Pediatric Inpatient Humanitarian Care in Combat: Iraq and Afghanistan 2002 to 2012 Mary J Edwards,

MD, FACS,

Michael Lustik,

MS,

Mark W Burnett,

MD,

Martin Eichelberger,

MD, FACS

The purpose of this study was to define the scope of combat- and noncombat-related inpatient pediatric humanitarian care provided from 2002 to 2012 by the United States (US) Military in Iraq and Afghanistan. STUDY DESIGN: A review of the Patient Administration Systems and Biostatistics Activity (PASBA) database for all admissions from 2002 to 2012 by US military hospitals in Afghanistan and Iraq for children 14 years of age and younger provided data to analyze the use of medical care. North Atlantic Treaty Organization Standardization Agreement (STANAG) injury codes provided injury cause and the ICD-codes provided diagnosis. In-hospital mortality, blood usage, number of invasive procedures, and hospital stay were analyzed by country and injury category. RESULTS: There were 6,273 admissions that met inclusion criteria. In Afghanistan, there were more than twice as many pediatric noncombat-related admissions (2,197) as pediatric combat-related admissions (1,095). In Iraq, the difference was minimal (1,391 noncombat vs 1,590 combat). The most common cause of noncombat-related admission in both countries was injury: primarily motor vehicle related and burns, which varied significantly by age. Older patients (older than 8 years in Afghanistan and older than 4 years in Iraq) were more likely combat victims. Mortality was highest for combat trauma in Iraq (11%) and noncombat trauma in Afghanistan (8%). The in-hospital mortality in both countries was 5% for admissions unrelated to trauma. Resource use was highest for combat trauma in both countries. CONCLUSIONS: Noncombat-related medical care was the primary reason for pediatric humanitarian admissions to United States military combat hospitals in Iraq and Afghanistan from 2002 to 2012. Combat-related injuries have a higher mortality than noncombat injuries or other admissions. (J Am Coll Surg 2014;218:1018e1023.  2014 by the American College of Surgeons)

BACKGROUND:

The primary role of a combat military hospital is to provide medical care to soldiers during warfare. However, the Geneva Convention specifies that an occupying force must ensure, to the greatest extent possible, the public health of the civilian population.1 Where there is a substantial security risk to civilian health care providers and Disclosure Information: Nothing to disclose. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government. This study was conducted under a protocol reviewed and approved by the US Army Medical Research and Materiel Command Institutional Review Board and is in accordance with the approved protocol. Received November 4, 2013; Revised December 26, 2013; Accepted December 30, 2013. From the Departments of Surgery (Edwards), Clinical Investigation (Lustik), and Pediatrics (Burnett), Tripler Army Medical Center, TAMC, HI; and the Department of Surgery, Children’s National Medical Center, Annapolis, MD (Eichelberger). Correspondence address: Mary J Edwards, MD, FACS, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Rd, TAMC, HI 96859-5000. email: [email protected]

ª 2014 by the American College of Surgeons Published by Elsevier Inc.

where inadequate local medical infrastructure exists, humanitarian, civilian medical care is a responsibility of military hospitals. Current United States (US) Army doctrine recognizes a role for the combat health system in stabilization and sustainment of military operations; however, provision of such care in a combat mission, or when a combat mission evolves to a counterinsurgency, is less well defined.2 The purpose of this study was to define the inpatient pediatric humanitarian medical mission in combat operations in Iraq and Afghanistan.

METHODS The Patient Administration Systems and Biostatistics Activity (PASBA), located at Fort Sam Houston in San Antonio, TX, collects prospective data for all patients admitted to United States military treatment facilities in the US and abroad, to include combat hospitals.3 Data for civilian patients 14 years of age and younger, treated at all US military hospital treatment facilities in Iraq and Afghanistan from January 2002 to November 2012, were

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Vol. 218, No. 5, May 2014

Edwards et al

available for analysis. Because patients older than 14 years were frequently combatants, they were not included in this analysis of humanitarian care. Data included age, International Classification of Disease (ICD-9) diagnosis and treatment codes, length of stay, discharge status, country of admission, and injury code according to the North Atlantic Treaty Organization Standardization Agreement (STANAG).4 The STANAG system is a unique, military trauma code system that provides information for non-combat and combat injury.4 Patients admitted to any military facility are assigned a STANAG trauma category between 0 and 9 describing the external cause and events surrounding the injury, and specifies if it is a direct result of combat. The children were placed into 1 of 3 groups for this analysis (Table 1). The combat trauma group (Group 1), comprised children with codes for injury as a result of the conflict; the noncombat trauma group (Group 2) contained children with codes for selfinflicted intentional trauma or trauma resulting from a nonmilitary injury. The nontrauma group (Group 3) comprised children without a STANAG or ICD-9 injury diagnosis. Four children with a missing STANAG code, but who had an ICD-9 injury code (800 to 999), were placed in the noncombat trauma category (Group 2). Thirteen children were excluded from the analysis because the STANAG injury code was imprecise (categories 2 and 3). Children with a category 5 to 8 code (14 patients) were excluded because these codes are specific to active duty military personnel. The number of noncombat-related admissions (Groups 2 and 3) were combined and stratified by country of

Table 1.

