Introduction
Over the past two decades, humanitarian mine action (HMA) stakeholders have devoted immense effort and resources to mitigating civilian harm from explosive ordnance (EO) including landmines, cluster munitions, explosive remnants of war, and victim-activated improvised explosive devices (IEDs). 1 In contemporary conflicts, use of all types of explosive weapons (EWs), including not only EO but also air-dropped munitions such as bombing and shelling, in densely populated areas causes disproportionate civilian casualties, threatening to overshadow gains made in EO clearance and disposal. 2,Reference Wild, Stewart and LeBoa3 For example, the highest number of cluster munition casualties was recorded in 2022 since the Convention on Cluster Munitions (Geneva, Switzerland) entered into force in 2008. This trend was largely driven by the extensive use of cluster munitions in residential areas of Ukraine, including attacks on protected civilian structures (eg, schools and hospitals). 4 The on-going use of EWs in current conflicts will result in unquantified future casualties before the conclusion of the war and afterwards due to explosive remnants. Reference Wareham5–8 In Gaza, nearly 18,500 Palestinians were injured and over 7,000 killed (66% women and children) between October 7 and the October 27, 2023 ground invasion by the Israel Defense Forces, nearly all of which were likely attributable to explosive-injury-related deaths from bombings and other air-launched munitions. 9
Humanitarian mine action refers to a set of activities and initiatives aimed at addressing the impact of EO on civilian populations and communities. These activities aim to minimize the threat posed by EO, allowing affected areas to be safely accessed and used for agriculture, housing, and access to services as well as to meet the needs of people injured, survivors, affected family, and community members. Largely, HMA is comprised of five complementary pillars: (1) EO risk education (EORE); (2) land release (ie, survey, mapping, marking, and clearance); (3) victim assistance (ie, emergency and on-going medical care, rehabilitation, psycho-social support, and socio-economic inclusion); (4) stockpile destruction; and (5) advocacy against the use of EO that are prohibited, indiscriminate, and/or cause disproportionate civilian harm. 10 The HMA sector is diverse and dynamic, with a variety of actors and structures collaborating at the global level and in EO-affected countries, including National Mine Action Authorities (Geneva, Switzerland) and Centers, HMA operators, survivors’ organizations, countries engaged in international cooperation and assistance, United Nations treaty (eg, Antipersonnel Mine Ban Convention [APMBC; convention on the prohibition of the use, stockpiling, production, and transfer of anti-personnel mines and their destruction] and Convention on Cluster Munitions), implementation support units, as well as public, private, and nongovernmental organizations (NGOs) providing the services included in victim assistance. The HMA stakeholders have an organized presence with significant medical capabilities in many conflict and post-conflict settings where local health infrastructure is often disrupted and humanitarian health actors are sparse. As such, HMA is uniquely positioned to contribute to strengthening emergency care systems to improve trauma care quality for civilian casualties of EO. Though HMA focuses predominantly on EO, such engagement would also yield benefits for casualties of EWs. Yet at present, few mechanisms for such care and coordination exist.
In November 2022, 83 countries adopted the Political Declaration on Strengthening the Protection of Civilians from the Humanitarian Consequences Arising from the Use of Explosive Weapons in Populated Areas (EWIPA). 11 Elsewhere, survivors of landmines and other EO/EWs are leading their communities to recovery in extraordinary examples of grassroots advocacy and action. 12 Continued prevention, clearance, and advocacy initiatives are necessary but insufficient given continued civilian casualties of EO/EWs. Many EO/EW incidents occur in low-resource settings, where post-injury care must be significantly strengthened to reduce death and disability (Table 1 13,14 ). Organized emergency care systems have demonstrated positive impact on preventable mortality, yet are challenging to organize given resource and security constraints in conflict-affected settings. Reference Berwick, Downey and Cornett15–Reference Salio, Pirisi and Ciottone19 A scoping review was conducted with the objective of identifying both evidence-based and feasible emergency care interventions that HMA stakeholders could engage in to support civilian casualties of EO/EWs. The synthesis of these interventions can help inform the development of a strategy for enhanced care and coordination between HMA and health stakeholders including Ministries of Health and the World Health Organization (WHO; Geneva, Switzerland) to improve outcomes for EO/EW casualties.
