MILITARY MEDICINE, 169, 3:187, 2004 Injury Patterns in Peacekeeping Missions: The Kosovo Experience Guarantor: MAJ George N. Appenzeller, MC USA Contributor: MAJ George N. Appenzeller, MC USA Proper medical deployment planning requires projecting injuries. For this reason, the injury patterns and mechanism of injury were reviewed for an 18-month period in Kosovo, and injury rates and mechanisms were extracted for review. Overall, there were 404 trauma patients treated during the study period. Isolated head and neck injuries accounted for 29.5% (119) of injuries, chest wounds 5.7% (23), abdominal wounds 4.5% (18), and extremities 33.4% (135). Multiply injured patients accounted for the remaining 27.0% (109). When subdivided by mechanism, penetrating injury made up 36.9% (149), whereas blunt trauma accounted for 63.1% (255). Motor vehicle accidents made up the majority of blunt trauma (72.2%). Of penetrating injuries, gunshot wounds accounted for 55%, blast wounds 38%, and stabbings 6.7%. The data clearly demonstrate that humanitarian and peacekeeping missions require preparation for a wide variety of mechanisms of injury beyond the typical penetrating trauma of combat situations. Introduction he Balkan s have become a major area of involvement for the T United States and other NATO countries militaries. Peacekeeping missions are continuing and new missions will likely continue to come to the forefront of our military service. The medical specialties are integral to the success of these missions. Services are required for medical readiness of our troops as well as those of allied countries. Humanitarian missions and nation building require intimate involvement of the medical fields and their supporting elements. Kosovo, in particular, is felt to be one of the world s hotbeds of ethnic violence, and NATO and U.S. forces have been performing peacekeeping operations in Kosovo since the air campaign ended in 1999. The U.S. Army has had a field hospital located at Camp Bondsteel, Kosovo since July 1999. Since that time, data have been collected including injury types and mechanisms of injury. The hospital at Camp Bondsteel served approximately 260,000 individuals in the U.S. area of operations in Southeastern Kosovo. It was the only trauma facility in the region and the only facility with a 24-hour surgical capability, computed tomography capability, and intrinsic evacuation assets. Also, during the time period of this study, civilian emergency services were virtually nonexistent in the U.S. area of operations, although nongovernmental organizations were beginning some rudimentary emergency medical services. 1 3 However, the multinational forces provided most prehospital care and transport. Chief, 91W, IET, Department of Combat Medic Training, 3151 W.W. White Road, Fort Sam Houston, TX 78234. Previously presented as a Poster Presentation for American College of Emergency Medicine, Government Services Chapter Joint Services Symposium, March 2002, Orlando, FL.. This manuscript was received for review in October 2002. The revised manuscript was accepted for publication in June 2003. For these reasons, the vast majority of trauma patients were brought to the Camp Bondsteel facility. The U.S. prehospital system was based on the standard NATO echelons of care. Buddy aid and EMT level care were provided in the field. Level 2 care was provided in one location approximately 20 minutes from Camp Bondsteel. This paucity of level 2 care was not felt to be a significant problem, primarily because of short distances and easy availability of both ground and air transport. The hospital at Camp Bondsteel provided a level 3 function. Resuscitative surgery and initial wound management and stabilizing procedures were performed. The hospital had a 72-hour hold policy, after which patients were either returned to duty/home or evacuated to an echelon 4 facility. At that time, the hospital was a temper tent-based facility equipped with two operating theaters, laboratory, blood bank, X-ray with a spiral computed tomography scanner, an 8-bed trauma bay, a 16-bed intensive care unit, and an intermediate care unit. There was minimal rehabilitative capacity. Staffing consisted of two general surgeons, one orthopedic surgeon, one emergency medicine physician, a family practitioner, an internist, two nurse anesthetists, and a radiologist. The hospital had an attached ambulance section, medical logistics, veterinarian, and psychiatrist. Nursing staff was typically 9 registered nurses and approximately 20 medics. Combat Support Hospitals are designed and deployed for the management of the severely injured in support of the combat mission. In contrast, peacekeeping operations often entail much broader mission requirements. Part of proper planning for these requirements includes projection of probable