Following terror attacks in Paris, Brussels, Manchester, Berlin and, most recently, London, experts at this year’s EFORT Congress in Vienna were clear about the ramifications that global terrorism has for healthcare systems. There is a need for better training of orthopaedic and trauma surgeons and immediate care physicians to treat terror victims, says EFORT President Prof Jan Verhaar.
“Terrorism is always something unforeseeable. We are not well–enough prepared for terrorism in Europe and must greatly improve our knowledge of the many implications these acts of violence have on our work,” Prof Verhaar said. “As an initial step, colleagues who have recently been directly confronted with the results of terrorist attacks in Paris, Brussels, Berlin or Israel have been invited to give presentations. By sharing the lessons they learned, they help prepare us for the unexpected, unwanted, but nevertheless, real possibility of a terrorist attack.”
Olivier Barbier, orthopaedic surgeon at Bégin Military Teaching Hospital, Paris, spoke of his experience of the attack in Paris on 13 November 2015: “We quickly realized we were facing the worst attack since World War II.” For 120 victims, the help came too late; another 302 sustained injuries, in some cases very serious ones. The Bégin Military Teaching Hospital treated 45 individuals from this latter group; 22 of them underwent emergency surgery for soft-tissue-lesions, ballistic fractures and abdominal wounds.
“It was the civilian application of war medicine,” Barbier notes. “The injured brought into military hospitals in such cases benefit from the staff’s professional experience with triage management and the principles of damage control.”
Following a practice often used in war-torn areas, the victims brought in were sorted by severity of injury. Eight were classified as T1 – those requiring treatment most urgently, ten were placed in the triage category T2, and 27 were deemed to be less urgent with a category of T3. This allowed the surgeons to perform a total of 50 operations in an orderly and efficient fashion.
“The key criteria in the initial hours after the terrorist attack are to manage the vital interests of the patients, call in additional medical personnel and ensure access to all operating rooms,” Barbier noted in his summary of this experience. In the end, the Parisian physicians had a respectable outcome, which has since been published in scientific journals: Twenty-four hours after the start of the attacks, all 302 of those injured were released from the emergency rooms and trauma units and all emergency operations were completed. Only four of the injured patients died.
Prof Verhaar said there is a need to update medical training: “In the accidents orthopaedic surgeons and traumatologists normally deal with, most of the victims have sustained a series of bone fractures and their survival depends on how, and in which order, these injuries are treated. However, terrorists often use weapons of war that cause injuries civilian medical personnel have rarely seen and that result in heavy bleeding. That is why civilian physicians must also be trained in the treatment of gunshot wounds and blast injuries.”
Israeli physician Prof Alexander Lerner spoke at the EFORT Congress on his experience at the Syrian border with the management of more than 800 refugees, some seriously injured: “The initial treatment should include general stabilisation and basic life support, bleeding control and, in many cases, effective minimal-invasive fracture immobilization. The most common problem is wound infection. Our experience has shown that radical primary debridement with stabilisation, using external fixation frames, staged treatment protocol, based on damage control principles, is crucial for the success and return, at least, to independence in basic daily functions.”
Prof Lerner highlighted another important point about his missions along the Syrian border: “Psychological support for patients and practitioners is essential. No one can handle the pressure, responsibility and challenges raised during treatment of helpless severely wounded people, and particularly, children.”