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AUTHOR QUERIES DATE 1/5/2017 MILMED JOB NAME D1600121 ARTICLE QUERIES FOR AUTHOR

Olivier Barbier et al.

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MILITARY MEDICINE, 182, X:X, 2017

Dynamic Insights on Surgical Activity in a New Modern Warfare: The French Role 2 in Bangui, Central African Republic AU1

MAJ Olivier Barbier, MC France*; LTC Pierre Pasquier, MC France†; MAJ Maelle Racle, MC France‡; MAJ Yoann Baudoin, MC France§; LTC Brice Malgras, MC France¶ ABSTRACT Introduction: In December 2013, France deployed more than 2,000 soldiers in Central African Republic with two main missions, to restore security and to improve the humanitarian situation. The objectives of this article were to analyze the surgical activity of forward surgical teams in Central African Republic over 2 years and to discuss features of training for deployed surgeons. Materials and Methods: From December 5, 2013, to September 30, 2015, we retrospectively reviewed the electronic surgical database. Surgical activity was described as patient status, type of lesion, surgical procedures performed, and anatomic regions involved. Results: During this study period, 431 surgical procedures were performed on 401 patients; 66% of the patients were civilians, 26% French soldiers, and 11% foreign soldiers. Surgical procedures were divided into 34% orthopedic activity and 66% general surgery activity. Orthopedic activity was mainly performed during the first months of the operation Sangaris, whereas general surgery occurred after summer 2014 with a return to peacetime. Conclusions: Our study demonstrated original and dynamic insights into the nature of surgical activity throughout the operation with mainly orthopedic surgery during the initial deployment for management of combat casualties and general surgery later, dedicated to elective surgery for local citizens. These data should enhance staffing, training, and deployment of future surgical teams in combat settings with continuous training programs to maintain specific competences, especially in cases of low surgical activity, such as virtual learning or e-learning that could be developed in the future.

INTRODUCTION In December 2013, France deployed more than 2,000 soldiers in the Central African Republic (CAR) with two main missions to restore security and to improve the humanitarian situation. The French military operation Sangaris was included in a United Nations mandate. At the same time, an International African-led Support Mission to the CAR (Mission Internationale des Nations Unies de Soutien à la Centre Afrique, MINUSCA) was deployed. The French Military Health Service deployed a Forward Surgical Team (FST) to set up a Role 2 (NATO classification) in Bangui.1 The mission of the Role 2 was to provide surgical treatment to French soldiers, foreign soldiers, and civilians. In a previous study, we reported the activity of the 14th Airborne FST in Bangui during its initial deployment.2 The purpose of this article is to document the wartime surgical experience of the Role 2 in CAR over 22 months and to compare these data with those from recent conflicts (Iraq, Afghanistan, and Mali). We hypothesized that this new conflict in Africa led to unique surgical activity of the FST, AU2

*Orthopaedic Department, Begin Military Teaching Hospital, 69 Avenue de Paris, 94160 Saint Mandé, France. †Intensive Unit Care, Percy Military Teaching Hospital, 101 Avenue de Henri Barbusse, 92140 Clamart, France. ‡Military Medical Center of Vincennes, Fort Neuf de Vincennes, Cours de Maréchaux, 75614 Paris Cedex 12, France. §Visceral Surgery Department, Percy Military Teaching Hospital, 101 Avenue de Henri Barbusse, 92140 Clamart, France. ¶Visceral Surgery Department, Begin Military Hospital, 69 Avenue de Paris, 94160 Saint-Mandé, France. © AMSUS – The Society of Federal Health Professionals, 2017 doi: 10.7205/MILMED-D-16-00121

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slightly different from previous conflicts, and that these data could aid in the staffing, training, and planning for future combat deployments. METHODS Over a period of 22 months (December 2013 to September 2015), the medical data of each patient operated on in the French Role 2 in Bangui were prospectively collected by surgeons. This record was stored within two operating room databases of the facility, both on a computer using FileMaker pro 2008 software (FileMaker Inc., Santa Clara, California) and in a logbook. We reviewed both the electronic and paper records. Data were analyzed retrospectively in a standardized database. The local French Health Military Commander approved this study. Data were collated by the specialty (orthopedic surgery or general surgery) of the principal operating surgeon. Patients were identified by number and classified according to their sex and status: French soldiers, foreign soldiers, and local citizens. Surgical activity was divided into four categories: “war-related trauma surgery,” “nonwar-related trauma surgery,” “nontrauma emergency surgery,” and “elective surgery.” War-related trauma surgeries dealt with civilian or military patients with combat-related injuries. These injuries were classified according to the mechanism and the degree of urgency in four categories: immediate (T1), delayed (T2), minimal (T3), and expectant (T4).3 Nonwar-related trauma surgeries dealt with casualties of domestic or road traffic accidents. Nontrauma emergency surgeries dealt with patients suffering from mainly infectious pathologies, and elective surgeries dealt with the local 1

