MILITARY MEDICINE, 181, 8:849, 2016

Role 1 Pediatric Trauma Care on the Israeli-Syrian Border First

Year of the Humanitarian Effort
Capt Yuval Bitterman, MC IDF*; MAJ Avi Benov, MC IDF*; COL Eton Glassberg, MC IDF*;
Capt Alexandra Satanovsky, MC IDF*; COL Tarif Bader, MC IDF*f; COL Ram Sagi, MC IDF*f

ABSTRACT Background: This article summarizes the experience with Role 1 care for 135 Syrian children who
received medical care during the year 2013 as part of an ongoing humanitarian effort. Methods: The database included
demographic information, point-ol-injury assessment and outcome, and was analyzed using SPSS. Results: Trauma
casualties were the majority of the group (84 cases), and mostly male. Almost one-third of casualties arrived more than
6 hours after injury, and time of injury was unknown in another third. The most common mechanism of injury was
shrapnel (51.2%), followed by gunshot wounds (22.6%). Gunshot wound victims were significantly older than shrap
nel and artillery victims ( p < 0.01, < 0.05, respectively). Only 14 cases (14.28%) underwent previous interventions in
Syria. Most of the casualties (44 cases, 52.4%) underwent at least one procedure during Role 1 treatment with a high
overall success rate (93.18%) that was not correlated to Advanced Life Support provider type (physician [MD], emer
gency medical technician-paramedic, or both). Mortality was low (3 cases). Conclusion: The study cohort exhibits several
unique features, including a delay in arrival to medical care, paucity of prior care and information, and the specific mech
anisms of injury. Our study suggests that Advanced Life Support providers do not differ significantly in Role 1 treatment
choices and procedure success.

INTRODUCTION airway management and performance of early life-saving

Since the beginning of the civil war in Syria in March 2011,
more than 190,000 people have been killed, out of which
more than 8,800 were children.' During that time, an esti
mated number of 1,500,000 were wounded according to The
Syrian Observatory for Human Rights.2 The local health sys
tem is struggling to cope with the huge numbers of casualties
while it suffers from medical personnel defection, bombed
hospitals, and shortage in supplies.
As a neighboring country, Israel is not a participating side
in this local conflict but is engaged in an ongoing humanitar
ian effort to aid Syrian civilians that come to the border seek
ing medical assistance.3 Since February 2013, more than 1,300
Syrian civilians have arrived at the Israeli border and received
medical care by Israel Defense Forces (IDF) medical teams.
Of them, 689 arrived during the first year, including 135 under
the age of 18 years. The medical treatment is not limited to
trauma casualties and is provided to sick people as well.
The first level of treatment (Role 1) is provided by mili
tary medical teams deployed along the border in the form of
battalion aid stations (BAS). Role 2 is in a nearby IDF field
hospital in the Golan Heights and Role 3 is in the civilian
hospitals in the northern part of Israel. Some casualties are
evacuated directly from the border to a civilian hospital.
The BAS is comprised of two medical teams, each con
sisting of an Advanced Life Support (ALS) provider (MD or
EMT-P) and two to three combat medics.4*The team pro
vides point of injury (POI) care and is capable of advanced
interventions, as well as administration of fluids and blood
products in accordance with remote damage control resus
citation principles. The BAS teams are mobilized using
armored ambulances and are responsible for providing medi
cal care as well as rapid evacuation of casualties to Role 2
or 3 facilities.3
Combat trauma differs significantly from that of the civil
ian setting3; in contrast with civilian trauma, injuries are
mostly penetrating trauma. Furthermore, the mechanism of
penetrating injury is more diverse and includes blast and
fragmentation injuries. Only a few reports were published
describing pediatric combat trauma, and most of them were
from the operations in Iraq and Afghanistan.6*" 10 These reports
were focused on the characteristics and the treatment given to
pediatric trauma patients arriving at the deployed Level 2
facilities (Combat Support Hospital [CSH]). In these reports,
pediatric patients comprised 3 to 10% of the admissions.69" ''
The published data in the literature about Role 1 pediatric
combat trauma care is very limited. Our article focuses on
pediatric patients epidemiology and Role 1 treatment. The
aim of the study is to summarize the accumulated experience
with Role 1 care for the pediatric casualties of the Syrian
conflict. We believe that lessons can be learned from our
experience and those might even influence policy regarding
POI care and medical teams preparedness for such chal
lenges in the future.

