A study in the September issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals says that hospitals must be prepared in the event of a conflict and have trained staff and equipment to treat injured and noninjured children who need urgent medical care. The report is based on the experience of training at a hospital in Iraq.
Military hospitals are likely to encounter injured children as wars move away from the battlefield and into civilian territories, according to background information in the article. Children sometimes serve as soldiers or are used as human shields. In addition, because war disrupts medical facilities in the affected area, children with other injuries or illnesses may seek medical care at U.S. military hospitals as well. When U.S. and coalition forces entered Iraq in 2003, Iraqi civilian hospitals were already understaffed and lacked the supplies and infrastructure needed to effectively care for citizens. From early in the conflict, medical care was offered to injured civilians in cases of severe injury, and hospital commanders could approve care for children with medical needs that could not be handled by the Iraqi system.
Lt. Col. Christopher P. Coppola, U.S.A.F., M.C., and colleagues at the Lackland Air Force Base, Texas, reported on the children treated at one level III (medical facility in a combat area) hospital in Balad, Iraq, from January 2004 to May 2005. The 332nd Air Force Theater Hospital is approximately 40 miles north of Baghdad and consists of a series of tents with concrete floors, linked by a corridor. The facility has a staff of 420 and can accommodate up to 24 intensive care unit beds and 80 additional beds; up to six surgeries can be performed at once.
"Our primary mission as a level III hospital was to provide evaluation, resuscitation and surgical care to combat-injured troops," the authors write. "However, our facility experienced 'mission creep' because of the presence of injured civilians, including children. Children additionally had dehydration and malnutrition, which contribute to increased mortality. After Jan. 1, 2005, a pediatric surgeon was available and a broader range of non-traumatic conditions were treated in children."
During the time period studied, 85 children with an average age of 8 years (age range one day to 17 years) were evaluated and treated at the hospital, accounting for 5.2 percent of all patients and 18 percent of treated Iraqi civilians. Forty-eight (56 percent) of the children were treated for traumatic injury, including 25 (52 percent) with a fragmentation wound, such as that inflicted by improvised explosive devices, mines or blasts. Of the children with injuries, 18 (38 percent) had wounds in the leg, 11 (23 percent) in the head, eight (17 percent) in the arm, eight in the abdomen and three (6 percent) in the chest. A total of 134 operations were performed on 63 children (74 percent of the total); each of the children had an average of 2.1 procedures. Five children died--two from burns, two from infection and one from complications following a traumatic head injury and transfer to a civilian facility.
The experience illuminates several key points regarding caring for children in a war zone, the authors conclude. Hospitals near battlefields should expect to treat civilians, including children. These children are likely to have fragmentation injuries, which are generally contaminated and likely to become infected, requiring multiple procedures. "Local health resources may be so disrupted that children cannot be safely discharged until they are well enough to survive under the care of their families," they continue. "To provide adequate care for children during war, expeditionary medical hospitals must prepare for them by providing the proper personnel, training and equipment."