Table 1. Explosive Ordnance Casualties and Health Care/Surgical Capacity by Country
Note: From Landmine Monitor 2023 13 and World Bank Data 14 ; it is important to note that the burden of EO is not known in many affected contexts due to inadequate casualty surveillance capacity. Further, IEDs are not fully captured in these data.
* Indicates State Parties to the Antipersonnel Mine Ban Convention.
Abbreviations: EO, explosive ordnance; IED, improvised explosive devices.
Report: Methods
Search Strategy
A scoping review was conducted of peer-reviewed and grey literature repositories to identify records describing trauma care interventions with feasible resource requirements applicable to civilian casualties of EO/EWs. Scoping review methodology was used given the heterogeneity of included literature as well as the specific aims of this review (ie, synthesizing existing evidence to derive opportunities for improved coordination between health and HMA stakeholders). A 2017 WHO review evaluating the impact of trauma systems and system components in low- and lower-middle income countries (LMICs) was updated during this review. Reference Reynolds, Stewart and Drewett20 Interventions with demonstrated efficacy in LMICs may have relevance to the environments in which EO/EW casualties occur, many of which are resource-constrained, and have the potential to be adapted for implementation in conflict settings. Additional search strings were constructed using keywords and database-specific index terminology to include interventions relevant to casualties of EO/EW (Supplement 1; available online only). Search terms for LMICs were developed from the Cochrane Effective Practice and Organization of Care (EPOC; London, United Kingdom) LMIC filters 2020 (v.4). A pre-review protocol was registered with Open Science Framework (Charlottesville, Virginia USA; Supplement 2 - available online only). Reference Wild21 Database searches were conducted in PubMed/MEDLINE (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); Embase (Elsevier; Amsterdam, Netherlands); Cumulative Index to Nursing and Allied Health Literature (CINAHL) on EBSCO (Ipswich, Massachusetts USA); Global Index Medicus (WHO); CABI Global Health (EBSCO); Cochrane Library (Wiley; Hoboken, New Jersey USA); Web of Science Core Collection (Clarivate Analytics; London, United Kingdom) – SCI-EXPANDED, SSCI, AHCI, ESCI; and Google Scholar (Google Inc.; Mountain View, California USA), as well as grey literature including organizational websites (eg, WHO and International Committee of the Red Cross [ICRC; Geneva, Switzerland]). Reference lists of eligible reports were screened for relevant records.
Eligibility Criteria
All reports from the 2017 WHO review were included in analysis. Reference Reynolds, Stewart and Drewett20 Eligibility criteria limited additional reports to those that described trauma care interventions in LMICs or civilian casualties of EO/EWs. The definition for EO was in accordance with International Mine Action Standard (IMAS; Geneva, Switzerland) 4.10, and EW was used to describe all forms of weapons causing explosive injuries including air-dropped munitions. 22 Eligible interventions and patient populations were limited to those from LMICs as defined by The World Bank (Washington, DC USA) economic classification (economic classification at study time point was utilized – for example, a record published in 2002 was evaluated for country income class at year of publication) or settings of active violence in non-high-income countries including international armed conflict, non-international armed conflict, and other armed violence. 23 Reports describing injuries of civilians or local non-NATO (North Atlantic Treaty Organization; Brussels, Belgium) coalition combatants were eligible for inclusion, consistent with previous comprehensive reports on this topic, as both populations are unlikely to be protected by body armor and may experience similar injury patterns. Reference Wild, Stewart and LeBoa3,Reference Gurney, Graf and Staudt24 Reports describing care rendered to military service members of high-income countries were not eligible. Due to limited data on the topic of interest, no studies were excluded based on study design, assessment of data quality, or risk of potential bias in keeping with WHO Rapid Review procedures. Reference Tricco, Langlois Etienne and Straus25 Date restrictions limited results to those published in or after the year 2000 to maintain relevance to modern conflict dynamics coinciding with the onset of the United States Global War on Terror in Afghanistan in 2001. Reports exclusively describing mental health and late rehabilitation interventions were excluded. Cross-sectional reports on injury epidemiology that did not describe an intervention were excluded. No language restrictions were applied. Google Translate was used for non-English language reports in which authors were not proficient.