injury patterns and mechanisms. In light of this, from July 1999 through December 2000, statistics were kept on all trauma patients. These were then reviewed and presented in this article. No names or other identifying data, other than a trauma number, were maintained or examined. Materials and Methods During the 18-month period from July 1999 until December 2000, records of all trauma visits to the emergency treatment section were recorded. The data included date, time, nationality, patient record number, diagnosis, surgeries performed, postoperative diagnosis, mechanism of injury, and an additional comment section. The data were reviewed by hospital staff for accuracy. From these data, injury rates and mechanisms were extracted for presentation. Results Overall, there were 404 trauma patients treated during the study period, primarily civilians (Fig. 1). Overall wound distribution is shown in Figure 2, which shows the total number and percentage of patients with each wound type. Figure 3 separates 187
188 Injury Patterns in Peacekeeping Missions Fig. 1. Patient demographics. Fig. 2. Overall wound distribution. Fig. 3. Isolated injuries. out the multiply injured patients from those with injuries isolated to a single anatomic area. Forty-four percent (178) of all patients had head and neck injuries, whereas only 29% (119) of the total patient population had isolated head and neck involvement. Twenty-one percent (83) had chest injuries with 6% (23) having injuries isolated to the chest. Overall, 13% (53) had abdominal wounds, but 4% (18) of patients had only abdominal wounds. Extremity injuries were the most common injuries occurring in 54% (220) of all patients, with 33% (135) of patients presenting solely with extremity injuries. When injuries are divided by mechanism, penetrating injury made up 36.9% (149), whereas blunt trauma accounted for 63.1% (255). Motor vehicle accidents (MVAs) made up 72% of blunt trauma and 45.5% of trauma overall (Fig. 4). Falls were the second most common cause of blunt injury followed by assault. Gunshot wounds accounted for 55%, blast wounds 38%, and stabbings 6.7% of penetrating injuries, whereas accounting for 20%, 14%, and 2.5% of overall trauma, respectively (Fig. 5). Figure 6 demonstrates the distribution of wounds for overall blunt trauma and its most common mechanisms. The data reflect the percentage of patients with injury to each anatomic area. Obviously, many patients had injuries to more than one location and therefore results in totals greater than 100%. Figure 7 demonstrates the data for penetrating trauma. Discussion During the 18-month period, there were 404 trauma patients. Approximately two-thirds were attributable to blunt trauma and only one-third was attributable to combat-type injuries. Seventy-four percent of blunt injuries were due to MVAs, accounting for 47% of overall trauma. During the study period, there was no licensing authority, the roads were small and poorly maintained, there was a lack of traffic control, and virtually nonexistent use of seatbelts. These factors and others likely combine to create the number of accidents seen, and it is not unreasonable to expect similar conditions in other areas requiring nationbuilding missions. Of the penetrating injuries, which we spend the majority of our time in the military preparing for, 55% was attributable to gunshot wounds, which accounted for 20% of all injuries treated. Mines and shrapnel-producing munitions produced 33% of penetrating injuries and 14% of overall injuries. When overall injury rates in Kosovo were compared with those of Vietnam and World War II 4 (Fig. 8), isolated chest and abdominal injuries were approximately the same. However, head/neck injuries were more than twice as frequent in Kosovo than either Vietnam or World War II. Multiple trauma victims were more frequent as well. Isolated extremity wounds were approximately one-half the World War II rate. The higher rate of head injury and multiple trauma is likely multifactorial. Distances between the injury scene and the hospital were small, and air evacuation assets were plentiful. There was typically only one to a few casualties at any one time. Furthermore, penetrating injuries were frequently from small arms and mines. All of these factors combined increase the likelihood that an injury will be survivable. Furthermore, wounds that may have been considered expectant in other circumstances were transported, as illustrated by the 21 individuals that were pronounced dead on arrival, a rate of 5%. Additionally, the large proportion of MVAs creates survivable head injuries that high-velocity gunshot wounds could not. This can be seen by viewing injury patterns by mechanism. Fifty-two percent of blunt injuries involved the head and neck as opposed to 29.5% of penetrating injuries.
