Humanitarian Surgical Care in the US Military Treatment Facilities in Afghanistan From 2002 to 2013

Medical units of the US military have operated for more than 15 years in Afghanistan, a country with among the lowest estimates of access to safe, timely surgical and anesthesia care.¹ Surgeons from the US military have delivered humanitarian surgical care (HSC) to local national civilians throughout the conflict, although previous large reports about this care focused on children.^2,3 To provide a more comprehensive accounting, we conducted a retrospective study on HSC provided by deployed US military medical units to local national civilians during the Afghanistan conflict.

The Walter Reed National Military Medical Center Department of Research Programs determined that this study was exempt from review by an institutional review board and did not require participant consent as all records received and analyzed by investigators were deidentified. P < .05 was considered statistically significant. Data were collected from January 1, 2002, to March 21, 2013, and data analysis took place from July 1, 2015, to March 1, 2016.

We queried the Patient Administration Systems and Biostatistics Activity, a military medicine administrative database, for noncombatant local national patients older than 15 years of age who underwent at least 1 surgical procedure (according to procedure codes of the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] Volume 3) in military treatment facilities in Afghanistan from January 1, 2002 to March 21, 2013. Our analysis excluded ICD-9 procedure codes 87 to 99, miscellaneous procedures. Patient demographics, nature of disease and injury, blood transfusions, length of stay, and in-hospital mortality were included. We examined patient subgroups according to their war-related (WR) or non–war-related (NWR) classification, which is based on the North Atlantic Treaty Organization’s Standardization Agreement 2050, a trauma code system that specifies cause of injury as WR or NWR.⁴ Admitting facilities determined an injury or condition to be WR if it occurred as a direct consequence of the conflict, including acute and chronic sequelae. We characterized treatment or care according to the World Bank 2015 Disease Control Priorities, which identified 44 essential surgical procedures.^5,6

From January 1, 2002, to March 21, 2013, a total of 5786 local national civilians underwent 9428 surgical procedures, accounting for 37 121 inpatient days. Of these patients, 4680 (80.9%) were male and 2853 (49.3%) were treated for NWR conditions. Compared with patients who had WR injuries, patients with NWR conditions were older (median [interquartile range] age, 26 [22-35] years vs 29 [22-40] years; P < .001) and had shorter lengths of stay (4 [2-9] days vs 3 [1-6] days; P < .001), fewer procedures (4859 vs 4569), lower blood transfusion requirements (943 [32.2%] vs 363 [12.7%]; P < .001), and lower in-hospital mortality (150 [5.11%] vs 104 [3.64%]; P = .006) (Table 1). Most NWR presentations were due to injury, but 1104 (38.7%) of these patients underwent elective or noninjury procedures.

When analyzed by organ system (Table 2), the most commonly performed procedures were on the musculoskeletal and integumentary systems, with patients with WR and NWR injuries undergoing procedures at similar rates (musculoskeletal, 1446 [29.8%] vs 1464 [32.0%]; integumentary, 1313 [27.0%] vs 922 [20.2%]). Noninjured patients had lower rates (musculoskeletal, 398 [24.0%]; integumentary, 233 [14.1%]; P < .001) but were more likely to undergo procedures associated with the digestive system or the eyes (421 [25.4%] and 144 [8.7%], respectively; P < .001).

Disease Control Priorities essential surgical procedures accounted for 3345 procedures (Table 2), and 583 (17.4%) procedures were performed for noninjury conditions. Traumatic injuries accounted for an additional 2762 surgical procedures (82.6%), most frequently orthopedic procedures for fractures (1455 [43.5%]). The essential procedures accounted for 1684 of 4859 WR procedures performed (34.7%) and 1661 of 4569 of NWR procedures performed (36.4%).

To our knowledge, this report is the largest, most comprehensive account of HSC provided to local national civilians by US military medical units in Afghanistan. Injured patients received most of the procedures, which is consistent with the high burden of trauma in low- and middle-income countries.¹ This report also shows the significant resources committed to noninjury and elective conditions. The procedures included those that are unexpected for combat-oriented medical units to perform (such as cataract surgery), reflecting the expertise and logistical support available in these units. Although the outcomes of the procedures or follow-up after discharge could provide valuable perspective, the data set limited our ability to characterize these elements.

The scope of HSC that can be delivered by a military medical unit is influenced by the complex interplay of capacity, humanitarian drive, operational tempo, strategic goals, and relationships with local governmental and nongovernmental medical resources. Eligibility and access to HSC varied widely by location, time frame, and cultural limitations. Our findings encourage continued discussion about the goals of and eligibility for military HSC. Who should be treated, and how do we integrate with the local health system? How should we prepare surgeons for deployment given that global surgery, as well as military trauma, is part of the deployed surgeon’s practice? These remain pressing questions for the current and future conflicts into which military surgeons are deployed.

Corresponding Author: Peter A. Learn, MD, Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 4301 Jones Bridge Rd, Bethesda, MD 20814 (peter.learn@usuhs.edu).

Accepted for Publication: June 11, 2017.

Published Online: September 13, 2017. doi:10.1001/jamasurg.2017.3142

Author Contributions: Drs Learn and Weeks had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.

Study concept and design: Weeks, Elster, Learn.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Weeks, Elster, Learn.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Weeks, Learn.

Administrative, technical, or material support: Learn.

Study supervision: Elster, Learn.

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy of the US Department of the Army, Department of the Navy, Department of the Air Force, Department of Defense, or federal government.