rapid transport to trauma centers within this time period is standard-of-care. We compared transport times of injured civilians in modern conflict zones to assess the degree to which injured civilians are transported within the golden hour in these environments.

Methods:

We evaluated PubMed, Ovid, and Web of Science databases for manuscripts describing transport time after trauma among civilian victims of trauma from January 1990 to November 2017.

Results:

The initial database search identified 2704 abstracts. Twenty-nine studies met inclusion and exclusion criteria. Conflicts in Yugoslavia/Bosnia/Herzegovina, Syria, Afghanistan, Iraq, Israel, Cambodia, Somalia, Georgia, Lebanon, Nigeria, Democratic Republic of Congo, and Turkey were represented, describing 47 273 patients. Only 7 (24%) manuscripts described transport times under 1 hour. Transport typically required several hours to days.

Conclusion:

Anticipated transport times have important implications for field triage of injured persons in civilian conflict settings because existing overburdened civilian health care systems may become further overwhelmed if in-hospital health capacity is unable to keep pace with inflow of the severely wounded.

Keywords

conflictwartrauma surgeryglobal healthglobal surgery
Type
Report from the Field
Information
Disaster Medicine and Public Health Preparedness , Volume 13 , Issue 5-6 , December 2019 , pp. 1074 - 1082
Copyright
Copyright © 2019 Society for Disaster Medicine and Public Health, Inc. 