Surgical Activity During the Operation Sangaris

population within the framework of medical assistance to the population (MAP). All surgical procedures were described by type and by anatomic region. Multiple operations performed on the same patient were only counted if they represented different operative procedures performed by different specialty surgeons (e.g., a fracture treated by the orthopedic surgeon and a laparotomy performed by the general surgeon on the same patient counted as two procedures) or if distinctly different operative procedures were performed by surgeons of the same specialty (e.g., a laparotomy and a thoracotomy performed by the general surgeon on the same patient in one procedure). We excluded multiple procedures of the same type if performed on different body parts or extremities (such as multiple location debridement). The purpose of these exclusions was to avoid overestimation of the FST’s activity. RESULTS During the study period, a total of 431 surgical procedures were performed within the Role 2. These procedures were performed on 401 patients. The mean age was 34 years (range, 0–80) and 73% were males. Twelve patients underwent more than two surgical procedures. No French soldier was included in this group. Two local citizens underwent a further procedure for a hematoma after elective surgery (one hernia, one thyroidectomy). Seven patients (four local citizens and three foreign soldiers) underwent a Damage Control Surgery (DCS). Because no evacuation could be conducted rapidly after the first stage of the DCS, these seven patients were operated on a second time for a repair procedure (three second-look laparotomies, three changes of external fixation, one after salvage amputation). The three others were infectious emergencies with iterative dressings. The evolution of the operative procedures by specialty F1 and by months is illustrated in Figure 1. During the study

FIGURE 1.

2

period, the general surgeon performed 66% of the surgical procedures, and the orthopedic surgeon 34%. Orthopedic activity was concentrated during the first months, whereas general surgeries increased after summer 2014 with the amelioration of the conflict. Regardless of the type of lesions, war-related trauma surgery represented 24% of the global surgical activity and elective surgery, 54%. Nonwar-related trauma surgery and nontrauma emergency surgery represented 12% and 10% of the global activity, respectively. The different types of surgery during the period study are illustrated in Figure 2. Warrelated trauma surgeries were mainly represented during the first 6 months of the operation Sangaris and elective surgery represented the majority of procedures after summer 2014. Figure 3 illustrates the evolution by months of the number of patients according to their status. Sixty-three percent of all surgical procedures concerned local citizens. The local citizens presented numerous indications for surgery, mostly elective surgery. A few were victims of injury, both unrelated to and related to the current on-going conflict. French soldiers represented 26% of all patients operated on at the Role 2 in Bangui during the study period, and foreign soldiers 11%. Over the course of the study period, surgery was primarily performed on soldiers during the initial deployment and after summer 2014, medical aid to the population represented the most important part of the surgical activity. When classified by anatomic region, surgical procedures were divided as follow: 45% for abdominal surgery, 21% for head or neck surgery, 4% for thoracic surgery, and 30% for limb surgery (17% for the lower limb and 13% for the upper limb), including vascular procedures. Regarding war-related related injuries and anatomic region, limb injuries represented 64% of them (40% for the lower limb and 24% for the upper limb). Abdominal, thoracic, and neck-head procedures concerned 12%, 13%, and 11% of

Comparison of the Surgical Activity During the Study Period: Orthopedic Surgery and General Surgery (With Linear Regression Curves).

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F2

F3

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FIGURE 2.

Monthly Numbers of Surgical Procedures According to the Specialty Involved.

war surgery procedures, respectively. War-related injuries involved the orthopedic surgeon in almost two-third of cases. The mechanism of war-related injuries was gunshot wounds in 46% of cases, explosions in 41% of cases, and vehicle motor accident in 13% of cases. The degree of urgency was 20% T1, 55% T2, 21% T3, and 4% T4. Regarding elective surgery, the general surgeon performed 97% of procedures with 66% being abdominal procedures and 30% cervical

FIGURE 3.

procedures. Limb surgery represented only 3% of elective surgery procedures. The majority (109 [69%]) of the procedures performed by orthopedic surgeons involved soft tissue injuries of the extremities and 14% of them were dedicated to the surgical management of fractures. Only nine open reductions and internal fixations of fractures were performed using pins for wrist fractures (6%) and 13 external fixations (8%) of

Monthly Numbers of Patients Operated on According to Their Status.

