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18th EFORT Annual Congress in Vienna – Terrorism: New challenges and more implications for the orthopaedic, trauma community
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The considerable media attention to the most recent war conflicts and terrorist attacks brings to the forefront the key role and responsibility of the orthopaedic and trauma practitioners in delivering an immediate and appropriate medical intervention for anyone who is wounded. Do all surgeons know how to face these exceptional mass casualty incidents?
The symposium “Terror Attacks: Are We Prepared?” that is scheduled during our upcoming EFORT Congress in Vienna will tell the experiences of several surgical teams from Paris to Syria. The main objective of this session is to highlight fundamental emergency principles to be acquired by all members of the EFORT community as part of their educational training. Having an anticipated plan for the rapid increase of patients in a hospital, mastering the triage principles or perfecting the damage control procedures are, for example, essential requirements to be fulfilled by any orthopaedic and trauma surgeon.
Friday 2 June 2017 | 08:15 to 09:45
Moderation: Jan Verhaar, EFORT president (Netherlands)
- Experiences from Brussels | Serge Jennes (Belgium)
- What Can We Learn from the Military? | Falk von Lübken (Germany)
- Experiences from the Border to Syria | Alexander Lerner (Israel)
- Experiences from Paris: Being a Military Surgeon | Olivier Barbier (France)
- Experiences from Paris: Being a Civil Surgeon | Charles Kajetanek (France)
On 13 November 2015, terrorism struck in Paris. The Bégin Military Teaching Hospital (MTH) and the Pitié-Salpétrière University Hospital, like several other hospitals in the city, needed to address a large number of gunshot victims. Damage control procedures were performed on-site and patients were transferred to different medical centers following the regulations of the French ambulance and emergency unit (SMUR - Service Mobile d'Urgence et de Réanimation) and the fire brigade. However, the medical and paramedical teams encountered major problems in the transfers to the appropriate hospital, particularly because three sites were attacked. In Bégin MTH, general triage principles were applied according to the NATO guidelines. From 45 patients hospitalized, 22 underwent emergency surgery for soft-tissue lesions, ballistic fractures (one of which was a cervical injury) and abdominal wounds.
The surgical protocol followed the damage control principles of the military operations. In Pitié-Salpétrière, 53 patients were accepted from 23:00 to 04:00, of which 29 surgeries had isolated or associated orthopaedic lesions. As civil hospitals are less prepared for this kind of mass casualty incident, the main objective was to efficiently align the key points during the first post-attack hours: manage patients’ vital priorities; recruit additional medical members; and gain access to the operation rooms.
The support of a psychiatrist was offered during the initial phase of the response to this attack to the victims and their families, as well as to caregivers working in this environment. The psychiatrist’s role was to help the personnel face an exceptional situation during which all the medical services resources were overwhelmed by the number and severity of casualties.
On 22 March 2016, terrorism struck in Brussels. The Burn Wound Center Queen, Astrid Military Hospital faced a sudden wave of trauma victims from the explosions that occurred at the city national airport and one metro station. Based on the initial damage control triage, 22 casualties, which included pediatric patients, occurred related to the blasts. Fragmentation and burn injuries were received and extensively examined in the hospital within fewer than 6 hours. Among these patients, five patients were transferred to the intensive care unit; 13 patients were treated within the medium care unit; and three patients were transferred further to other hospitals for ophthalmologic advice and back surgery.
A total of nine surgeries were performed on the same day and many more in the week following the attack, which increased the challenge for the medical personnel in a short-term manner, but also showed that the military medical staff was well prepared to face a burden of polytrauma patients. Several resources were put forward as essential in the management of the situation: coaching and training; damage control resuscitation; second lecture of any X-ray exam; and continuous monitoring of early and late vascular injuries, among others. Moreover, the key logistical points to consider for debridement and wound care are the availability of large spaces to receive and triage patients, and having experienced staff and medical emergency supplies on hand.
Treating Syrian refugees
Since 2013, more than 800 severely injured Syrian causalities (men, women and children) have been admitted and treated in the trauma unit of the regional hospital of Zefat, the closest Israeli medical center to the Syrian border (40 km). Most of these patients sustained polytrauma and complex injuries to the limbs. Damage control principles and a staged treatment protocol are immediately applied for management of all the patients hospitalized, but surgical priority is given to children and severely injured patients only. Indeed, this civil hospital receives all these unexpected severely injured causalities in parallel to the daily medical activities provided regularly to local citizens.
The experience in this hospital showed that radical debridement during the first surgical intervention, open surgical wound and primary minimally invasive external stabilization are crucial for the success of the treatment and a good outcome with return to functional independent, including weight-bearing and basic daily functions. In most of the cases treated, patients returned home after the final wound closure with no need of further surgical interventions. Unfortunately, there is no long-term follow up due to the local political conditions.
In any conflict setting, efficient medical triage and first vital treatment need to be immediately performed on the site of the attack. All decisions for transfer and management should be taken based on life support and limb salvage. Transportation should be fast, safe and supported by medical staff. As most injuries found in a terror background are inflicted by explosions or gunshots, the initial treatment should include general stabilization and basic life support, bleeding control and, in the many cases, immobilization. Hospital treatment should be based on the damage control principles, primary external fixation stabilization and open wound care.
Most patients need several surgical interventions with late conversion to definitive bone fixation and soft-tissue reconstruction. Regarding the possible medical complications in patients from conflict settings, the most common problem is wound infection, which can become the ultimate discouraging factor for an already overwhelmed medical team, but needs to be anticipated in all cases. Finally, yet importantly, the psychological support for patients and practitioners is essential. No one can handle the pressure, responsibility and challenge raised during treatment of helpless severely wounded people, and particularly, children.
The shared experience of colleagues who directly faced exceptional mass casualty incidents will allow a deep analysis of extremely complex situations, which are both unexpected and difficult to cope because of the resources needed and the psychological burden generated. Important principles to follow, medical interventions to prioritize and key points to integrate in the surgeon’s training will emerge from the discussion with the participating speakers giving an overview of the orthopaedic and trauma basic procedures needed to feel prepared for any kind of emergency situation.
Attendance to this session is included in the full congress registration. You can sign up on the registration platform to secure your place.
- For more information:
- 18th EFORT Congress in Vienna: Main Theme
- 18th EFORT Congress in Vienna: fees and registration
- Triage, teamwork lessons learned from earthquakes, tsunamis and terrorist attacks