Data Management
Records were maintained using Covidence Review Software (Veritas Health Innovation; Melbourne, Australia). Two independent reviewers screened all records identified by title and abstract to determine relevance to eligibility criteria. A senior reviewer arbitrated discrepancies. Full-text reports of eligible records were retrieved and screened by two independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) methodology was followed and search results were reported accordingly (Figure 1; Supplement 3 - available online only). Reference Tricco, Lillie and Zarin26
Figure 1. PRISMA-ScR Diagram of Selected Reports.
Data Extraction and Analysis
A standardized extraction database was developed to capture elements including study information (eg, year, location, and study design); intervention details (eg, target population, duration, format, and resource requirements); and outcome measures (eg, mortality and clinical performance improvement). Given the range of methodologies and metrics of intervention efficacy presented, structured qualitative analysis of reports was conducted and data were synthesized in narrative format. Reference Chandler, Higgins and Deeks27 Study quality was assessed using the Quality Assessment with Diverse Studies (QUADS) score (Supplement 4; available online only). Reference Harrison, Jones, Gardner and Lawton28
Intervention Synthesis and Coordination Opportunities
To present data in a manner harmonized with the WHO Emergency Care System Framework (ECSF), interventions were categorized by phase of care: (1) layperson first response (LFR - community members without formal medical training; ECSF “scene”), (2) prehospital (providers with medical training providing care in the prehospital setting; ESCF “transport”), and (3) facility-based (trauma care rendered by providers in a health facility; ESCF “facility”). 29 Formal framework synthesis methodology such as Best Fit Framework Synthesis was not adopted due to a lack of appropriate candidates for pre-existing models against which to code. Specifically, data could not be coded against existing emergency care frameworks, including the WHO ECSF, as these did not take into account the need to encompass only those interventions that could be feasibly supported by HMA stakeholders through existing operations. Two key interventions were selected from each phase that: (1) had been successfully implemented in resource-constrained settings, (2) possessed potential to reduce trauma-related mortality among EO/EW casualties, (3) had high or very-high level quality evidence as assessed by QUADS score, and (4) could feasibly be supported by HMA stakeholders. Criteria (1)-(3) were evaluated through standard scoping review methodology while criterion (4) was evaluated qualitatively by coauthors within the HMA sector and through a separate process of semi-structured interviews with HMA sector experts. Reference Wild30 In domains where more than two interventions met all of the above criteria, priority was given to those with the most robust QUADS scores or those described in multiple reports, as well as compatibility with integration in existing HMA activities. These interventions were then synthesized into an over-arching series of potential opportunities for HMA stakeholders to engage in emergency system strengthening to improve trauma care for civilian EO/EW casualties in a manner consistent with the WHO ECSF and Trauma Pathway. 31 These interventions were designated as links in a Civilian Casualty Care Chain (C-CCC).
Report: Results
Search Results
A total of 28,104 records were identified by this search strategy with 13,909 duplicate records excluded (Figure 1). The remaining 14,195 records were screened for relevance, 14,094 of which were excluded. Full-text reports of the remaining 101 records were evaluated with 53 reports excluded: 20 did not describe interventions of interest, 14 were previously undetected duplicates, 12 did not describe the patient population of interest, and seven full-texts were unavailable. Forty-eight reports met eligibility criteria. The 2017 WHO review contained 74 additional reports. Sixteen additional reports were identified from reference lists of eligible reports. In total, 138 reports met eligibility criteria and were included in analysis. Quality of evidence varied widely as assessed by QUADS criteria, with 25 reports qualitatively evaluated as very low, 17 as low, 50 as moderate, 27 as high, and 19 very high (Supplement 3; available online only). Reference Harrison, Jones, Gardner and Lawton28
Geographic Distribution
Interventions from 47 countries were described (Figure 2). The most frequent countries were Ghana and India (n = 10 each), Iraq (n = 9), Iran and Uganda (n = 8 each), and Brazil, Cambodia, and Mexico (n = 7 each). Remaining reports were broadly distributed including 45 in Africa, 36 in Asia, 23 in Latin America, and 22 in the Middle East. Fifteen reports represented interventions deployed in multiple countries not adequately specified for disaggregation.