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fractures were performed. Four cases (3%) included an acute amputation. Sutures of a tendon of the hand were performed for six patients (4%) and six patients underwent hardware removal (4%). One fasciotomy was performed. The orthopedic surgeon also performed specialized surgery, including one craniotomy, one intermaxillary block, three (2%) vascular repairs for limb injuries, and four (3%) flaps. General surgeons performed 66% of the operative procedures at the Role 2. Seventy-four percent of these procedures were elective surgery, with 104 hernia repair surgeries (39%), 57 thyroidectomies (22%), 33 hysterectomies (12%), and 44 soft tissue procedures (17%) for abscesses or lipomas. Laparotomies were applied in seven cases (3%) of general surgical procedures and only six appendectomies by the Mac Burney approach (2%) were performed. Ten urology procedures (4%), such as treatment for hydrocele or nephrostomy, were performed. No vascular repairs, thoracotomies, or splenectomies were performed by general surgeons. DISCUSSION This article analyzed the details of the surgical activity of the French Role 2 in Bangui during the operation Sangaris. First, with only 401 procedures over a period of 22 months, our surgical experience illustrated that the surgical activity of a FST deployed in a Role 2 can be moderate. Series from other Role 2s have previously reported this same point. Indeed, during the first months of Operation Enduring Freedom from October 2001 to April 2002, the 250th FST carried out 68 surgical procedures on 50 patients and the 274th FST carried out 103 surgical procedures.4,5 In 2001, in Afghanistan, a Forward Resuscitative Surgery System in Camp Rhino performed 46 surgical procedures in 6 weeks.6 In 2002, Beekley et al reported 112 surgical procedures performed on 90 patients over a period of 6 months with the 102nd FST in Kandahar (Afghanistan).7 Thus, the surgical activity of a Role 2 is more limited than in other medical treatment facilities such as Role 3s in Iraq and Afghanistan.8–10 Second, our surgical experience included not only traumatic injuries from the current conflict but also elective procedures dedicated to MAP. Analysis of monthly evolution of the surgical activity is interesting. During the deployment, orthopedic surgery was mostly concentrated at the beginning of the operation Sangaris with war-trauma related injuries. After summer 2014, with return to peacetime, general surgeon activity increased in accordance with the development of elective surgery. Furthermore, the number of procedures increased with the development of MAP in safe conditions for the FST, after return to peacetime. In the French doctrine, the aim of MAP is to improve the medical environment of civilian populations in which a foreign armed force operates, either as a complement to the activity of specialized organizations (international humanitarian organizations, nongovernmental organizations, International Committee of the Red Cross), or while waiting for 4

the restoration of the local health services.11,12 Therefore, MAP is a key component of the mission because humanitarian care participates in maintaining individual surgeon skills and improves unit skill sets while benefiting the local population. The importance of these actions, even if it remains difficult to assess, is determinant for the prepositioned forces.13,14 By means of their substantial and strong symbolic contribution to the missions of the present forces, this activity tends to facilitate the acceptance of the presence of foreign Armed Forces and contributes to giving them a positive image, through concrete actions directly perceived by local populations. The MAP support cannot bear the weight of the humanitarian crisis in a country on its own. The first mission of a Role 2 is to offer a permanent surgical support to the deployed force. However, during periods where there are no combat casualties (after summer 2014 in our study), the activity of MAP is a regular surgical activity for the FST deployed in a Role 2.10,14,15 In this context, surgeons deployed in these units could be faced with balancing how to engage and commit themselves, their unit’s personnel, and their limited supplies. Humanitarian care in a combat zone can lead to a real ethical dilemma for surgeons between their first mission to support deployed forces and their medical ethic requiring them to treat every injured patient. To help them, the French Military Health Service reaffirmed recently in its military medical doctrine that its primary mission is the operational health support of the deployed forces but MAP is also highlighted. Indeed, humanitarian care aims to participate in the local health needs arising from the conflict, dealing at the same time with undeniable operational limitations. This problem can be a source of difficulties: (1) In its political and strategic position, because it can cause confusion between humanitarian assistance and military operations. (2) In the planning and conduct, because of the lack of reliable initial identification of needs and a real appreciation of their consequences. In the French doctrine, a rational approach is used in order to maintain efficiency in any action taken by distinguishing the desirable ideal and the expertise of generosity: humanitarian care is carried out for the benefit of the people respecting the priority to support forces. So, five principles are promoted: (1) Duality: care is exercised in priority toward soldiers and can also be employed for the civilian population on a command decision. The principle of duality implies the concept of reversibility. (2) Control of contributions: Humanitarian care does not alter the capacity of the health service. (3) Relevance: Humanitarian care must be relevant and consistent with the expected benefit of the armed forces effects. MILITARY MEDICINE, Vol. 182, XXX 2017

