Emergency Departments

Abstract

Emergency physicians (EPs) are well-trained to deal with a wide range of acute illnesses and traumatic injuries. However, they are at times confronted with public health emergencies of international concern, such as epidemics, pandemics, natural disasters, large-scale industrial accidents (chemical spills, aircraft crashes), and wars. Under such conditions, the emergency medical system of care delivery becomes the triage epicenter for an exponentially larger number of citizens; the above-mentioned public health threats can occur instantly or may develop gradually over a period of months or even years. On February 24, 2022, when Russia invaded Ukraine, the emergency departments (EDs) in and around the affected area had to face a new kind of battle.[1] Regional and national emergency medical systems were confronted with all the difficulties of COVID-19 while also dealing with new monumental challenges of refugees, traumatic war injuries, restricted movement, lack of medical supplies, and the threat of food insecurity. At the time of writing this manuscript, the Russia-Ukraine conflict is regionalized, but the threat of escalation looms over the entire planet. The tentacles of war extend far beyond the zone of combat, manifesting as economic, social, and political consequences. While academicians will try to explain the differences between wars, special military operations, and other forms of armed conflict, the civilians affected will tell you there is no difference. What is happening in Ukraine is for all intensive purposes a war, and it has put humanity on the precipice of a third world war with the ongoing threats of nuclear, chemical, and biological weapons use. What can EDs expect during a war? The EPs “on the ground,” near the war zones, can expect overwhelming patient volumes, horrifying injuries of war, shortage of medical supplies, and destruction of infrastructure in the initial phases. As the war continues, they will face problems with refugee health, placement of the unhoused, food shortages, chronic medical conditions, mental health manifestations in both health-care workers and civilians, and knock-on effects for generations to come [Figure 1].Figure 1: Impact of war on various domains of health care and well-beingIn this article, we outline some of the potential impacts of conflicts and wars on clinics, hospitals, EDs and the health-care delivery in general, focusing on facilities located in and around the conflict zones. We also discuss fundamental aspects of preparing for such events. HISTORICAL CONTEXT OF WAR, EMERGENCY DEPARTMENTS, AND SURGEONS Historically, war efforts require active participation of civilian surgeons and EPs due to the large volume of casualties presenting within a short period, challenging the existing system to cope with war injuries and forcing the already deployed medical forces to call upon assistance from parallel health systems. In addition, war provides concentrated experiences in trauma care, traditionally resulting in significant bedside innovation and advances in related clinical approaches and techniques. The following remarks by Sir George H Makins, renowned World War I surgeon, at the Bradshaw Lecture to The Royal College of Surgeons of England in 1913 vividly convey the facts and realities of war. “At all periods, the opportunities afforded by the field of battle have exercised a strong attraction to the surgeons both from the instinct of patriotism and the fact that in no other branch of surgery can experience be so rapidly gained. One battle can afford more material and that of a more varied nature than many years of experimental work.”[2] The old adage “He who wishes to be a surgeon should go to war” still applies. It is well known that many medical providers took their grim experiences from the Vietnam war and repurposed them to transform the emergency medical systems, EDs and in-hospital trauma care, thus saving millions of lives in their local communities.[3] Medical breakthroughs and discoveries resulting from surgical experiences during military conflicts have undoubtedly transformed the way we practice medicine and surgery today. Novel programs of triage and health assessment, trauma combat care, and multiple surgical and emergency procedures can be traced directly to the battlefield management of wartime injuries.[4] It is essential that these trauma concepts be taught to the civilian medical force in a standardized manner using a uniform, shared language. Combat casualty care is substantially different and uniquely challenging when compared to civilian trauma care. War theatres are characterized by injuries that include complex, multi-cavity, blunt and penetrating, shrapnel, burn, and blast wounds, often presenting as mass casualty scenarios.[56] Exsanguinating torso and limb hemorrhages are common and are among the most common types of preventable deaths in the battlefield.[7] To help address the latter, appropriate damage control assets can be deployed in the form of “forward surgical teams” and other similar implementations, streamlining critical patient flow back to awaiting surgical teams. Management of battlefield injuries is not taught in civilian ED training, resulting in very limited insight and knowledge which is nonetheless necessary in unforeseen war or disaster situations. War surgery is a specialized skill that needs to be learned and should be taught in medical schools, and reinforced on regular basis thereafter.[8] Targeted medical conferences and seminars helped health-care workers acquire the necessary knowledge and skills to manage COVID-19. Similarly, we feel that all major medical and surgical conferences can have dedicated sessions on war injury management / skills. The international committee of the Red Cross has taken the lead in this specific area by organizing a seminar in Geneva on “The management of patients with war wounds.”[9] One of the key parameters used to evaluate the overall lethality of a particular battlefield / war theatre, especially in the context of the effectiveness of combat casualty care, is the case fatality rate. It was recorded at 19.1% in World War II, 15.8% in the Vietnam war, and 8.6% at the end of Operation Iraqi Freedom and Operation Enduring freedom.[10] Over the past 150 years, killed-in-action fatalities have increased, primarily due to the increased lethality of newer weapons, while the died-of-wounds fatalities have decreased from 13% to 3% because of improved medical and trauma care.