Figure 2. Geographic Distribution of Interventions Included in Analysis.
Intervention Types and Phase of Care
Reports included in analysis described 40 LFR interventions, 35 prehospital interventions, 62 facility-based interventions, and one that could not be categorized. Trauma care training courses (TCTCs) were the dominant intervention type (n = 84). For LFR, TCTCs were most frequent (n = 36; eg, emergency first aid training provided to commercial drivers in Ghana and Nigeria), Reference Mock, Tiska, Adu-Ampofo and Boakye32,Reference Olumide, Asuzu and Kale33 followed by layperson transport systems (n = 2). For prehospital interventions, TCTCs targeting prehospital personnel were most frequent (n = 18; eg, trauma training for prehospital personnel in landmine-contaminated regions of Iraq and Cambodia), Reference Husum, Gilbert and Wisborg34 followed by Emergency Medical Services (EMS) coordination (n = 12; eg, notification systems to alert receiving facility of incoming patients). Reference Mitra, Kumar and O’Reilly35 Facility-based interventions included TCTCs for health facility clinical personnel (n = 30), trauma systems organization initiatives (n = 17; eg, establishment of designated trauma teams with standardized roles in Pakistan), Reference Hashmi, Haider and Zafar36,Reference Sarmiento Altamirano, Himmler and Chango Sigüenza37 and hospital-based clinical care protocols (n = 13; eg, standardized trauma protocols for management of patients with traumatic brain injury [TBI] in Colombia). Reference Kesinger, Nagy and Sequeira38 Cost effectiveness and data collection were the primary focus of six and three reports, respectively. Reference Arreola-Risa, Mock and Lojero-Wheatly39–Reference Kannan, Kalanzi, Osiro and Reynolds47 Interventions focused on pediatric trauma and burn care were described by only two reports each. Reference Gallaher, Banda and Robinson48–Reference Barthel, Pierce and Goodhue51 Intervention details are highlighted in Table 2 Reference Mock, Tiska, Adu-Ampofo and Boakye32–Reference Hashmi, Haider and Zafar36,Reference Kesinger, Nagy and Sequeira38,Reference Mock, Quansah, Addae-Mensah and Donkor52–Reference Tolppa, Vangu and Balu66 and summarized completely in Supplement 3.
Table 2. Selected Interventions by Phase of Care
Note: For complete summary of reports included in analysis, see Supplement 3 (available online).
Abbreviations: ALS, Advanced Life Support; ATLS, Advanced Trauma Life Support; BEST, Better and Systematic Team Training; BTLS, Basic Trauma Life Support; CPR, Cardiopulmonary Resuscitation; DRC, Democratic Republic of Congo; ED, Emergency Department; EFAR, Emergency First Aid Responders; EMS, Emergency Medical Services; EMT, Emergency Medical Technician; EMWT, Emergency Ward Management of Trauma; GCS, Glasgow Coma Scale; GETC, Guidelines for Essential Trauma Care; GP, General Practitioner; GPS, Global Positioning System; ICU, Intensive Care Unit; ISS, Injury Severity Score; HIV, Human Immunodeficiency Virus; IV, Intravenous; LFSA, Life-Supporting First Aid; LMIC, Low- and middle-income country; MSF, Médecins sans Frontières; NGO, Nongovernmental Organization; OSCE, Objective Structured Clinical Examination; PSS, Physiologic Severity Score; SMART, Surgical Management and Reconstruction Training; STaRTLE, Surgical Techniques and Repairs in Trauma for the Low-resource Environment; STP, Standardized Trauma Protocol; TACS, Trauma and Acute Care Surgery; TBI, Traumatic Brain Injury; TFRC, Trauma First Responder Course; US, United States; WHO, World Health Organization.