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(4) Exemplary: Humanitarian care enhances the action of the force, being organized with a goal of public health by implementing strict ethical principles and being visible through communication actions carried out by the command, avoiding the pitfall of over-media. (5) No interference: Medical support forces should not compete with the local health system. They act because of the lack of any available alternative. Finally, the authorization for the FST’s role in performing MAP comes about from a superior command directive. It is important to emphasize that FSTs are a forward combat oriented team and they are not used as a civilian medical facility at all. They provide a wide spectrum of surgical care not requiring specific devices (e.g., nails, screws, and prostheses). The goal of our Role 2 is not to fulfill the needs of a local population whose basic health care requirements are also important; that is different from the goals of a Role 3. Third, for war-trauma related injuries, nearly two-thirds of surgical procedures were performed by the orthopedic surgeon. The majority of them concerned soft tissue injuries and extremity surgeries. General surgeon activity represented 94% of elective surgery. This finding is slightly different from data reported in the other medical facilities like Role 3s, where orthopedic surgeons can perform numerous elective surgery procedures, with dedicated devices.8–10 Indeed, in French Roles 2s, no material dedicated for internal fixation is available. The main task of the Role 2 is the management of combat casualties with both surgical and resuscitative damage control. With advances in personal protective equipment, lesions of the limbs are predominant. Moreover, improvement in medical management on the battlefield and in the capacity for rapid evacuation leads to fewer killed in action.16–18 During the 22 months of the operation Sangaris, only three French soldiers were killed in action. Thus, surgeons are faced with survivors with severely mutilated limbs and extremely challenging surgical cases. The acute amputation rate was low in our study in comparison in previous studies.10–14 The three amputations performed were primary or completion amputations. Nevertheless, only acute amputations were counted because the follow-up for patients take in care was poor and we could not know how many limb injury patients went on to receive amputations after our initial surgical care. A major limitation of our report is the exclusion of trauma patients who did not require a surgical procedure in the operating room. Therefore, a significant number of chest injuries managed with chest tubes in the emergency room were excluded. Finally, our data on types of surgical procedures performed clearly illustrates the breadth of practice required for a military surgeon deployed in an austere setting. Performance of vascular repairs, skin grafting, urologic procedures, and neurosurgical procedures by nonspecialist surgeons are MILITARY MEDICINE, Vol. 182, XXX 2017

unique in a military setting. Providing adequate training opportunities as part of the work-up training for military surgeons will continue to be challenging but will likely require experience at high-volume trauma centers and clinical rotations with different subspecialty surgical services (e.g., neurosurgery and vascular surgery). In France in 2007, the French Military Health Service Academy (Ecole du Valde-Grâce, Paris, France) offered an advanced course of surgery for deployment in combat zones (CACHIRMEX—cours avancé de chirurgie en mission extérieure), with special focus on DCS and management of mass casualties incidents. Moreover, an additional predeployment training at the Health Tactical Training Centre (CEFOS-Centre de Formation Opérationnelle Santé) was recently developed to improve the preparation of French FSTs.8,19,20 The last challenge is to permit surgeons to maintain their competences when they are deployed if activity is moderate. Continuous training programs could be implemented for surgeons deployed in Role 2s to maintain specific competences in cases of low surgical activity. Anatomically realistic perfused surgical training mannequins or other types of training through a combination of didactics, hands-on simulationbased training, video review, and evaluation are beginning to be developed.21,22 Virtual learning and e-learning could also be developed. CONCLUSIONS Some points analyzed in this report are similar with those of previous studies: small volume of activity, war-related trauma surgery for French soldiers, and elective surgery for local citizens. However, we illustrated dynamic insights into the nature of surgical activity throughout the operation Sangaris. Orthopedic surgery was mainly involved during the initial deployment for management of combat casualties presenting at the Role 2 with limb injuries, whereas general surgery was performed later during the deployment and was dedicated to elective surgery for local citizens. Analysis of such data can help to enhance staffing, training, and deployment of future surgical teams in combat settings. Continuous training programs could be implemented for surgeons deployed in Role 2s to maintain specific competences in cases of low surgical activity. ACKNOWLEDGMENTS Thanks to all military surgeons who took part in these operations and who managed these patients.