METHODS
*Medical Corps, Israel Defense Forces, m.m 021419, Ramat Gan, Israel.
D a ta S o u rc e
tDepartment of Military Medicine, Hebrew University, Jerusalem, Israel.
AMSUS - The Society of Federal Health Professionals, 2016 We performed a retrospective review of the IDF Trauma
doi: 10.7205/MILMED-D-15-00427 Registry (ITR) for Syrian pediatric patients treated in Israel

MILITARY MEDICINE, Vol. 181, August 2016 849

 Role 1 Pediatric Trauma Care on the Israeli-Svrian Border

between February and December 2013. All records of casu was divided to five categories: unknown, up to 1 hour, 1 to
alties under the age of 18 arriving at the Israeli-Syrian border 3 hours, 3 to 6 hours, and more than 6 hours.
from February 16 to December 31, 2013, were extracted.
The ITR is a pre-hospital registry active since 1996 under Mechanism of Injury
the Trauma and Combat Medicine Branch in the Medical The mechanism of injury was collected from the patients
Coips Headquarters and it includes data collected from POI history and/or was defined by the treating ALS provider.
to rehabilitation. Data from POI is collected from casualty Injury mechanisms were classified into 9 groups: unknown,
cards that are attached to trauma patients and contain data gunshot wound (GSW), artillery, improvised explosive device
about the mechanism and the location of the injury, demo (IED), blunt trauma, burns and smoke inhalation, fragmenta
graphic information, vital signs, and interventions preformed tion injury, disease, and recurrent admission (Table I). The
on the patients (Fig. 1). Casualty cards serve as the trauma above categories were created from the subset of categories
patients records and means of data transfer between Roles. found on the casualty cards and from free text written on the
Upon arrival at the hospital, the data card is scanned and card (Fig. 1). Casualties returning to Israel for further treat
sent to the Trauma and Combat Medicine Branch, where it ment (i.e., another operation, removal of external fixation)
is fed into the ITR. The study did not utilize any informa after a prior admission were defined as recurrent patients.
tion from higher levels (roles) of treatment or data col
lected retrospectively.
Injury Sites
Injury sites were recorded on the casualty card by the ALS
Demographic Data provider, who marked injuries on a human silhouette and also
Patient's age, gender, time of injury, and date of arrival were wrote in free text. Injury sites were divided into seven groups:
taken from patients history. The time from injury to arrival head/cervical spine, eyes, chest, abdomen, pelvis, upper limbs,
and lower limbs.

Treatment and evacuation card Treatment

U
EtunMA fritai patient'* reamer and (0 Injury time Some casualties underwent prior treatment in Syria. Informa
tion regarding prior treatment was obtained from the patients
consciousness Injuries Location (mar*} history and physical examination or, in the minority of cases,
Hooes rwtrespcod J |ij3rAiseBuniiset j Alert from medical documentation that was brought with the patient.
Time Intervention Assessment The few procedures that were performed in Syria included
j| jW itlV V '
injMfy?
j A A A intubation, chest drainage, laparotomy, fixation of fractures,
wound closure, and amputations.
11 j C#tatr^D(MPi ^ t*- p Ij
The treating ALS provider type was noted as being an
i
I0***1 9
Ym
Breathing
injury?

to Bj j \ t i/: \ l MD. EMT-P, or both. Procedures performed during Role 1
h
R **p r*intm m 'i treatment were coded, and the number of attempts and suc
Saturation: i it j i ! cess or failure was recorded for each attempt of a procedure.
" ) - ^
v$
Shock? O
No
c qi i ) \ o
11| MV
)
Administration of medications, fluids, and freeze-dried plasma
(FDP) were noted, including dosage (where applicable). Success
ji iWCuM
H.R.
)} n or failure of a procedure was defined and recorded by the POI
j | Boreg
Blood Pr**um % 4/ U team. Ventilation without definitive airway and administration
---------iFTH-
-2Q su n n
D Injury' m*eh*At*m

