Emergencies, T Trauma, and Shock · 36 Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012 of the central government into the provinces. [1] PRTs concentrate in three

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36 Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012

of the central government into the provinces.[1] PRTs concentrate in three areas: governance, reconstruction, and security.[2] To improve governance, PRTs work with appointed provincial governors, police chiefs, and elected provincial councils to increase capacity and improve the provision of services. In reconstruction, PRTs initially engage in quick impact, village improvement projects to ‘win hearts and minds’. Finally, PRTs provides a security presence in their areas.

The mission of a role II military hospital is to provide a rapidly deployable initial surgical service to stabilize non-transportable patients from the area of operations. The capabilities of the medical detachment and surgical squads are to provide life- and limb-saving surgery in the combat zone with subsequent hospitalization up to 48 hours with pre- and postoperative care of patients. Moreover, it provides care and treatment of acute illness, injury, or wounds in patients who are able to return to duty as soon as possible, and gives emphasis on prevention.

INTRODUCTION

Provincial Reconstruction Teams (PRTs) are small, civilian-military units that assist provincial and local governments to govern more effectively and deliver essential services.[1]

The purpose of PRTs in Afghanistan is to extend the authority

Address for correspondence: Dr. Stavros Gourgiotis, E-mail: [email protected]

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DOI: 10.4103/0974-2700.93110

Original Article

The results of the three-month co-operation between a German and a Greek surgical team in a role II military hospital in Afghanistan

Stavros Gourgiotis, Christos Triantafyllou1, Athanasios Karamitros2, Katrin Thinnes3, Wolfgang Thüringen4, Roland Schmidt5

Department of Second Surgical, 401 General Army Hospital of Athens, 1Department of Anaesthesiology, 424 General Army Hospital of Thessaloniki, 2Department of First Orthopaedic, 251 General Air force Hospital of Athens, Greece, 3Department of Anaesthesiology and Intensive Care, German Armed Forces Hospital of Koblenz, 4Department of Orthopaedic and Vessel Surgery, 5Department of Visceral and Thoracic Surgery, German Armed Forces Hospital of Ulm, Germany

ABSTRACTBackground and Aim: There are a lot of unique challenges for the military medical personnel assigned to Afghanistan. We evaluate the results of the co-operation between a German and a Greek surgical team during a 3-month period in a role II hospital. Materials and Methods: Patients who were admitted to the role II German hospital of Kunduz were evaluated. We reviewed the type of diseases, mechanism and location of injuries, management, types of surgical procedures, blood supply, and outcome. Results: The data included 792 ISAF patients, 18 NGOs patients, and 296 local patients. Out of them, 71.6% of the patients were ISAF personnel; 51 patients underwent a surgical operation; 35 of them were operated in an emergency base. Fifty-five surgical procedures were performed. In 22 (43.1%) of these patients, orthopedic procedures were performed, while in the rest 29 (56.9%) patients the operations were of general surgery interest. Gunshot injuries were the main mechanism of injury for locals, whereas ISAF personnel were usually presented with injuries after IEDs and rocket attacks. A total number of 11 patients were transferred to role III military hospitals for further treatment within 24 hours. Conclusions: The co-operation between surgical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in a combat environment.

Key Words: Casualty, combat, military, surgery, wound

Gourgiotis, et al.: Surgical teams in Afghanistan

37Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012

The intent of this study was to analyze the database of a role II hospital of PRT Kunduz in North Afghanistan in order to describe the acute and elective cases, which were managed, and find the distribution of wounds and the mechanisms of injuries during the current conflicts. In particular, it focused in the 3-month co-operation between two surgical teams (one from Germany and one from Greece) under very difficult and unique war challenges.

MATERIALS AND METHODS

From July 21, 2009 through October 20, 2009, 1,106 patients were admitted to the role II hospital of PRT Kunduz. There were 1,041 male (94.1%) and 65 female (5.9%) patients with an age range of 1 to 70 years (median age: 32.4 years).

