Introduction The People’s Republic of China has been successfully deploying medical teams to support the peacekeeping mission at the Level 2 Military Hospital in Mali since December 2013. The aim of this paper was to compare the current practice in Chinese Peacekeeping Level 2 Military Hospital with the severe trauma treatment standards reported in China.
Methods A retrospective analysis was conducted between 26 April 2014 and 18 May 2016 using records stored in the Chinese Peacekeeping Level 2 Hospital (CHN L2). From 19 May 2016 to 31 March 2017, the data were prospectively collected for all casualties presenting in the hospital. Emergency response time, prehospital transit time, emergency rescue time, consultation call time and mortality were compared with the data from a study that evaluated the effects of standard rescue procedure (SRP) in improving severe trauma treatment in different hospitals across China.
Results Indexes obtained from the analysis of CHN L2 data were equal or surpassed indexes reported in the study evaluating the implementation of SRP in Chinese hospitals.
Conclusion The deployed CHN L2 delivered a high standard of care in Gao, Mali, and generally surpasses the Chinese standards. This can mostly be attributed to an efficient coordination of work during both prehospital and in-hospital stages of rescue.
- trauma treatment
- Chinese level 2 military hospital
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Integration of prehospital and in-hospital care is of key importance for the success of rescue work.
The Chinese military has accumulated extensive experience by sending out peacekeeping medical teams.
The deployed Chinese Peacekeeping Level 2 Hospital had delivered a high standard of care that equals or surpasses the Chinese standards.
According to the Memorandum of Understanding between the United Nations (UN) and the government of the People’s Republic of China, the Chinese government has agreed to contribute personnel, equipment and services for a Level 2 hospital to assist the United Nations Multidimensional Integrated Stabilization Mission in Mali (MINUSMA). Since 26 April 2014, China has successfully deployed four medical teams to support Chinese Peacekeeping Level 2 Hospital (CHN L2) in Super Camp, Gao, Mali. Most of the members come from a tertiary care referral military facility in China.
The CHN L2 was established in support of MINUSMA; it is a purpose-built facility staffed with specialists in emergency medicine, general surgery, orthopaedic surgery, anaesthesia, intensive care and internal medicine that delivers care to UN peacekeeping troops, police, employees, volunteers and sometimes local civilians for humanitarian reasons. It consists of a 2-bedded resuscitation room, 2-bedded intensive care unit, 20-bed ward, 1 operating room, a laboratory and a blood bank; a plain X-ray machine and a portable ultrasound device are also available on site. The capability of CHN L2 is to provide first-line and second-line healthcare, emergency resuscitation/stabilisation, life-saving surgical intervention, primary dental care and evacuation of casualties to the next level of medical care (Level 3 or Level 4). Trauma governance is vital to ensure that deployed troops are treated appropriately and safely. The aim of this study was to compare trauma treatment standards in a forward peacekeeping combat field with that of trauma systems in China.
All casualties with a definite diagnosis of trauma or combat injury were identified for the period 26 April 2014 to 18 May 2016. This period was before the authors arrived to the mission area, and therefore the data were retrospectively collected from the documents stored in CHN L2. From 19 May 2016 to 31 March 2017, data were prospectively collected for all casualties presenting in CHN L2 and combined with a subsequent retrospective review of prehospital documentation and transfer notes.
Emergency response time, prehospital transit time, emergency rescue time, consultation call time and mortality were compared with the data from a study that evaluated the effects of standard rescue procedure (SRP) in improving severe trauma treatment in 12 tertiary care referral facilities in different cities across China.1 This study was used for comparison because before implementation of SRP severe trauma treatment practices in these hospitals in general represented current practices for severe trauma treatment in China. However, it is worth noting that the set of data that was chosen for comparison represents the trauma treatment after implementation of SRP in these facilities. Implementation of SRP allowed to improve the efficiency of work significantly and the level of trauma treatment became higher than the average level in other Chinese hospitals. This set of data was chosen in order to account for certain specifics of work of a peacekeeping military hospital that is fully dedicated to the treatment of trauma as opposed to work of Chinese non-military hospitals, where SRP is not implemented and severe trauma treatment system is still under development. Data were analysed using SPSS V.13.0 software using a χ2 test, with significance at p<0.01.
Between 26 April 2014 and 31 March 2017, 1235 cases in total were recorded in the CHN L2. Data on 871 cases were retrospectively collected and data on 364 were collected prospectively. In total, 109/1235 cases were due to combat injury (injuries resulting from enemy action), and 47/1235 were from trauma (fall or traffic accident). These 156 cases from trauma were chosen for further research.