Injury Patterns in Peacekeeping Missions 189 Fig. 4. Blunt trauma mechanism of injury. Fig. 5. Penetrating trauma mechanism of injury. The reverse relationship is seen with chest and abdominal trauma when comparing blunt with penetrating injury in Kosovo. Penetrating injury involved the chest and abdomen, 29.5% and 21%, respectively, vs. only 15.3% and 8.6% in blunt injuries. Two factors likely account for the difference. First, most of the blunt trauma was in the form of rapid deceleration injuries (MVAs and falls) in which significant chest and abdominal injuries may lead to rapid exsanguination. Second, with shrapnel and gunshot injuries, the chest and abdomen present the largest area for injury and patients may survive long enough to reach the trauma center provided vital structures are not penetrated. It should also be noted that the majority of patients were civilians and not wearing body armor. Extremity injuries were 14% more frequent in penetrating trauma than in blunt trauma. The lethality of penetrating head and torso injuries and for military casualties, the use of body armor, which has been correlated with decreased chest and upper abdominal injuries, 5 will likely continue to result in an increased relative rate of extremity injury. Furthermore, 75% of mine injuries involved the extremities, increasing the overall rate for penetrating injury. This relationship of mines with extremity injury has been found in accidents in mine-clearing
190 Injury Patterns in Peacekeeping Missions Fig. 6. Wound distribution by mechanism: blunt trauma. Fig. 7. Wound distribution by mechanism: penetrating trauma. operations in which 59% involved the extremities. 6 An additional study in Sri Lanka found that 56% of mine blasts resulted in extremity injuries. 7 The frequency of isolated head injury in MVAs likely decreased the relative rates of both extremity and multisystem injuries for the blunt trauma group, magnifying the difference between the two groups. Conclusion We must be prepared for a wide range of injury types and mechanisms during deployment. Our preparations for support- Fig. 8. Wound distribution by conflict.
Injury Patterns in Peacekeeping Missions ing humanitarian and peacekeeping operations must go beyond the penetrating and blast trauma found in the typical combat situations. We must prepare, staff, and equip for MVAs and other mechanisms of trauma previously seen primarily in civilian practice. References 3. Lis J, Eliades MJ, Benishi D, Koci B, Gettle D, VanRooyen MJ: Post-war Kosovo: Part 3. Development and rehabilitation of emergency services. Prehospital Disaster Med 2001; 16: 275 80. 4. Emergency War Surgery: Second United States Revision of the Emergency War Surgery NATO Handbook, p 183. Edited by Bowen TE, Bellamy RF. Washington, DC, U.S. Government Printing Office, 1988. 5. Mabry RL, Holcomb JB, Baker AM, et al: United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. Trauma 2000; 49: 515 29. 6. Brown R, Chaloner E, Mannion S, Cheatle T: Ten-year experience of injuries sustained during clearance of anti-personnel mines, Lancet 2001; 258: 2048 9. 7. Meade P, Mirocha J: Civilian landmine injuries in Sri Lanka. Trauma 2000; 48: 735 9. 1. Vanier VK, VanRooyen MJ, Lis J, Eliades MJ: Post-war Kosovo: Part 1. Assessment of prehospital emergency services. Prehospital Disaster Med 2001; 16: 263 7. 2. Eliades MJ, Lis J, Barbosa J, VanRooyen MJ: Post-war Kosovo: Part 2. Assessment of emergency medicine leadership development strategy. Prehospital Disaster Med 2001; 16: 268 74. 191