The medical records were reviewed for demographic information regarding patients’ status, sex, and age. Variables including type of diseases, mechanism and location of injuries, physical findings, laboratory findings, Glasgow Coma Scale (GCS) score, and radiologic imaging (X-rays and ultrasound) at the time of initial patient presentation were recorded. Operative or non-operative management, type of surgical procedures performed, blood supply, and outcome (uneventful recovery, postoperative complications, mortality and cause of the death) were also collected.

Patients were divided into three groups; ISAF (International Security Assistance Force which includes United States and other NATO coalition forces), NGOs (including members of non- government organizations), and local nationals (LNs), which included personnel of the Afghan National Army and National Police as well as Afghan civilians. Furthermore, the patients were divided in three groups according to the types of diseases they were managed for.

RESULTS

The data included 792 ISAF patients, 18 NGOs patients, and 296 local patients. The majority of them (71.6%) were ISAF personnel followed by local patients (26.8%). Four children were included among the local patients. They were 2 males and 2 females aged 11, 3, 6, and 1-year-old, respectively, and they were operated for non-combat burn injuries (gasoline and hot water).

One male and 1 female among the ISAF patients were operated for burn wounds (20% and 15% of total body surface, respectively). They were admitted to Intensive Care Unit (ICU) postoperatively and transferred to military hospitals in Germany within a maximum time of 24 hours. Furthermore, 2 ISAF patients with the diagnosis of H1N1 positive and 1 patient with severe upper gastrointestinal bleeding were transferred to Germany. The demographic features are summarized in Table 1.

During our time study period, 33.4% of the patients had a diagnosis of disease with internal medicine interest, while 37.5%

of the patients had general surgery interest diseases. The rest 31.7% were orthopedic patients. Table 2 shows the distribution of diseases (acute and chronic) according to the field of interest.

Of the 1,106 patients treated, 51 (4.6%) patients underwent a surgical operation. Of these 51 patients, 35 (68.6%) were operated immediately while 16 (31.4%) were operated as elective cases. A total number of 55 surgical procedures were performed; it was observed due to the fact that in 3 patients four second looks were performed within the maximum time of 48 hours after the initial operation. Forty (78.4%) of the patients were locals and 11 (21.6%) were ISAF personnel. In 22 (43.1%) of the patients, orthopedic procedures were performed while in the rest 29 (56.9%) patients the operation were of the general surgery interest. Table 3 summarizes the patients needed emergency or elective surgical procedure, while Table 4 summarizes the total number of emergency and elective surgical procedures by specialization and nationality.

Ten of the operated patients and 1 patient with severe upper gastrointestinal bleeding were transferred to role III military

Table 1: Patients demographics

Variable Patients (n = 1,106) Sex (male / female)Nationality

ISAF 792 (71.6) 750 / 42 (94.7 / 5.3)

NGOs 18 (1.6) 16 / 2 (88.9 / 11.1)

LNs 296 (26.8) 275 / 21 (92.9 / 7.1)

Sex

Male 1,041 (94.1)

Female 65 (5.9)

Age (years)

Mean 32.4

Range 1-70

Values in parentheses are percentages; ISAF: U.S. and other coalition forces; NGOs: members of non government organizations; LNs: local nationals

Table 2: Distribution of diseases according to the field of interest

Specialization Patients (n = 1,106)Internal medicine 369 (33.4%)

Ear, nose and throat 37

Ophthalmology 24

Neurology 13

Dermatology 16

Endocrinology 3

Cardiology 12

Respiratory 43

Gastroenterology 51

Other 170

Orthopaedic 322 (31.7%)

General Surgery 415 (37.5%)

Soft tissue trauma 57

Head injuries 9

Burns 8

Thoracic trauma 4

Other 337



hospital in Afghanistan or military hospitals in Germany for further treatment within 24 hours. Only one ISAF personnel patient with severe gunshot head injury was dead during admission. During the hospitalization time no severe complications were observed.

