Treatment of lower extremity injuries due to antipersonnel mines: Blast resuscitation and victim assistance team experiences in Cambodia

Military Medicine, Jul 2003 by Parr, Reagan R, Providence, Bertram C, Burkhalter, William E, Smith, Allan C

The two teams comprising the fiscal year 2001 Blast Resuscitation and Victim Assistance mission had the opportunity to learn from and practice mine injury treatment principles with experienced local and international war surgeons in Cambodia. Treatment principles were modifications of International Committee of the Red Cross recommendations. A total of 14 acute lower extremity mine injuries were treated. Surgery generally consisted of an open amputation or thorough irrigation and debridement using equipment readily available in any U.S. military field hospital. The surgical techniques will be described in detail. Delayed primary closure occurred 5 days later followed by prosthesis fitting (for amputees) in an International Committee of the Red Cross facility 12 weeks later. Other options and techniques will be discussed with an emphasis on applicability to U.S. military field surgery.

Introduction

Cambodia is a county of approximately 10 million citizens in a primarily agrarian society. Since the 1970s, multiple conflicts ranging from the rule of the Khmer Rouge to Vietnamese occupation to civil war have ravaged and destabilized the country.1 During this period of conflict, the different factions frequently mined areas not only to channel troop movements or to provide defense, but also to terrorize and to control movements of the local population.1,2 The locations of the various minefields were poorly documented and the various factions failed to remove mines after their usefulness was complete.1 As a consequence, there are an estimated 6 to 10 million land mines in Cambodia, a concentration of 142 mines per square mile.1,2 This combination of a high concentration of invisible, unknown mines coupled with a society returning to the fields or venturing into forests in search of firewood has led to more than 36,000 mine amputees in Cambodia and a 1 per 236 incidence of amputation.1,3

The large number of mine injuries in Cambodia has placed additional strain on a slowly rebuilding health care infrastructure destroyed by the Khmer Rouge during its rule from 1975 to 1979.1 To assist the developing health care system in Cambodia, the United Nations, the International Committee of the Red Cross (ICRC), several nongovernmental organizations, and other groups have become involved in Cambodia.1 Emergency, an Italian nongovernmental organization serving civilian war victims in Iraq and Afghanistan as well, runs the 80-bed trauma hospital for the Battambang province in northwest Cambodia.2 In the calendar year 2000, the local and international surgical staff at the Emergency Surgical Center for War Victims performed 143 emergency mine-related surgeries.

To provide education and training in the acute management of blast injuries as well as to provide humanitarian assistance, the Department of Defense established the Blast Resuscitation and Victim Assistance (BRAVA) program in fiscal year 1998. Previous missions had gone to locations in Sri Lanka. The Emergency Surgical Center for War Victims was selected to be the location for the fiscal year 2001 BRAVA teams. Two teams comprising the fiscal year 2001 BRAVA mission had the opportunity to learn from and practice mine injury treatment principles with experienced local and international war surgeons in Cambodia.

The purpose of this study is to describe the perioperative and operative management of acute lower extremity mine injuries as learned from experienced war surgeons in Cambodia. Focus will be on a unique below knee amputation technique. The applicability of these techniques to U.S. military war surgery will also be discussed.

Materials and Methods

The two BRAVA teams spent 3 weeks each on missions to Cambodia. The first team was comprised of an orthopedic surgeon, a general surgeon, a general surgery resident, an anesthesiologist, and five additional ancillary personnel. The second team was comprised of an orthopedic surgeon, an orthopedic surgery resident, a plastic/hand surgeon, an anesthesiologist, and five additional ancillary personnel. The cases and experiences discussed will be a compilation of the two teams' experiences.

The BRAVA teams performed 103 reconstructive or elective cases. The 34 general surgery cases consisted mainly of herniorrhapies and excision of goiters and masses. The 69 orthopedic/plastic/hand cases were comprised of surgery for polio residuals, congenital deformities, chronic osteomyelitis, or fracture complications. The teams also participated in 25 blast injury cases consisting of 23 mine injury cases and 2 gunshot wound cases. Of the 23 mine injury cases, 9 were delayed primary closures (DPC), revisions, or upper extremity cases, and 14 were acute lower extremity surgeries The focus of the remainder of this study will be the lessons learned from the evaluation and treatment of these 14 acute lower extremity mine injury cases as learned from experienced local and international war surgeons.

Prehospital Treatment

Civilian victims treading directly on pressure-activated anti-personnel mines caused the majority of the injuries. From the point of injury, usually on a farm or in a forest (during wood collecting), patients were transported by friends or family members to a forward positioned aid post. The Emergency hospital has trained medics to staff five aid stations in the rural portions of the Battambang province.