GCS *** Vin * to Wt Gun shot

2Q-jj 40 ' SlTltfct
IthaiatfOA
Fall E.vplasi-Jfi TABLE I. Mechanism of Injury
3D * 5 0 SQ
airo ib r. f-iosn n d iid c r toommi r*;-:nafc Olfrti Animal iTjck Bum.
Mechanism No. %
Qutcfc <XI>rrwmt*Oil (bodyrotattooandpacking) Diagnostic arid
comments. Fragmentation Injury 43 51.19
Additional treatment GSW 19 22.62
Tnukran Ov _j*.
Artillery 10 11.90
1. 1 1 Blunt Trauma 9 10.71
HkT,*. 1 ****** LJ IED 3 3.57
MMdrs-i 1! n 3.57
Unknown 3
1 3.57
3
. . ...
tvsK-Bariiw: This*
. h
DPOTratfcui ------
B Burn and Smoke Inhalation
Disease 32
Midi Ulutnl Recurrent 19
fto t ttii Sen Q A ir Q L and D Rrtun*J'sKrty
_ j ~ L
Percentage is shown out of trauma cases and ordered by prevalence (n = 135).
FIGURE 1. IDF-MC treatment and evacuation card. GSW, gun shot wound; IED, improvised explosive device.

850 MILITARY MEDICINE, Vol. 181, August 2016

 Role 1 Pediatric Trauma Care on the Israeli-Syrian Border

of drugs or fluids were not included in success-rate calcu TABLE II. Injury Sites Prevalence of Trauma Casualties
lations because of ambiguity in defining success.
Site No. %
Limbs (Total) 40 47.61
Statistical Analysis Upper Limbs 14 16.66
Statistical analysis was done using SPSS software package 19 Lower Limbs 30 35.71
(IBM, Armonk, New York). Mann-Whitney nonparamet- Head/Cervical Spine 28 33.33
ric tests were conducted to test constant shift between Chest 14 16.66
Eyes 13 15.47
groups, and nonparametric correlations were performed using Abdomen 11 13.09
Spearmans test. The t test and analysis of variance measures Pelvis 7 8.33
have been carefully used after checking the amount of valid N
Percentage ordered by descending prevalence (n = 84).
and the hypothesis of a normal distribution. The Scheffe post
hoc multiple comparison test was performed later to evaluate
differences between specific groups. Univariate analysis was (p = 0.07), falls with pelvic and head injuries (p = 0.069,
used to test the effect of independent variables on the depen p = 0.075, respectively).
dent variables while neutralizing intervened variables.
The study was approved by the Israel Defense Force Med Injury Site
ical Corps (IDF-MC) Institutional Review Board.
Limb injuries were the most common injuries (47.6%), most
of them in the lower limbs (75%). One-third of the casualties
RESULTS suffered from head or cervical spine injuries (Table II).
Demographic Characteristics Thirty-two casualties (38.08%) were injured in more than
One hundred thirty-five pediatric Syrian patients received one site.
medical assistance from IDF medical teams between Febru
ary and December 2013. Pediatric patients amounted to 19.59% Mortality
of the patients who arrived during the study duration (689 Three cases of the 84 acute trauma casualties resulted in
casualties in total). Two patients (1.48%) returned immedi death in one of the treatment levels (3.57%), all of the casu
ately to Syria after treatment, 34 (25.19%) were evacuated alties suffered from severe head injuries, and two also suf
to a Role 2+ facility and later discharged, and 99 (73.33%) fered multitrauma.
were evacuated to Role 3 civilian hospitals. Eighty-four
patients were acute trauma casualties, 19 were nontrauma Treatment
patients, and 32 were those returning for further treatment Most of the casualties (44 cases, 52.4%) underwent at least
in Israel. Trauma casualties were significantly older than one procedure during Role 1 treatment (Table III). The most
nontrauma patients (average age 12.45 5.01 vs. 7.21 common procedure was insertion of an intravenous (IV)
5.81 years, p < 0.001). There was a clear male predomi catheter (28, 33.33%), followed by endotracheal intubation
nance in both groups (70.79% in trauma and 68.42% in (10, 11.9%). Only 13 cases (15.47%) underwent more than
nontrauma). The mean age in the male group was also found one procedure. FDP usage was increased significantly over
to be significantly higher than in the female group (12.85 time (p = 0.028), while no other trend was found in other
5.36 vs. 8.96 4.69 years respectively,/) < 0.0001). procedures or administration of drugs and fluids. The over
all reported procedure success rate was high (94.23%) with
Time From Injury
Less than 10% of the casualties arrived within 1 hour of
injury and almost one-third arrived 6 hours or more after TABLE ill. Procedures Performed by Role 1 Medical Teams on
the initial injury. Time since injury was unknown in almost Trauma Casualties
one-third of the casualties. Procedure No. %
No Procedure Performed 40 47.61905
Mechanism of Injury IV Catheter 28 33.33333
The most common mechanism of injury was fragmenta Intubation 10 11.90476
Tranexamic Acid 6 7.142857
tion injury (51.2%), followed by GSWs (22.6%) and blunt
Ventilation Without Definitive Airway 6 7.142857
force trauma (11.9%) (Table I). GSW victims were signifi Unknown 5 5.952381
cantly older than fragmentation injury and artillery victims Hemostatic Dressing 4 4.761905
(p < 0.01, < 0.05, respectively). Mechanism of injury Chest Drain 2 2.380952
was not correlated with gender. Some correlations with Intraosseous Catheter Insertion 1 1.190476
Foley Catheter for Hemostasis 1 1.190476
borderline significance were found between mechanism of
injury and the injured site: IED with lower limb injuries Percentage ordered by descending prevalence (n = 84).