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Surgical Activity During the Operation Sangaris 3. Hurtado TR, Montoya C: Echelon I interventions and triage are effective and concordant with echelon II care in combat operations. Mil Med 2009; 174(8): 786–90. 4. Place RJ, Rush RM, Arrington ED: Forward surgical team (FST) workload in a special operations environment: the 250th FST in Operation ENDURING FREEDOM. Curr Surg 2003; 60(4): 418–22. 5. Peoples GE, Gerlinger T, Craig R, Burlingame B: The 274th Forward Surgical Team Experience during Operation Enduring Freedom. Mil Med 2005; 170(6): 451–9. 6. Bilski TR, Baker BC, Grove JR, et al: Battlefield casualties treated at Camp Rhino, Afghanistan: lessons learned. J Trauma 2003; 54(5): 814–21. 7. Beekley AC, Watts DM: Combat trauma experience with the United States Army 102nd Forward Surgical Team in Afghanistan. Am J Surg 2004; 187(5): 652–4. 8. Bonnet S, Gonzalez F, Poichotte A, Duverger V, Pons F: Lessons learned from the experience of visceral military surgeons in the French Role 3 Medical Treatment Facility of Kabul (Afghanistan): an extended skill mix required. Injury 2012; 43(8): 1301–6. 9. Brisebois RJ, Tien HC: Surgical experience at the Canadian-led Role 3 Multinational Medical Unit in Kandahar, Afghanistan. J Trauma 2011; 71(5 Suppl 1): S397–400. 10. Barbier O, Malgras B, Versier G, Pons F, Rigal S, Ollat D: French surgical experience in the Role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery. Orthop Traumatol Surg Res 2014; 100(6): 681–5. 11. Darre E, Rouanet P: Service de santé des armées et aide médicale aux populations: objectif ou moyen? Sante Decision Management 2008; 11: 183–98. 12. Godart P, Darre E: L’aide médicale aux populations: la vision du service de santé des armées. Bull Etudes Marine 2007; 38: 37–45.

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13. Beitler AL, Junnila JL, Meyer JH: Humanitarian assistance in Afghanistan: a prospective evaluation of clinical effectiveness. Mil Med 2006; 171(9): 889–93. 14. Malgras B, Barbier O, Petit L, Rigal S, Pons F, Pasquier P: Surgical challenges in a new theater of modern warfare: the French Role 2 in Gao, Mali. Injury 2016; 47(1): 99–103. 15. Woll M, Brisson P: Humanitarian care by a forward surgical team in Afghanistan. Mil Med 2013; 178(4): 385–8. 16. Brown KV, Guthrie HC, Ramasamy A, Kendrew JM, Clasper J: Modern military surgery: lessons from Iraq and Afghanistan. J Bone Joint Surg Br 2012; 94(4): 536–43. 17. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012; 73(6 Suppl 5): S431–7. 18. Pasquier P, Dubost C, Boutonnet M, et al: Predeployment training for forward medicalization in a combat zone: the specific policy of the French military health service. Injury 2014; 45: 1307–11. 19. Mathieu L, Joly B, Bonnet S, et al: Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience. Int Orthop 2015; 39(10): 1887–93. 20. Bonnet S, Gonzalez F, Mathieu L, et al: The French Advanced Course for Deployment Surgery (ACDS) called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects. J R Army Med Corps 2015; 162(5): 343–7. 21. Kellicut DC, Kuncir EJ, Williamson HM, Masella PC, Nielsen PE: Surgical team assessment training: improving surgical teams during deployment. Am J Surg 2014; 208(2): 275–83. 22. Kirkpatrick AW, Tien H, LaPorta AT, Lavell K: The marriage of surgical simulation and telementoring for damage-control surgical training of operational first responders: a pilot study. J Trauma Acute Care Surg 2015; 79(5): 741–7.

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