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References

REFERENCES

Cowley, RA. A total emergency medical system for the State of Maryland. Md State Med J. 1975;24(7):37–45.Google ScholarPubMed
Cowley, RA. The resuscitation and stabilization of major multiple trauma patients in a trauma center environment. Clin Med. 1976;83:16–22.Google Scholar
Lerner, EB, Moscati, RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001;8(7):758–760.10.1111/j.1553-2712.2001.tb00201.xCrossRefGoogle ScholarPubMed
Rogers, FB, Rittenhouse, KJ, Gross, BW. The golden hour in trauma: dogma or medical folklore? Injury. 2015;46(4):525–527.CrossRefGoogle ScholarPubMed
Sampalis, JS, Denis, R, Lavoie, A, et al. Trauma care regionalization: a process-outcome evaluation. J Trauma. 1999;46(4):565–579.10.1097/00005373-199904000-00004CrossRefGoogle ScholarPubMed
Dinh, MM, Bein, K, Roncal, S, et al. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury. 2013;44(5):606–610.10.1016/j.injury.2012.01.011CrossRefGoogle Scholar
Tien, HC, Jung, V, Pinto, R, et al. Reducing time-to-treatment decreases mortality of trauma patients with acute subdural hematoma. Ann Surg. 2011;253(6):1178–1183.CrossRefGoogle ScholarPubMed
Clarke, JR, Trooskin, SZ, Doshi, PJ, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420–425.Google ScholarPubMed
Clevenger, FW, Yarbrough, DR, Reines, HD. Resuscitative thoracotomy: the effect of field time on outcome. J Trauma. 1988;28(4):441–445.10.1097/00005373-198804000-00004CrossRefGoogle Scholar
Newgard, CD, Schmicker, RH, Hedges, JR, et al. Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort. Ann Emerg Med. 2010;55(3):235–46.e4.10.1016/j.annemergmed.2009.07.024CrossRefGoogle Scholar
Goldberg, MS. Death and injury rates of U.S. military personnel in Iraq. Mil Med. 2010;175(4):220–226.10.7205/MILMED-D-09-00130CrossRefGoogle Scholar
Kotwal, RS, Howard, JT, Orman, JA, et al. The effect of a golden hour policy on the morbidity and mortality of combat casualties. JAMA Surg. 2016;151(1):15–24.10.1001/jamasurg.2015.3104CrossRefGoogle ScholarPubMed
Martin, MJ, Eckert, MJ, Schreiber, MA. Relationship of a mandated 1-hour evacuation policy and outcomes for combat casualties. JAMA. 2016;315(3):293–294.CrossRefGoogle ScholarPubMed
Howard, JT, Kotwal, RS, Santos-Lazada, AR, et al. Reexamination of a battlefield trauma golden hour policy. J Trauma Acute Care Surg. 2018;84(1):11–18.10.1097/TA.0000000000001727CrossRefGoogle ScholarPubMed
Rubenstein, LS, Bittle, MD. Responsibility for protection of medical workers and facilities in armed conflict. Lancet. 2010;375(9711):329–340.10.1016/S0140-6736(09)61926-7CrossRefGoogle ScholarPubMed
Aboutanos, MB, Baker, SP. Wartime civilian injuries: epidemiology and intervention strategies. J Trauma. 1997;43(4):719–726.CrossRefGoogle ScholarPubMed
Murray, CJL, King, G, Lopez, AD, et al. Armed conflict as a public health problem. BMJ. 2002;324(7333):346–349.10.1136/bmj.324.7333.346CrossRefGoogle ScholarPubMed
Forrester, JD, Forrester, JA, Basimouneye, JP, et al. Sex disparities among persons receiving operative care during armed conflicts. Surgery. 2017;162(2):366–376.10.1016/j.surg.2017.03.001CrossRefGoogle ScholarPubMed
Patel, P, Gibson-Fall, F, Sullivan, R, et al. Documenting attacks on health workers and facilities in armed conflicts. Bull World Health Organ. 2017;95(1):79–81.10.2471/BLT.15.168328CrossRefGoogle ScholarPubMed
Uppsala University. Uppsala Conflict Data Program [cited November 19, 2017]. http://ucdp.uu.se/. Published 2017. Accessed October 28, 2018.Google Scholar
Hudolin, T, Hudolin, I. Surgical management of urogenital injuries at a war hospital in Bosnia-Hrzegovina, 1992 to 1995. J Urol. 2003;169(4):1357–1359.CrossRefGoogle Scholar
Kristek, J, Sego, K, Has, B. Surgical treatment of patients with penetrating chest injuries sustained in war. Med Glas (Zenica). 2012;9(1):56–60.Google ScholarPubMed
Milotic, F, Uravic, M, Raguz, K, et al. Penetrating liver war injury: a report on 172 cases. Mil Med. 2003;168(5):419–421.Google ScholarPubMed
Vrankovic, D, Splavski, B, Hecimovic, I, et al. Analysis of 127 war inflicted missile brain injuries sustained in north-eastern Croatia. J Neurosurg Sci. 1996;40(2):107–114.Google ScholarPubMed