Intervention Format and Resource Requirements
The TCTC format and duration ranged widely. Most incorporated both didactic and hands-on skills components. Course duration was one-to-two days in most LFR trainings. Reference Mock, Quansah, Addae-Mensah and Donkor52,Reference Jayaraman, Mabweijano and Lipnick67,Reference Boeck, Callese and Nelson68 While some prehospital and facility-based TCTCs were conducted in one-to-two days (eg, specialized flap techniques for reconstruction of soft tissue defects), Reference Wu, Patel and Caldwell69 others extended over months such as an emergency medical technician (EMT) certification program in Mexico and the highly impactful “Village University” program, which adopted an intensive format with three 150-hour courses. Reference Arreola-Risa, Vargas, Contreras and Mock53,Reference Husum, Gilbert and Wisborg54 Seven reports presented data on intervention cost effectiveness. Reference Arreola-Risa, Mock and Herrera-Escamilla40–Reference Jacobs, Men, Sam and Postma44,Reference Altintaş, Bilir and Tüleylioğlu70,Reference Wesson, Boikhutso and Bachani71
Outcomes
Heterogenous outcome measures were utilized to assess intervention efficacy. Varied assessment strategies were reported for TCTCs including pre- and post-course skills and knowledge, as well as self-assessed participant confidence. Thirty-nine reports presented mortality as an outcome with variable definitions (eg, mortality in the emergency department [ED] versus in-hospital mortality). Significant reductions in trauma-related mortality were observed for interventions at all phases of care (eg, the “Village University” LFR and prehospital trauma care trainings [40% to 15% post-intervention]; Reference Husum, Gilbert and Wisborg34 a trauma team activation and prehospital notification intervention in India [relative risk {RR} 0.11 for death in the ED]; Reference Mitra, Kumar and O’Reilly35 and a standardized protocol for management of patients with thoracic trauma in Thailand [25% to approximately 15% post-intervention mortality]). Reference Chittawatanarat, Ditsatham, Chandacham and Chotirosniramit72 Five reports presented data on functional outcomes at discharge. Reference Kesinger, Nagy and Sequeira38,Reference Bertol, Van den Bergh and Trelles Centurion55,Reference Khan, Amatya and Hoffman73–Reference Hauswald, Ong, Tandberg and Omar75 Other outcomes included process measures such as clinical (eg, blood transfusion and procedural interventions) as well as systems measures (eg, prehospital transport times and time to the operating room); resource utilization (eg, length of hospital stay and intensive care unit admission); and complications (eg, surgical site infection and venous thromboembolism).
Synthesis into a Bundle of Interventions: Civilian Casualty Care Chain (C-CCC)
At each phase, two key interventions were selected with evidence of successful implementation in resource-constrained settings and potential to reduce mortality that could feasibly be supported by HMA stakeholders through existing operations and capabilities. These interventions were concatenated into a series of opportunities for HMA engagement with emergency care systems strengthening to improve trauma outcomes among EO/EW casualties structured across a continuum of care from point-of-injury to treatment at a health facility. These interventions were designated links in the C-CCC (Figure 3.) By phase of care, interventions included: LFR training and organized layperson casualty transport systems; prehospital TCTCs and notification systems for prehospital providers to alert facilities of incoming casualties; and facility-based TCTCs as well as trauma team organization and activation protocols. The C-CCC does not itself represent an emergency care framework as it lacks many of the elements needed for a complete continuum of response. Rather, this structure highlights selected areas of targeted intervention where HMA stakeholders can leverage their expertise to support health stakeholders with a shared goal of reducing preventable death and disability among EO/EW casualties.
Figure 3. Links in the Civilian Casualty Care Chain (C-CCC)
Note: 1. The C-CCC outlines a selected set of interventions that represent opportunities for HMA stakeholders to engage in health sector initiatives to improve emergency care of EW casualties. The C-CCC is not itself an emergency care pathway, as it lacks many of the emergency care system components needed for a continuum of response. Rather, it highlights specific areas of targeted action in which HMA stakeholders might leverage their existing capabilities, infrastructure, and operations to support local emergency care systems to improve trauma care for EW casualties. 2. Interdisciplinary refers to the interprofessional nature of robust ECO care, engaging all relevant health care providers including physicians, surgeons, nurses, and health officers.