[11] The Joint Theater Trauma System, coupled with purpose-driven research and continuous performance improvement process (focused empiricism), including the deployment of modern tourniquets and hemostatic dressings to control bleeding, far forward surgical capability, advanced combat casualty evacuation with en-route blood product delivery are among the key features of this highly advanced, modern battlefield care delivery process.[12] Forward mobile surgical teams actively incorporate the resuscitation and stabilization skills of EPs and have the ability to perform one major and one minor surgery without resupply at austere locations.[13] Furthermore, highly specialized “damage control” resuscitative teams are capable of caring for several patients in the forward environment depending on location and situation. These forward surgical teams can also create a makeshift blood bank, which is essential in battlefield trauma. It is very important that these military concepts are also taught in the civilian healthcare sector. The adoption of clinical quality management guidelines, especially battlefield clinical practice guidelines, has been shown to improve outcomes on the battlefield as they standardize key aspects of immediate casualty care.[14] Only organizations and professionals with conflict experience, international humanitarian law training, and a strong understanding of the high-risk environments (in which they may find themselves) should be deployed near the frontlines. DESTRUCTION OF HEALTH-CARE INFRASTRUCTURE Although protected by international conventions, hospitals continue to be among strategically significant and vulnerable targets of the enemy. Conflicts often devastate essential health services and pose both direct and indirect danger to human life. Health-care workers are often caught in the crossfire. The World Health Organization (WHO) has already listed over 600 verified attacks on medical facilities and workers by Russian forces as of October 14, 2022. A significant number of medical personnel in Syria (847) and Afghanistan (14) have been killed since 2015.[15] There are instances of several doctors being executed in the context of hostile / enemy combatant care scenarios.[16] Because of the inherent danger to life, health-care staff often flee the conflict zones. In Syria, 50% of the health workers and 95% of physicians living in Aleppo have left the country since 2011, and in Iraq, almost half of all the health professionals have emigrated since 2014.[17] In Nigeria, almost all health workers have escaped areas controlled by Boko Haram since 2012, leading to the closure of 450 health facilities.[17] The remaining health-care staff who are ill-equipped to deal with the additional case burden presenting in EDs, and likely lack essential training in acute diseases and combat emergencies, are left to cope during the conflicts.[17] This highlights our earlier point that structured training for war related injuries and associated events should be a required part of medical school and post-graduate medical education curricula. The well-prepared ED will be significantly more resilient when facing the various challenges of war [Figure 2].Figure 2: Impact of war on facilities, patients, medical personnel, and suppliesMEDICAL SUPPLIES SHORTAGES The International Federation of Red Cross and Red Crescent Societies has stated, “Health care is most needed where it is most difficult to deliver.”[18] This applies particularly in the context of war and conflict zones, where health-care delivery is inherently significantly disrupted. Under such circumstances, EDs can be overburdened by the cumulative effect of combined civilian and combatant injuries, as well as the acute emergencies in vulnerable populations that include children, pregnant women, the elderly, and patients with chronic diseases.[18] The medical supplies, essential drugs, and facilities in conflict zones face the constant risk of becoming disrupted, leaving frontline personnel with severely limited resources, all while treating the most severely injured patients. Frontline physicians and nurses are often required to work for extended hours, caring for the most acutely sick and gravely wounded victims. They may also need to ration supplies and care, often making extremely difficult life-and-death decisions. Burnout is highly prevalent, frequently extending to (and affecting) providers in the neighboring countries that receive a large number of refugees (most often women, children, and the elderly fleeing the war). Triage, transfer, and prolonged casualty care of the injured need to be taught to the EPs, who may need to provide initial stabilization and treatment before transferring the injured to a mobile field hospital, then to a regional hospital, then to a tertiary hospital. In a war zone, regional disaster networks need to be established, with shared planning and logistics, including transfer criteria and protocols for the hospitals providing initial care. The personnel with appropriate training should be stationed at each point and “level of care.” Those with the most combat trauma care experience should be proximal to the frontline, taking active leadership roles. Other important considerations and resources needed during armed conflicts include: Emergency supply stock, including generators, water supplies, blood, and oxygen Assignment and preparation of facilities to receive patients based on geographic location Mapping of safe zones, transfer zones, and protected zones Planning transport modalities and routes, putting in place transfer protocols based on medical situation, number of patients, availability of resources at hospitals involved, etc. Individual tracking of patients throughout the referral pathway and beyond Cross credentialing of providers at facilities based on disaster or emergent needs Consideration of laws to address various critical needs and protect providers working under these dire circumstances Cooperation between what are normally competing facilities through regional networks Ability of government officials to more easily verify core credentials and waive nonapplicable bureaucratic requirements for health-care staff Coordination of overall command and control Ethical considerations for the treatment of combatants Food, water, facilities for sleeping, hygiene for staff Various essential security considerations, including both physical and cyber security Data collection systems strengthening to include clinically appropriate indicators of standard practices to accurately document the quantity and quality of care. REFUGEE HEALTH, PLACEMENT, AND INTEGRATION Both the absolute number of refugees as well as the time span over which the influx occurs will have a significant impact on health-care resources of countries providing refuge. For example, Turkey, Lebanon, and Jordan have received over 2 million refugees from Syria in their EDs and hospitals seeking emergency and chronic disease care.