According to the anesthesiologists’ point of view, a few differences between ISAF and LNs members were noticed. More than 75% of the local patients had temperature higher than 37°C, without any clinical or laboratory findings of infection. The fact that the LNs patients required significantly less doses of analgesia (opioids, non steroids anti-inflammatory drugs, and local anaesthetics) than the ISAF ones has also to be reported as well as the fact that in many cases of operated LNs patients the analgetic doses, which were used were more than 50% less in comparison with the ISAF soldiers. Furthermore, despite the fact that all the LNs patients were being covered by triple scheme of anti-nausea and anti-vomiting drugs during the operation, all of them had significant postoperative nausea and vomiting. Unfortunately, we cannot provide any scientific explanation for these people definitions. Continued analysis and further investigation of these patients including their habits and characteristics should give some answers.

DISCUSSION

The United States (U.S.) established the first PRTs in Afghanistan in 2002.[1] There are now 27 PRTs in Afghanistan operating under the NATO-led ISAF.[2] PRTs are led by the U.S. and 12 other NATO and coalition partners; another dozen countries contribute personnel, financial, and material support. There is no overarching concept of operations or organizational structure for PRTs in Afghanistan. In north and west, PRTs are operated by European countries and engage in peacekeeping.[2] In south and east, U.S., British, Canadian and Dutch PRTs provide the civilian side of counterinsurgency (COIN) operations.2 PRTs depend on a vast array of civilian and military funding programs and sources.[1]

The German PRT in Kunduz has over 1,300 personnel and a large economic assistance unit located separately from a military force that operates under caveats that severely circumscribe its operations.

The role II military hospital in PRT Kunduz in North Afghanistan provides increased medical and surgical treatment

capability focusing in emergency cases and dental care including limited preventive dentistry. Moreover, it supplies treatment of chronic and elective cases, mental health services, occupational and preventive medicine. It is supported by X-ray, ultrasound, laboratory facilities, 2-bed ICU, technicians, and blood supplies, which usually consist of up to 50 units of packed red blood cells (PRBCs). It also has the capability of administering initial resuscitation and stabilization of casualties in the field of action using ground ambulances, wheeled, track vehicles, and helicopters. It finally provides ward services for up to 15 patients under normal conditions expanding to 25 patients in cases of mass casualties within a few hours.

The two surgical teams (German and Greek) performed triage, initial resuscitation, stabilization, and preparation of sick, wounded, or injured patients for evacuation. They also provided consultation, medical, and surgical service for LNs, NGOs, and ISAF patients with chronic, elective diseases. Both the teams were consisted of two general surgeons, one orthopedic surgeon, one resident in orthopedic, two anesthesiologists, and one resident in anesthesiology. They operated with one operating room table. However, in cases of mass casualties a total number of three operating room tables could be used.

The mentioned 3-month co-operation between the two surgical teams took place in a German military hospital. Obviously, this fact was established the hierarchy of the teams; there was a German head anesthesiologist, a German chief surgeon, and a German head nurse. Each surgical team was on call every second day. If there were patients who were needed a simple surgical management, the on call team was responsible for them. However, in cases of mass casualties or in cases of severe injured patients both the surgical teams were working together for managing all these wounded patients. German and Greek personnel in the same specialty sometimes were working together in the operating room, while sometimes they were working separately. There was no official or a standard protocol. The plan and the action were based on the daily circumstances. English language was the common language between the two teams. All the members of both the surgical teams were speaking the english language in a high level and all medical care was carried out in english as well.

In the 3-month period of the deployment of the combined surgical team, 21 patients were operated because of gunshot injuries, 3 patients due to improvised explosive devices (IEDs), one patient due to knife injuries, while 4 patients were operated for no combat burn wounds. We had no blunt injury in our study.

Thirteen of the 29 mentioned patients with gunshot or IEDs injuries of the extremities had sustained a fracture. Gunshot injuries were the main mechanism of injury for LNs personnel, whereas ISAF personnel were usually presented with burns after IEDs and rocket attacks. There was also one LNs patient with knife injuries of the abdomen and the left leg. One of the gunshot wounds was in the head and neck region, one in

Table 3: Emergency and elective surgical procedures by specialization, nationality, and sex

Specialization Nationality / patients

Number of procedures

Emergency / elective procedures

Male / female

General surgery LNs / 24 24 9 / 15 22 / 2

ISAF / 5 5 3 / 2 4 / 1

Orthopaedic LNs / 16 19 13 / 6 16 / 0

ISAF / 6 7 7 / 0 6 / 0

ISAF: U.S. and other coalition forces; LNs: local nationals



Table 4: Emergency and elective surgical procedures by specialization and nationality