The most common mode of prehospital transport was helicopter (113/156 casualties). The Chinese medical evacuation team (AMET) delivered 72 of the casualties to Super Camp, and the Netherlands or Germany AMET delivered 41 of them to CHN L2. The other 43 (27.6%) were transported by armoured ambulances, soft-skinned ambulances or commercial vehicles.
The mean age of the 156 casualties was 27.1±3.3 years. In total, 110 (70.5%) casualties were peacekeeping soldiers, and half of them (62.564%) were Senegalese who were in charge of escort and patrol, followed by Chadian (17.1%), Nigerian (9.4%) and Togolese (7.3%). Forty-six (29.5%) casualties were civilians who were hired by the UN as truck drivers or workmen.
Emergency response time was defined as the time within which AMET was ready to dispatch, meaning that all of the team members and medical equipment were inside the armoured ambulance. The mean time was 5.1±3.1 min. There is no traffic congestion in Gao, so the prehospital transit time was defined as the time within which the casualties were transported from anywhere to CHN L2. For the casualties transported by helicopter, the time was defined as the time from the airport to our hospital. The mean time was 20.4±5.1 min. The emergency rescue time and consultation call time were defined as the time within which the first doctor and the team leader or a specialist arrived, respectively. The waiting time was zero; it means that the emergency doctor and the team leader or a specialist were waiting for the casualties at the gates of the hospital. The mortality rate was 0.6%, principally because the most serious casualties were sent to Bamako directly. All of these indexes were compared with the indexes from the study evaluating implementation of SRP in Chinese hospitals. According to the study, after the implementation of the SRP, the average emergency response time, the average prehospital transit time and the average emergency waiting time were 10.11±3.21 min, 22.39±4.32 min and 3.26±0.89 min, respectively, the average consultation time was zero and the in-hospital mortality rate was 20.49%±3.11%.1 The comparison showed that the indexes obtained from the analysis of CHN L2 data were equal or surpassed indexes reported by Yin et al. (Table 1).
A consultant, who was either a team leader or a supervisor in CHN L2, was present in 100% of cases. With regard to airway management, it was performed by an anaesthesiologist in each case. Surgical care was largely specialist delivered and led either by the primary or assisting surgeon. According to these criteria, only three cases (1.9% of those requiring surgery) were performed solely by an attending surgeon, all of which were minor procedures such as superficial wound debridement. Radioscopy was performed in 127 cases (81.4%) as part of the initial management. The standard of CHN L2 is to transfer the casualties to the X-ray room within 45 min from arriving at the hospital, and this was met in 117 cases (92.1%), with a mean time to X-ray of 25.4±5.7 min. The longest waiting time was 67 min due to the mass casualties arriving on 31 May 2016 when 16 casualties were sent to our hospital at the same time after a suicide vehicle bomb terrorist attack.
For documentation, the L2 record of all trauma casualties was in the form of the UN Medical Note. Of patients discharged from the L2, 100% had appropriate transfer documentation. Ultrasound examinations were performed in 15.7±5.1 min, according to the FAST principles and in turn with the radioscopy.
The PLA has now offered >30 000 personnel in the mission of peacekeeping. The first peacekeeping medical team was deployed to Congo (King) in April 2013. Peacekeeping medical teams were also deployed to such countries as Liberia, Sudan and Mali in November 2013, May 2006 and December 2013, respectively.2 They also began to introduce many Chinese standards to the UN medical standards of practice, ensuring the highest level of medical support to peacekeeping troops.