Discussion
In this review, identified were trauma interventions conducted in LMICs with applicability to the care of civilian EO/EW casualties in resource-constrained settings. The objective was to synthesize the literature on existing interventions to inform enhanced coordination between HMA and health stakeholders to strengthen emergency care systems to improve trauma outcomes among EO/EW casualties. This analysis demonstrates a heterogenous but comprehensive evidence base for interventions at each phase of care that can feasibly be supported through existing HMA capabilities and operations. Main findings included: (1) a high degree of variability in format, quality of monitoring, and evaluation strategies/outcomes reported within each intervention type; (2) significant gaps in the domains of pediatrics and burns, both highly relevant to the context of blast injury; and (3) opportunities exist for HMA stakeholders to engage in numerous interventions across a continuum of care from point-of-injury to treatment at a health facility in a manner supportive of existing frameworks such as the WHO ECSF and Trauma Pathway (Table 3).
Table 3. Implementation Strategies and Research Gaps
Note: WHO Emergency Care System Framework: https://www.who.int/publications/i/item/who-emergency-care-system-framework.
Abbreviations: CFAR, Community First Aid Responder; EMT, Emergency Medical Teams; EORE, Explosive Ordnance Risk Education; EW, Explosive Weapons; HeRAMS, Health Resources and Services Availability Monitoring System; LFR, Layperson First Responder; ToT, Training of Trainers; WHO, World Health Organization.
Heterogeneity in Intervention Format, Oversight, and Outcomes Reporting
Even in the absence of well-resourced formal emergency care systems, a coordinated approach engaging local health actors in the implementation of evidence-based trauma care practices can save lives. This was demonstrated by the Tromsø Mine Victim Center’s “Village University” where trauma care training for LFRs and health care workers in areas of Iraq and Cambodia contaminated with mines reduced mortality from 40% to 15% over a five-year period. Reference Husum, Gilbert and Wisborg34,Reference Husum, Gilbert and Wisborg76 Yet, LFRs and prehospital TCTCs are not equivalent and vary widely with respect to course format, duration, resource intensiveness, and monitoring and evaluation strategies. For example, in contrast with the intensive format and five-year prospective follow-up of the “Village University” program, one LFR training program in Brazil was disseminated via television demonstration to reach a wide audience of commercial viewers. Reference Capone, Lane, Kerr and Safar56 Such variation is under-studied but can be assumed to yield significant implications for intervention efficacy and outcomes. Further, engagement of local communities in intervention design varied by report. Community participation was a core tenet of the “Village University” program and is a recognized pillar of effective mine action. Reference Bottomley77 Context-appropriate adaptations included initial needs assessment, use of translators in all local languages, measures to account for varying levels of participant education and literacy, and use of inexpensive and locally available materials such as cardboard, strings, paper towels, and goat carcasses. Reference Anderson, Kayima and Ilcisin78–Reference Van Heng, Davoung and Husum81 Adaptation of trauma care interventions in conflict requires even greater attention to contextual variability, mandating close engagement with local actors. Overall, the heterogeneity observed highlights an opportunity to create best practice standards including monitoring and evaluation strategies for TCTC design in conflict-affected and resource-constrained settings more broadly. Reference Tang, Kayondo and Ullrich82,Reference Stewart83
Evidence Gaps
This review identified numerous gaps and opportunities for further research and targeted quality improvement initiatives. Concerningly, these coincide with some of the most vulnerable patient populations demonstrated to have disproportionately high mortality in conflict. Reference Wild, Stewart and LeBoa84 Only two reports each were described in the areas of pediatrics and burn care. Reference Gallaher, Banda and Robinson48–Reference Barthel, Pierce and Goodhue51 Multi-dimensional injuries (eg, combined blunt, penetrating, and/or burn injuries) commonly result from EO/EWs. The vulnerability of children to the impact of EWs in conflict has been examined in detail elsewhere. Reference Wild, Stewart and LeBoa84,Reference Wild, Reavley and Mayhew85 Several existing initiatives may catalyze advances in pediatric trauma care in conflict, including the Global Society for Humanitarian Pediatrics and the Pediatric Blast Injury Partnership. Reference Garcia, Amsalu and Harkensee86,87 A dedicated Pediatric Trauma Resuscitation Course is in development by the latter group and should be promulgated as a supplemental module to existing TCTCs. Burn care guidelines and training initiatives exist, led by organizations including International Society for Burn Injuries (League City, Texas USA), Interburns (Cardiff, United Kingdom), and WHO. Reference Holden, Ogada and Hebron88–91 These efforts should be scaled and integrated with existing TCTCs focused on EO/EW casualties as thermal injury is one sequela of blast injury with particularly severe associated morbidity and far-reaching consequences for resource utilization, rehabilitation, and functional outcomes.