MILITARY MEDICINE, Vol. 181, August 2016 851

 Role 1 Pediatric Trauma Care on the Israeli-Syrian Border
only two failed intubation attempts (on the same casualty)
and one failed IV line insertion. Other procedures were suc
cessful on the first attempt and are stated in Table III.
Reported success rates were not in correlation to casualty
age and the type of the ALS provider (MD, EMT-P, or both).
The most commonly used analgesics were morphine and
ketamine (13 and 5 cases each). The use of analgesic drug
during treatment and the choice of the specific analgesic
drug were not correlated with casualty age. Moreover, anal
gesics use and dings chosen did not vary throughout the year.
Fourteen cases (14.28%) of trauma casualties underwent
previous interventions in Syria. Intubation and wound sutur
ing were the most common procedures (5 cases each).
DISCUSSION
Our study describes the accumulated experience of the IDF
medical teams providing Role 1 care for the pediatric casual
ties and patients of the Syrian conflict during the year 2013.
Demographic Characteristics and Mechanism
of Injury
Trauma casualties were significantly older than nontrauma
casualties and displayed a male predominance. GSW injuries
were correlated with male gender and older age, whereas
fragmentation injury and artillery were correlated with youn
ger age. We assume that these might be explained by the
tendency of older children, especially males, to be near or
even participate in the combat. The same phenomenon, of
male predominance with older age in GSW victims, has been
described in previous reports from the operations in Iraq and
Afghanistan.6'9 In contrast to previous reports,9 fragmentation
injuries and injuries because of artillery accounted for a larger
portion of casualties in our study (51.19% and 11.9% vs.
13% and none, respectively). The data also differ from that
published by Wilson et al,10 in which the most common
mechanism of penetrating injury was IED explosion, and
GSWs were the least common. One might speculate that
this is testimony to the nature of the ongoing conflict in
Syria, in which children are often caught in the crossfire
and to the type of weapons utilized (urban warfare with
small arms vs. convoy attacks and IEDs).
Outcome
Overall mortality rate was low (3 fatalities), and thus we
were not able to analyze independent factors influencing
mortality. We assume that the low mortality rate might be in
part because of the case mix: more than one-third of our
patients arrived 6 hours or more after injury. This undoubt
edly resulted in a selection bias, favoring the survivors. The
same delay in time from injury to arrival was seen in a pre
vious report on the first half-year of the humanitarian effort
by Benov et al.3 Moreover, some of the patients received
prior medical treatment in Syria (14.28%, 14 cases). The
effect of prior treatment in Syria is difficult to determine. On
852
one hand, the treatment might have contributed to the sur
vival of arriving trauma casualties. On the other hand, 5 of
the 13 casualties underwent primary combat wound suturing,
a procedure which is not recommended for combat injuries
which tend to become infected. This might pertain to the
heterogeneous nature of health care and caregivers currently
operating in Syria. In addition, prior treatment was more
common in the pediatric population than in the scarce num
ber of adults who arrived after prior treatment. It is possible
that the few medical resources that still exist are devoted to
the pediatric cases.
Treatment
Overall reported procedure success rate was high (94.23%)
and did not differ between types of ALS providers. Further