Specialization / Nationality Diagnosis ProcedureGeneral surgery / LNs (24 patients / 24 procedures)

Right inguinal hernia (E) Bassini hernia repair

Right shoulder gunshot soft tissue injury Debridement

Both thighs burn wounds Mesh grafts

Left inguinal hernia (E) Bassini hernia repair

Haemorrhoids (E) Milligan-Morgan haemorrhoidectomy

Face gunshot wound and soft tissue injury Debridement

Gunshot wound of right femoral region Debridement


Extensive scaring of left popliteal region + phimosis (E) Mesh graft + circumcision

Left forearm gunshot injury Debridement and fasciotomy

Hypoplastic testis in the inguinal canal (E) Orchectomy

Burns of face and both legs Wounds debridement

Burns of both hands, legs and back Wounds debridement

Burns of both feet, hands and chest Wounds debridement

Abdominal and left leg knife injury Exploratory laparotomy, drainage, and debridement

Gunshot wound of chest wall soft tissue Debridement

Gunshot wound of left ankle and fracture of left talus Debridement

Acute appendicitis Appendicectomy

Gunshot wound of mandibullar Debridement

Gunshot injury of both feet at plantar surface Debridement

IED explosion and left shoulder trauma. Comminuted fracture of left scapular body + fracture of left acromion and distal clavicle + left proximal humeral fracture extending to the humeral head + extensive damage to the origin of deltoid muscle and rupture of the rotator cuff

Debridement, wound VAC

Bilateral inguinal hernia (E) Bassini hernia repair

Right inguinal hernia (E) Bassini hernia repair


General surgery / ISAF (5 patients / 5 procedures)

Phimosis (E) Circumcision

Bilateral inguinal hernia (E) Bassini hernia repair

Burn wounds of face and both upper and lower limbs Wounds debridement

Gunshot injury of right testis and right upper femoral region Orchectomy + debridement

Acute appendicitis Appendicectomy

Orthopaedic / LNs (16 patients / 19 procedures)

Left leg gunshot wound and irreparable popliteal artery torn Over the knee amputation

Right tibia gunshot wound and fracture Debridement and external fixation

Right arm gunshot wound and supracondylar fracture of the humerous External fixation (was followed by two 2nd look, 24 and 48 hours later)

Gunshot injury and left femur fracture / right leg soft tissue injury Debridement and external fixation / debridement

Gunshot injury and left supracondylar femoral fracture Debridement and bridging external fixation

Gunshot injury of left hand and foot Distal phalanx amputation of left index and 2nd/3rd amputation of left foot

Pseudarthrosis of the right humerous (E) Revision of the ORIF using iliac bone graft

Gunshot wound and left femur fracture Debridement and external fixation

Gunshot injury and supracondylar left humerous fracture / soft tissue injury of left forearm with multifocal lesions of radial artery

Debridement and external fixation / repair of radial artery (was followed by a 2nd look debridement 24 hours later)

Left ankle gunshot injury and fracture of left talus Debridement

Pseudarthrosis of right humerous (E) Revision osteosynthesis and autologous iliac bone graft

Malunion of left femur after old fracture treated conservatively (E) Open ORIF

Gunshot injury of the right arm + supracondylar comminuted right humeral fracture + extensive soft tissue injury

Debridement + external fixation or right humeral fracture + wound VAC

Diabetic foot (E) 5th toe amputation at metatarsophalangeal level

Old right tibia fracture (E) Removal of plate osteosynthesis

Pseudarthrosis of left radius (E) Revision osteosynthesis of left radius+shortening of the ulnar+bone grafting

Orthopaedic / ISAF (6 patients / 7 procedures)

4th metacarpal fracture Open reduction internal fixation (ORIF)

5th digit external tendon rupture End to end repair

Right arm gunshot wound and flexor carpi radialis rupture Debridement and end to end reconstruction (was followed by a 2nd look debridement 24 hours later)