C-CCC: Selected Interventions and Potential Implementation Strategies through Coordination with HMA
The HMA stakeholders have significant potential to contribute to support emergency care systems strengthening in settings affected by EO/EWs given the medical resources of demining teams and well-established operational presence in many conflict and post-conflict settings. Within the HMA sector, improved engagement in trauma care capacity building represents a concrete opportunity for implementation of victim assistance strategies as outlined in three critical mine action treaties (the APMBC, Convention on Cluster Munitions, and Protocol V of the Convention on Certain Conventional Weapons), as well as the recently adopted IMAS 13.10 on Victim Assistance in Mine Action. 92–94 The following interventions do not represent a complete casualty care pathway, but rather highlight a series of selected areas in which HMA capabilities could be leveraged to significantly enhance health sector initiatives to improve the outcomes of civilians injured by EO/EWs.
At the LFR phase, HMA stakeholders can engage in LFR trainings in the EO/EW-affected communities where they work. Given the lack of organized prehospital transport systems in many resource-constrained conflict settings, linking this initiative with the development of organized layperson transport mechanisms (eg, motorcycles, bicycles, and donkeys) holds potential to reduce care delays. Reference Sharma, Bovier and Jha57,Reference Shehu, Ikeh and Kuna58,95,Reference Green, Quigley and Kureya96 The impact of transport times on mortality is well-described, and prolonged prehospital times are a significant barrier to improving survivability of EO/EW-related injury. Reference Forrester, August and Cai97–Reference Shackelford, Del Junco and Mazuchowski99 Building on existing HMA infrastructure, potential implementation strategies for LFR trainings would include an enhanced EORE package with trained community liaison staff. Key existing resources include the “Village University” curriculum and the WHO Community First Aid Responder (CFAR) training. Alternative implementation strategies could involve demining staff within local communities or at a safe periphery from a worksite, as these individuals are all trained to a level of basic trauma care provision in accordance with IMAS 10.40. Reference Falder, Potokar and Kynge100 Consideration must be given to adequate guidance to protect trained LFRs from sustaining injury if responding to EO/EW casualties and supporting their mental health after administering aid. In conjunction with these efforts, given the exemplary precedent set by the HMA sector for standardized data collection practices in challenging operational environments, layperson data enumerators could be trained to further strengthen surveillance. Reference Hoogeveen and Pape101–103
At the prehospital phase, HMA stakeholders can support TCTCs with more advanced content for prehospital medical personnel (eg, multiple casualty triage, care of multi-dimensional injuries/complex blast wounding patterns such as burns, mangled extremities/compartment syndrome, tympanic membrane rupture/ocular injuries, blast lung, and TBI), as well as prehospital notification systems. Key existing resources for prehospital TCTCs focused on blast injury include ICRC’s Blast Trauma Care Course and the WHO-ICRC Basic Emergency Care module on Conflict-Related Injuries. 91,104 Prehospital notification systems were described by only one report included in this review, but in high-resource settings, have been identified as one of the trauma system components most associated with decreased mortality. Reference Liberman, Mulder, Jurkovich and Sampalis105 Though such systems may face implementation challenges in areas of limited telecommunications, they likely represent an under-explored opportunity to improve patient outcomes. In other contexts, village radios have been used for emergency preparedness in remote settings and could be applied in the context of EO/EW casualty evacuation. Reference Selvaraj and Kuppuswamy106