[18] At the time of this publication, Poland had recorded over 1.4 million refugees from Ukraine under temporary protection scheme, with a total of more than 7.6 million refugees recorded worldwide.[19] The neighboring countries are allocating health-care resources for both current and anticipated future refugees, most of whom are at the extremes of their ages and may need urgent health-care support upon reaching their intended destinations.[20] It is essential that plans be put in place to adequately prepare for the sheer volume of patients with chronic illnesses that will need to be accommodated. (i.e., dialysis, continuing cancer care, diabetes, etc.) Refugees constitute a vulnerable group due to language barriers, social isolation, financial restrictions, both acute and chronic physical and mental health problems, noncontinuity of previous healthcare plans, and lack of accurate or complete medical records (including immunization history). UNANTICIPATED DISEASE TRANSMISSION Data from 16 countries with the highest number of refugees, representing 12% of the global population, demonstrated a significant attributable burden of newly identified polio and measles cases between 2010 and 2015.[21] Furthermore, the immunization coverage for diphtheria, pertussis, and tetanus was below 85% coverage in many among the studied countries.[21] The sudden increase in the burden of infectious diseases may lead to significant outbreaks in the countries providing refuge to the fleeing citizens. Consequently, a robust public health system needs to be in place to mitigate these dangers. The ongoing humanitarian work by Medecins Sans Frontiers in Ukraine in the areas of tuberculosis (TB), HIV, and mental health had come to a halt in Ukraine when the war started.[17] Public health experts have expressed concerns that the ongoing conflict between Russia and Ukraine could represent a significant setback for TB control in Eastern Europe, especially since Ukraine as a country that reported approximately 30,000 new TB cases annually. Of concern, it has the fourth-highest reported incidence of multidrug resistant (MDR) TB rates out of 53 countries of WHO European region.[22] The outflux of Ukrainians is statistically likely to disseminate MDR TB, and the surrounding nations in Eastern Europe need to scale up the TB screening and treatment programs to effectively safeguard against outbreaks of MDR TB in their population. Ukrainian refugees are also at increased risk of experiencing moderate-to-severe COVID-19 as just 35% of the country’s population received vaccinations against COVID-19. Consequently, the EDs will most likely have to bear the brunt of the resulting increase in more severe COVID-19 presentations.[22] FOOD SHORTAGES, FAMINE, AND NUTRITIONAL DEFICIENCIES The Global Food Security report states that 46% of the population in the developing world lives in countries affected by civil conflicts.[23] The impact of conflicts on food security and nutritional deficiencies is evident from the fact that over the past two decades, the number of provably affected children in countries experiencing armed conflict has increased from 97.5 million to 112.1 million.[23] Child malnutrition can therefore be considered a surrogate marker for food shortages in affected geographic areas. Wars and conflicts affect food security through the destruction of infrastructure, roads, storage facilities, lack of governance, inflation of prices, corruption, and overall shortage of food supplies. The adverse weather and climate-related events in the countries that are already grappling with wars and conflicts have the potential to create an insurmountable burden on the already depleted food supplies. The impact of conflicts on food security can also spiral into a more extensive worldwide food crisis, as is currently the case with the ongoing Russia and Ukraine conflict.[24] These two countries are responsible for a approximately 25% of the global wheat exports.[24] Forty percent of wheat and corn from Ukraine is shipped to the Middle East and Africa, where many countries are already finding it difficult to deal with hunger issues and their own ongoing civil conflicts.[24] This conflict between Russia and Ukraine the food security of of millions of in the Middle Africa, and likely conflicts are known to in food security the may also As an example, the developing and food security in over the past months has in civil leading to and can into a larger HEALTH-CARE wars, and have the potential to affect health-care providers both and was both highly and reported during the COVID-19 of the geographic and to be highly around the Although all staff may be EPs and nurses are the most severely affected during such with in of when compared to physicians in the civil war in of physicians reported and and 25% were to physical by Health-care workers are also to developing in war zones. to of health-care workers severe in government hospitals of the experiencing a military The effects were more among compared to and among nurses compared to of including and is and inherently to severe trauma. In addition, affected health-care providers from from due to prolonged work combined with the all of the can in significant mental health for health-care Although the wartime experience is for medical and and no or should be to the of war, experiences reported by who were to the conflict were as both highly and were to more to difficult conditions, more with their patients, and more They reported in their and of skills associated with the treatment of wartime injuries are also as are more and Medical training should include the management of acute and chronic associated with war and armed conflict, to the of a highly and medical trauma care, management of wide of penetrating, and combined injuries, triage in war, the deployment and of a blood bank, and management of the effects of human acute and as well as constitute just a of the multiple of such a the of the it is that physicians be to face the of war. support and Conflicts of There are no conflicts of

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