Pediatric Humanitarian Care in Combat

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injury and year. The Group 1 (combat trauma) and Group 2 (noncombat trauma) children were further stratified by cause of injury and country of war. The in-hospital mortality, percentage of children who required transfusion, and location of injury were compared among the 3 groups of children (Group 1, combat trauma; Group 2 noncombat trauma; Group 3, nontrauma). Length of stay was calculated as the difference between admission date and discharge date plus 1. Invasive procedures were defined as an ICD-9 treatment code between 0 and 86.99. Chi-squared tests and 2-sided Fisher’s exact tests were used to compare in-hospital mortality and transfusion rates, and an analysis of variance followed by pairwise post-hoc t-tests with Tukey-Kramer adjustment for multiple comparisons was used to compare length of stay and counts of invasive procedures. Length of stay data were transformed to the log scale, and counts of invasive procedures were transformed to the square root scale to enhance normality for analysis. Means were transformed to the original scale for presentation (eg, geometric mean for length of stay). Statistical significance was established at p < 0.05, and SAS software v. 9.2 (SAS Institute Inc) facilitated analysis of the data.

RESULTS In the 11-year period from 2002 through 2012, 6,328 children 14 years of age and younger were admitted to US military treatment facilities in Iraq and Afghanistan. After excluding 55 children for a coding error, 6,273 pediatric admissions remained for analysis; 3,292 (52%) were in Afghanistan and 2,981 (48%) were in Iraq.

Pediatric Admission Grouping for Analysis

Description of group for analysis

Group 1: combat trauma Battle wound/injury: Direct result of action by or against an organized enemy (declared war only) Battle/wound injury: Other battle casualties Group 2: noncombat trauma Intentionally inflicted nonbattle injury: intentionally self-inflicted All other patients: traumatic nonmilitary injuries Group 3: nontrauma admissions No STANAG code given and ICD-9 admission code not 800e999 Not analyzed Intentionally inflicted nonbattle injury: Result of intervention of legal authority Intentionally inflicted nonbattle injury: Assault inflicted by another person Accidental injury: Active duty service members only: on duty, off duty, during maneuvers, during scheduled training No STANAG code given, but ICD-9 admission code 800e999 STANAG, North Atlantic Treaty Organization Standardization Agreement.

STANAG trauma category

n

0 1

2,685

4 9

1 2,101

None

1,486

2 3

13

5-8 None

14 4

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Edwards et al

Ages and categories of these children are shown in Table 2. There were a total of 71 (1%) infants under 1 year of age; 842 (13%) children 1 to 3 years of age; 2,204 (35%) children 4 to 7 years of age; 1,828 (29%) children 8 to 11 years of age; and 1,328 (21%) children 12 to 14 years of age. Figure 1 compares the incidence of combat-related pediatric admissions to noncombat-related admissions by location and date. In Iraq, combat-related injuries to children were more common than other admissions in 2006 and 2007, and similar in number during 2004 and 2005. Noncombat admissions in Iraq were more frequent in 2003, and from 2009 to 2011. In Afghanistan, noncombat admission for children was more common than combat-related admissions every year. Table 2 summarizes the total number of pediatric admissions by category and by country. Combat trauma dominated admissions in Iraq for children 4 to 14 years of age. However, in children 1 to 3 years of age, noncombat trauma was most common. Admission of infants 1 year of age or under was usually for a nontrauma diagnosis. From 2003 to 2011, the total number of noncombat pediatric admissions in Iraq was 1,391, compared with 1,590 admissions for pediatric combat trauma. In Afghanistan, the most common cause of admission for all children was noncombat trauma, followed by combat trauma, and then a nontrauma condition. Infants were commonly admitted for a nontrauma diagnosis. Children 1 to 7 years of age were most likely admitted for noncombat trauma, and children older than 7 years of age with an injury were frequently a consequence of

Table 2.

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Pediatric Humanitarian Care in Combat

combat. The total of pediatric noncombat-related admissions (Groups 2 and 3, n ¼ 2,197) in Afghanistan was more than double the total number of injuries due to combat (Group 1, n ¼ 1,095). The ICD-9 code diagnosis for admission was variable by country, but patterns did emerge. For nontrauma admissions in Afghanistan, thalassemia was the most common diagnosis for children between the ages of 1 and 8 years, followed by cleft lip or palate for all age groups except infants. Burn and skull fracture were the most common noncombat injury diagnoses for admission in Afghanistan. Injury to the head, eye, and abdomen were common combat trauma admission diagnoses. In Iraq, nontrauma admission for follow-up care after surgery, pneumonia, congenital anomaly, and altered neurologic status were common. Burn was a frequent diagnosis for noncombat trauma admission in Iraq. In patients younger than 8 years of age, combat trauma usually involved the head. For children 12 to 14 years of age, thoracic and extremity injury dominated this category. Abdominal injury was a frequent admission diagnosis in Iraqi children older than 1 year of age. In infancy, childbirth and neonatal care were the common reasons for admission and for nontrauma humanitarian admissions in Iraq. Table 3 demonstrates the common causes of pediatric injury by country. In Afghanistan, children were most likely to be injured in combat by an explosion. In Iraq, children with combat injuries were most frequently shot. Noncombat trauma consisted primarily of motor vehicle-related injury, burn and falls in both countries, followed by penetrating trauma.

Group Admission Totals by Age and Country

Injury type

Iraqi Group 1: Combat trauma Group 2: Noncombat trauma Group 3: Nontrauma admission Total Afghan Group 1: Combat trauma Group 2: Noncombat trauma Group 3: Nontrauma admission Total Total Group 1: Combat trauma Group 2: Noncombat trauma Group 3: Nontrauma admission Total, n (%)

Age, y, n 4 to 7

Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012.

The purpose of this study was to define the scope of combat- and noncombat-related inpatient pediatric humanitarian care provided from 2002 to 2012 by...
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