Opportunities for HMA engagement at the facility-based phase are fewer due to multiple factors, including the diversity of stakeholders at this level as well as the complexity of clinical care provided. Nonetheless, actors within the HMA sector can contribute to clinical capacity-building by supporting trauma team organization (ie, the establishment of structured trauma teams with designated roles that engage in resuscitation rehearsals) and activation protocols (ie, mechanisms whereby a trauma activation is triggered by prehospital notification of incoming casualties). Reference Hashmi, Haider and Zafar36,Reference Bertol, Van den Bergh and Trelles Centurion55,Reference Wu, Patel and Caldwell69 Resource requirements necessary to organize trauma teams among health facility staff, to establish protocols for trauma team activation, use checklists, and conduct trauma resuscitation rehearsals are relatively minimal with potentially significant impact on patient outcomes. Reference Wild, Mock and Lim107 For example, the use of a standardized trauma intake form even in the absence of formal trauma teams was found to reduce trauma-related mortality from 17.7% to 12.1% at one hospital in Ghana. Reference Gyedu, Stewart, Nakua and Donkor108 The HMA stakeholders can also help advocate for the importance of specialized facility-based TCTCs addressing key issues affecting EO/EW casualties (eg, amputation techniques and soft tissue reconstruction), which have demonstrated significant capacity to improve rates of limb salvage. Reference Bertol, Van den Bergh and Trelles Centurion55,Reference Wu, Patel and Caldwell69 Such initiatives must be contextualized within broader emergency care systems strengthening led by national and multi-lateral health stakeholders, and require close coordination with Ministries of Health and the WHO. 109
Potential HMA implementation partners at the prehospital and facility-based phases include paramedics (designated intermediate care providers [ICPs]), with training delivered either for additional incentives during off-duty hours at a safe periphery from a worksite so long as they remained within the worksite’s designated fixed response time, or separately arranged to coincide with their own refresher trainings at a health facility. Providing training in such an arrangement is in accordance with IMAS 10.40 3.2.2, which stipulates that ICPs may “fulfill a dual role in low-risk clerical duties outside the active worksite.” Reference Falder, Potokar and Kynge100 In instances where ICPs were accredited through their affiliated mine action organization in a process separate from local health institutions, memoranda of understanding with local authorities would need to be instituted to formalize this role and address liability concerns. Increased coordination with local Ministries of Health for facility-based interventions would be mutually beneficial for HMA stakeholders. Such engagement would provide refresher training opportunities for HMA ICPs as well as ensure that an adequate level of care is provided should they need to evacuate their own casualties to these sites, such as the tragic attack on the HALO compound in Afghanistan. Reference Rahim and Ives110
Limitations
This review had several limitations. First, to capture a range of trauma care interventions in settings applicable to civilian EO/EW casualties, no studies were excluded based on study quality. While study quality was descriptively assessed using a QUADS scoring framework, these evaluations were not used as exclusion criteria. Second, since study quality was utilized as a criterion to select interventions as links in the CCCC, and since training initiatives tended to have higher QUADS scores, training initiatives were favored in this synthesis. Other interventions exist with potential opportunities for HMA engagement, particularly at the level of coordination, readiness, preparedness, and response in resource-constrained conflict and post-conflict settings. Finally, significant heterogeneity exists in the data presented by included reports, which precluded pooled analysis. Nonetheless, this review conducts a comprehensive synthesis of the evidence base for trauma care interventions that may inform resource-feasible solutions to improving the care of EO/EW casualties.
Conclusion
As indiscriminate use of landmines, cluster munitions, IEDs, and other EWs disproportionately affects civilians in conflict settings globally with reverberating consequences for decades from explosive remnants of war, improving the quality of trauma care for casualties is essential. This review synthesized the evidence base on trauma care interventions in resource-constrained settings applicable to the care of EO/EW casualties to propose a strategy for improved care and coordination between HMA stakeholders and trauma care providers. By linking the global and country-level humanitarian Health and Protection Clusters, HMA stakeholders can potentiate efforts to build capacity among trauma care providers in conflict-affected settings, reducing preventable death and disability caused by EWs.
Conflicts of interest/funding
The authors have no competing interests to declare. HW is supported by the Global Health Equity Scholars Program NIH FIC and NIH OBSSR (Award no. D43TW010540).
Supplementary Materials
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X24000669
Open access