5th metacarpal fracture Fixation with Kwives

Right radius gunshot injury and fracture Debridement

Burn wounds of face and both legs / left tibia fracture Wounds debridement / external fixation

(E): elective case; ISAF: U.S. and other coalition forces; LNs: local nationals



the chest wall region, one in the testis, while the majority of the injuries which required emergency surgical treatment were gunshot injuries of the extremities (5 in the upper limb, 7 in the lower limb, 1 in both upper and lower limbs). Only 2 ISAF soldiers were treated surgically for gunshot wounds of the extremities (both of them had gunshot injuries in the upper limbs) and one for gunshot injury of the right testis. Many authors have recently reported the high percentage of the extremity injuries during the Operations Iraqi and Enduring Freedom.[3,4]

Gunshot wounds of the extremities in war action are distinctive of their devastating injury pattern. It is self-evident that all these injuries were thought of as potentially contaminated. Soft tissue compromise may be extensive. In our study, 3 patients with severe soft tissue injuries were re-operated for a 2nd and 3rd look debridement within 48 hours. Vacuum assistant fascia closure (VAC) technique was used in 3 another patients for the treatment of extended soft tissue injuries with residual cavities. In 2 patients there were multiple entry and exit points.

Vascular compromise was evident in 4 patients. One patient with a tibia fracture presented with an irreparable rapture of the popliteal artery 7 hours after the injury; this fact made an above the knee amputation inevitable. The second patient with a distal femoral fracture was presented with an ischemic distal leg but normal circulation was reestablished after fracture reduction and stabilization with external fixation. The third patient had multifocal lesions of the radial artery (4 partial lesions) in its course through the forearm. Finally, 1 patient with a forearm soft tissue injury required fasciotomy of the forearm due to impeding compartment syndrome.

In this study, 6 patients with burn wounds were treated; 4 LNs children and 2 ISAF personnel. All the children had noncombat burn wounds due to gasoline or hot water while the ISAF personnel burn wounds were because of IEDs. The anatomic distribution of burns seen in this study is typical of both military and civilian burn data.[5,6] The hands, forearms, and face were the most commonly affected areas. It is necessary to be noticed that burns to these areas are highly morbid and have significant cosmetic and functional consequences.

The vast majority of the internal medicine cases were treated conservatively in the role II hospital. Two of the ISAF personnel patients were found to be positive in H1N1. They had all the symptoms of new influenza. It must be noticed that these 2 patients had just arrived from Europe. After diagnosis they were transferred immediately to military hospitals in Germany. Another 3 LNs patients with huge thyroid gland and hyperthyroidism received the appropriate medication and were planned to be operated some weeks or months later after normalization of the thyroid hormones. Finally, 1 ISAF patient was admitted with severe upper gastrointestinal bleeding because of esophageal varicose due to portal vein hypertension. He was unstable and received 5 PRBCs and 4 units of fresh frozen

plasma after his intubation. He was admitted to ICU and was transferred to military hospital in Germany within 24 hours. A total number of 11 patients transferred to a role III military hospital in Afghanistan or to military hospitals in Germany for further treatment.

Nursing care has also to be emphasized. There were registered nurses, critical care nurses, emergency department and surgical nurses, as well as licensed practical nurses. They were trained personnel in the resuscitative, surgical, and perioperative management of patients. They were required to administer drugs and blood products, manage ventilated patients, assist in surgical procedures, and occasionally to place body tubes.

It is important to be underlined the ideal co-operation between the Greek and the German surgical team in this 3-month period. It is noteworthy that while the members of the German surgical team had repeated experience of similar missions, it was only the first mission of this kind for their Greek colleagues. Despite their disproportionate experience, the two medical teams had an unimpeded collaboration, which could be attributed to the fact that both teams had almost the same patient management plans, the same wound management protocols, very similar guidelines for antibiotic administration and the same pain relief plan. The authors also recognize that this study has noticeable limitations. Principally, because of the nature of this study (heterogeneous group of patients including acutely injured and chronically diseased), we are unable to generate conclusions based on the available data. Another limitation here is that we had no opportunity for a complete follow-up, especially from the majority of the LNs patients. After their discharge from the hospital, many of them were transferred to regional Afghan hospitals for further treatment and their follow-up was carried out by local doctors or physicians. It is self evident that final results and late complications are not enrolled in this study.