more, it seems that Role 1 treatment choices (of analge
sics and procedures) did not differ among ALS providers.
The reported success rate of endotracheal intubation (9 of
11 attempts, 81.81%) is surprisingly high and similar to
those shown by air transport personnel.12 Prior articles regard
ing experience in treating pediatric combat trauma casualties
were only from higher treatment levels (CSHs) and called for
the use of pediatric specialists and addition of pediatric sup
plies to CSHs.6'13 However, these reports have not shown a
decrease in mortality rate because of addition of a pediatrician
or pediatric intensive care specialist to a CSH. Three possible
explanations for the lack of difference between the types of
ALS providers include the high rate of overall success, the
nature of Role 1 care that is generally guided by protocols and
limits free choice, and that both EMT-Ps and MDs did not
specialize in pediatric care.
Apart from increasing use of FDP, there were no changes
in procedures performed or drugs administered over time.
The increased use of FDP in pediatric cases might be due to
several reasons: success in treatment of adult population, ris
ing confidence in administering FDP in a Role 1 setting, and
factors concerning availability of the product (requisition of
vials for each medical team). It is noteworthy that the study
cohorts were the first to receive single-donor FDP in the
prehospital setting.
Providing medical assistance to civilians of a country that
is considered to be an enemy of Israel is commensurate with
the IDF-MC oath: To extend a helping hand to the wounded
and the sick, whether common or distinguished, friend or
foeto each with respect. This spirit, found in IDF-MCs
oath and practiced by other nations and militaries worldwide,
is the foundation of humanitarian efforts around the globe.
The fact that patients returned for further treatment of their
free will implies the trust built during the humanitarian effort.
LIMITATIONS
The study has several noteworthy limitations: the informa
tion was gathered from casualty cards filled at the POI,
which are succinct and more prone to data inaccuracies.
MILITARY MEDICINE, Vol. 181, August 2016
 Role l Pediatric Trauma Care on the Israeli-Syrian Border
The characteristics of the study population, language bar
riers, and the clandestine nature of the humanitarian effort
led to information gaps regarding mechanism, time of injury,
and medical documentation elaborating on prior treatment.
Finally, the low number of mortality cases did not suffice
for advanced statistical analysis.
CONCLUSION
Our study population incorporates several unique features that
make it stand apart from recent reports on pediatric combat
trauma (from the operations in Iraq and Afghanistan). These
features include the high percentage of pediatric patients, the
delay in arrival to medical care, the paucity of prior medical
care and information, and the specific mechanisms of injury.
Our data implies that ALS providers (EMT-P and MD) are
all capable of treating combat pediatric trauma and do not
differ significantly in Role 1 treatm ent choices and proce
dure success.
Further research using more elaborate physiological infor
mation regarding each patient is needed to fully investigate
differences between MDs and EMT-Ps. Widening the scope,
with data regarding treatment of all of the casualties treated
during 2014, might allow further statistical investigations.
ACKNOWLEDGMENT
We wish to thank Dr. Ron Kedem for his assistance in performing the sta
tistical analysis in this study.
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