Rukavina, A, Glavic, Z, Fajdic, J, et al. War-related transformation and work of surgery service of the Pozega Medical Center, East-Croatian Hospital unaffected by direct war activities. Mil Med. 1995;160(12):604–608.10.1093/milmed/160.12.604CrossRefGoogle ScholarPubMed
Tucak, A, Lukacevic, T, Kuvezdic, H, et al. Urogenital wounds during the war in Croatia in 1991/1992. J Urol. 1995;153(1):121–122.10.1097/00005392-199501000-00043CrossRefGoogle ScholarPubMed
Lovric, Z. Reconstruction of major arteries of extremities after war injuries. J Cardiovasc Surg (Torino). 1993;34(1):33–37.Google ScholarPubMed
Petricevic, A, Ilic, N, Radonic, V, et al. Our experience with 2693 wounded treated at the Split University Hospital during the 1991-1995 period. Int Surg. 1998;83(2):98–105.Google ScholarPubMed
Barhoum, M, Tobias, S, Elron, M, et al. Syria civil war: outcomes of humanitarian neurosurgical care provided to Syrian wounded refugees in Israel. Brain Inj. 2015;29(11):1370–1375.10.3109/02699052.2015.1043346CrossRefGoogle ScholarPubMed
Hornez, E, Ramiara, P, Mocellin, N, et al. Surgical management of Syria’s war casualties: experience from a French surgical team deployed in the Zaatari refugee camp (Jordan). Eur J Trauma Emerg Surg. 2015;41(2):143–147.10.1007/s00068-014-0424-5CrossRefGoogle Scholar
Biswas, S, Waksman, I, Baron, S, et al. Analysis of the first 100 patients from the Syrian civil war treated in an Israeli district hospital. Ann Surg. 2016;263(1):205–209.10.1097/SLA.0000000000001230CrossRefGoogle Scholar
Akkucuk, S, Aydogan, A, Yetim, I, et al. Surgical outcomes of a civil war in a neighbouring country. J R Army Med Corps. 2016;162(4):256–260.10.1136/jramc-2015-000411CrossRefGoogle Scholar
Aras, M, Altas, M, Yilmaz, A, et al. Being a neighbor to Syria: a retrospective analysis of patients brought to our clinic for cranial gunshot wounds in the Syrian civil war. Clin Neurol Neurosurg. 2014;125:222–228.10.1016/j.clineuro.2014.08.019CrossRefGoogle ScholarPubMed
Angelici, AM, Montesano, G, Nasti, AG, et al. Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia. Ann Ital Chir. 2004;75(4):461–464.Google Scholar
Kiladze, MA, Lominadze, NG, Goderdzishvili, VT, et al. Surgical services and transformation of civil hospital during “August War 2008” in Georgia. Int Surg. 2011;96(1):1–5.10.9738/1335.1CrossRefGoogle ScholarPubMed
Ahmed, A. Selective observational management of penetrating neck injury in northern Nigeria. S Afr J Surg. 2009;47(3):80, 82–85.Google ScholarPubMed
Bauhahn, G, Veen, H, Hoencamp, R, et al. Malunion of long-bone fractures in a conflict zone in the Democratic Republic of Congo. World J Surg. 2017;41(9):2200–2206.10.1007/s00268-017-4008-5CrossRefGoogle Scholar
Nitecki, SS, Karram, T, Ofer, A, et al. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1–8.CrossRefGoogle Scholar
Haik, J, Tessone, A, Givon, A, et al. Terror-inflicted thermal injury: a retrospective analysis of burns in the Israeli-Palestinian conflict between the years 1997 and 2003. J Trauma. 2006;61(6):1501–1505.10.1097/01.ta.0000209401.59510.3aCrossRefGoogle ScholarPubMed
Shapira, SC, Adatto-Levi, R, Avitzour, M, et al. Mortality in terrorist attacks: a unique modal of temporal death distribution. World J Surg. 2006;30(11):2071–2077.10.1007/s00268-006-0048-yCrossRefGoogle ScholarPubMed
Solmaz, I, Kural, C, Temiz, C, et al. Traumatic brain injury due to gunshot wounds: a single institution’s experience with 442 consecutive patients. Turk Neurosurg. 2009;19(3):216–223.Google ScholarPubMed
Murad, MK, Larsen, S, Husum, H. Prehospital trauma care reduces mortality: ten-year results from a time-cohort and trauma audit study in Iraq. Scand J Trauma Resusc Emerg Med. 2012;20:13.CrossRefGoogle Scholar
Moreels, R, Pont, M, Ean, S, et al. Wartime colon injuries: primary repair or colostomy? J R Soc Med. 1994;87(5):265–267.Google ScholarPubMed
Bendinelli, C. Effects of land mines and unexploded ordnance on the pediatric population and comparison with adults in rural Cambodia. World J Surg. 2009;33(5):1070–1074.CrossRefGoogle ScholarPubMed
Husum, H, Gilbert, M, Wisborg, T, et al. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma. 2003;54(6):1188–1196.10.1097/01.TA.0000073609.12530.19CrossRefGoogle ScholarPubMed