A number of factors contributed greatly to the integration of German and Greek surgical teams during the time period of their co-operation.• Daily teaching sessions (by both German and Greek

colleagues), concentrating on trauma management along standard Advanced Trauma Life Support (ATLS) and Battlefield Advanced Trauma Life Support (BATLS) protocols and these had been attended by doctors, nurses, and medics from both units. These sessions demonstrated that there were no fundamental differences in practice between the two surgical teams.

• The two surgical teams had set up and exercised some combined incident scenarios of mass casualties.

• Some of the Greek nurses had previously worked with German doctors and nurses at the ISAF field hospital in Kabul.

• The Greek anesthesiologist and the Greek surgeon had previously worked at combined German-Greek training courses in Germany.



The prime purpose of this study was to focus on the unique features not only of the war trauma but also of elective and chronic cases and their management regarding the restraints imposed by the personnel and equipment of a role II hospital in the field of action. These information and thoughtful review of these data in addition with the collection of combat casualty data, at a similar level, should be the beginning of optimal medical planning, training, and research as well as should allow more analysis and should provide means for improving patient care in the combat environment of Afghanistan.

In our point of view, all medical personnel and especially military surgeons should be properly trained, agile, skilful, and prepared for special aspects like polytrauma, mass casualty situations with triage, special field medicine requirements, and field hemostatic techniques. These special military medical skills must be specifically promoted and formed during the training of military medical personnel who is active in surgical fields abroad and especially under these difficult circumstances as our experience mentioned in German military hospital in Kunduz. Furthermore, trauma training centers with carefully designed and planned combined multination programs in areas such as neurosurgery, pediatric, urology, gynecology and obstetrics, hygiene and atomic, biological and chemical protection. Emphasis should be placed on practical lessons with purpose to provide training in the specific surgical procedures appropriate to the life-threatening soft tissue trauma cases to be expected during this kind of operations. Sufficient attention should also be paid to collaboration with adjacent disciplines, emergency treatment, anesthesia, and intensive care. All types of physicians and a good level of specialist experience and teamwork skills are essential elements within a medical organization. In addition, because of the high turnover of the deployed nurses and physicians working in this challenging environment, there is a need to develop standardized treatment guidelines.

CONCLUSION

The co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage not only mass war casualties but also elective cases of military personnel and civilians. Thorough evaluation of the results of such collaborations as well as common training or continuous education based on similar protocols of patient management will ensure even better outcomes.

REFERENCES

1. Borders R. Provincial reconstruction teams in Afghanistan: A model for post conflict reconstruction and development. J Develop Soc Transform 2004;1:5-12.

2. McNerney MJ. Stabilization and reconstruction in Afghanistan: Are PRTs a model or a muddle? Parameters 2005;35:32-46.

3. Peoples GE, Gerlinger T, Craig R, Burlingame B. Combat casualties in Afghanistan cared for by a single forward surgical team during the initial phases of Operation Enduring Freedom. Mil Med 2005;170:462-8.

4. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008;64:295-9.

5. Kauvar DS, Wolf SE, Wade CE, Cancio LC, Renz EM, Holcomb JB. Burns sustained in combat explosions in Operations Iraqi and Enduring Freedom (OIF/OEF explosion burns). Burns 2006;32:853-7.

6. Wolf SE, Kauvar DS, Wade CE, Cancio LC, Renz EP, Horvath EE, et al. Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom. Ann Surg 2006;243:786-95.

How to cite this article: Gourgiotis S, Triantafyllou C, Karamitros A, Thinnes K, Thüringen W, Schmidt R. The results of the three-month co-operation between a German and a Greek surgical team in a role II military hospital in Afghanistan. J Emerg Trauma Shock 2012;5:36-41.

Received: 16.08.10. Accepted: 15.11.10. Source of Support: Nil. Conflict of Interest: None declared.

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Emergencies, T Trauma, and Shock · 36 Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012 of the central government into the provinces. [1] PRTs concentrate in three