Bowyer, GW. Afghan war wounded: application of the Red Cross wound classification. J Trauma. 1995;38(1):64–67.10.1097/00005373-199501000-00018CrossRefGoogle ScholarPubMed
Husum, H. Effects of early prehospital life support to war injured: the battle of Jalalabad, Afghanistan. Prehosp Disaster Med. 1999;14(2):75–80.10.1017/S1049023X0002731XCrossRefGoogle ScholarPubMed
Valles, P, Van den Bergh, R, van den Boogaard, W, et al. Emergency department care for trauma patients in settings of active conflict versus urban violence: all of the same calibre? Int Health. 2016;8(6):390–397.10.1093/inthealth/ihw035CrossRefGoogle ScholarPubMed
Morris, DS, Sugrue, WJ. Abdominal injuries in the war wounded of Afghanistan: a report from the International Committee of the Red Cross Hospital in Kabul. Br J Surg. 1991;78(11):1301–1304.CrossRefGoogle ScholarPubMed
Forrester, JD, Forrester, JA, Kamara, TB, et al. Self-reported determinants of access to surgical care in 3 developing countries. JAMA Surg. 2016;151(3):257–263.10.1001/jamasurg.2015.3431CrossRefGoogle ScholarPubMed
Soffer, D, Klausner, JM. Trauma system configurations in other countries: the Israeli model. Surg Clin North Am. 2012;92(4):1025–1040. x.10.1016/j.suc.2012.04.007CrossRefGoogle ScholarPubMed
The World Bank. World Bank Country and Lending Groups: World Bank Group. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups. Published 2019. Accessed October 28, 2018.Google Scholar
Simunovic, VJ. Health care in Bosnia and Herzegovina before, during, and after 1992-1995 war: a personal testimony. Confl Health. 2007;1:7.10.1186/1752-1505-1-7CrossRefGoogle ScholarPubMed
Ball, CG, Williams, BH, Tallah, C, et al. The impact of shorter prehospital transport times on outcomes in patients with abdominal vascular injuries. J Trauma Manag Outcomes. 2013;7(1):11.CrossRefGoogle ScholarPubMed
Giannou, C, Baldan, M. Transport and Forward Projection of Resources, War Surgery: Working with Limited Resources in Armed Conlict and Other Situations of Violence, 1. Geneva, Switzerland: International Committee of the Red Cross; 2010:134–135.Google Scholar
The White Helmets. Support the White Helmets. https://www.whitehelmets.org/en/. Published 2018. Accessed October 28, 2018Google Scholar
Fosse, E, Husum, H. Surgery in Afghanistan: a light model for field surgery during war. Injury. 1992;23(6):401–404.CrossRefGoogle ScholarPubMed
Carmichael, JL, Karamouzian, M. Deadly professions: violent attacks against aid-workers and the health implications for local populations. Int J Health Policy Manag. 2014;2(2):65–67.10.15171/ijhpm.2014.16CrossRefGoogle ScholarPubMed
Trelles, M, Stewart, BT, Kushner, AL. Attacks on civilians and hospitals must stop. Lancet Glob Health. 2016;4(5):e298–e299.CrossRefGoogle ScholarPubMed
Giannou, C, Baldan, M. Applicable International Humanitarian Law, War Surgery: Working with Limited Resources in Armed Conlict and Other Situations of Violence, 1. Geneva, Switzerland: International Committee of the Red Cross; 2010:35–44.Google Scholar
Fox, H, Stoddard, A, Harmer, A, et al. Emergency Trauma Response to the Mosul Offensive, 2016–2017. https://www.humanitarianoutcomes.org/Emergency_Trauma_Response. Published March 2018. Accessed May 20, 2019.Google Scholar
Rossaint, R, Bouillon, B, Cerny, V, et al. The STOP the Bleeding Campaign. Crit Care. 2013;17(2):136.10.1186/cc12579CrossRefGoogle ScholarPubMed
Spiegel, PB, Garber, K, Kushner, A, et al. The Mosul trauma response: a case study. 2018:36-7. Johns Hopkins Center for Humanitarian Health. http://hopkinshumanitarianhealth.org/assets/documents/Mosul_Report_FINAL_Feb_14_2018.pdf. Accessed May 20, 2019.Google Scholar
Mehmood, A, Chan, E, Allen, K, et al. Development of an mHealth trauma registry in the Middle East using an implementation science framework. Glob Health Action. 2017;10(1)1380360.CrossRefGoogle ScholarPubMed
Zargaran, E, Schuurman, N, Nicol, AJ, et al. The electronic Trauma Health Record: design and usability of a novel tablet-based tool for trauma care and injury surveillance in low resource settings. J Am Coll Surg. 2014;218(1):41–50.CrossRefGoogle ScholarPubMed
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