According to a review of the road traffic injury treatment network in mainland China, it was found that in cases of traffic injury the organisation of prehospital care, involvement of senior medical staff and immediate in-hospital care were deficient in most hospitals in China. Currently, there is no uniform standard of prehospital care in China. There are three major types of ambulance units in different first-tier and second-tier cities in China: ambulance units that are owned by hospitals across the city and get appointed by an independent administration command centre; ambulance units that are owned and get appointed by large-scale hospitals; and ambulance units that are owned and get appointed by independent emergency centre that transfer patients to cooperative hospitals. In smaller municipalities, prehospital care solely relies on the ambulance units from local healthcare facilities.3 The air rescue network in China is not developed and helicopters are not widely used as a prehospital mode of transportation. Prehospital care procedures are not standardised and at times the staff lacks adequate training. In places where the ambulance unit is owned by independent emergency centre, the major task of the rescue team is to transport the patient to the hospital and their abilities in triage and treatment are limited.1 Due to the lack of direct communication between such emergency centres and the local hospitals, the assessment of injuries and a call for consultation are always made after the arriving of the patient at the hospital.4 Although some hospitals have dedicated emergency and critical care departments with permanent integrated teams that play leading role in diagnosis and treatment, in the majority of the hospitals, specialists from different departments of the hospital have to be called for a consultation. They make a diagnosis and establish the treatment plan. When a call for consultation is made, it takes a certain time for the specialists to respond and arrive from their respective clinical departments, or in some cases to free themselves from other clinical work before responding to the call. In cases of multiple injuries, rescue procedures might be delayed by an argument between the specialists from different departments while trying to determine in which department the patient should be admitted. In-hospital patient care can be initiated only after a primary diagnosis is acquired and all the necessary hospitalisation procedures are completed. All these factors delay emergency rescue and decrease the efficiency of the rescue work. Whereas, in contrast, in the CHN L2, all members live, eat and work in close proximity to the facility, and have few external distractions or other non-military responsibilities; it allows the specialists to respond quickly at the same time making it more convenient. Integrated team has a strong team spirit, team leader focuses on the patient’s overall condition and makes timely decision accordingly. These were few of the most important reasons why a Level 2 hospital delivered a high standard of care that was equal to a Chinese tertiary care facility where an effective SRP is implemented.
At the end of our mission in Gao, having experienced managing CHN L2, we had organised a medical system conference that was attended by all Level 1 hospitals and AMETs in the mission area. Moreover, we established a communication network in Super Camp and at least four times participated in exercises that were held between all medical teams in Sector East of MINUSMA. It made it possible every time for the accurate information of casualty to be transferred to CHN L2 earlier than the casualty arrives at the hospital and allowed doctors, nurses and in some cases even the surgical team leaders, an anaesthesiologist and other specialists to get ready and wait in the emergency room. These were the main reasons why the consultation call time and the waiting time of availability of a specialist was reduced to zero. The 100% availability of a consultant in anaesthesia to provide airway management was proven to be equally important to ensure that the highest standard of care was delivered in every case.5 In single-casualty presentations, the surgical team leader was immediately available and was directly supervising. In multiple-casualty situations, specialists in general and orthopaedic surgery, intensive care specialists and even the deputy commander who was in charge of the medical affairs were invited to lead the trauma teams. Due to time limitations of our 1-year mission, we could not follow-up all the casualties we rescued. But the preliminary results show good outcomes in most cases, and it proves right the old Chinese saying that being prepared ahead of time is ‘winning at the starting line’.
In 10 casualties, plain radiographic imaging was not performed within 45 min of arrival in the CHN L2. Further analysis of these cases revealed that they all occurred during multiple serious casualty situations where several casualties presenting simultaneously required imaging and, therefore, had to be prioritised. Pending X-ray patients were either managed in the resuscitation room or the intensive care unit. Ultrasound, ECG examination and blood tests were performed during this time. The ultrasound machine was not required by the UN; furthermore, it was not even included in the UN inspection manual; but under the circumstance that there was no CT available in Level 2 hospital, an ultrasound machine was essential in diagnosing thorax and abdomen closed injuries, especially blast injuries.6 The use of plain but not digital X-ray machine in CHN L2 hospital posed some challenges because the former needs longer time in X-ray film processing.
The casualties that were being transferred from CHN L2 to the Level 2+ hospital in Bamako or Level 3 hospital in Dakar had photocopies of all notes, images and scans in addition to a transfer summary. A dedicated medical information recorder acted either as the trauma chart scribe or as a supervisor of the scribe during the resuscitation and had no direct clinical role. These data were used to shape medical organisation and provide insight into equipment issues.7 For example, according to the English translation of the recorded medical data, improvised explosive devices (IEDs) were the predominant threat to the peacekeeping troops in Sector East of MINUSMA; thus some suggestions regarding the safety precautions were given to the operation department. It included the suggestion not to take off the helmet even inside armoured personnel carrier because the displacement of the vehicle in IED explosion will cause head injury. It leads to the conclusion that there maybe more benefit in dedicating a medical information recorder in combat medical team of PLA because the doctors and nurses usually could not forsake their primary duties in order to keep records.
The Chinese People’s Liberation Army has deployed more than 280 of its medical personnel with each successive rotation to provide seamless, continuous care for UN military and civilian personnel in Mali from December 2013. This study demonstrates that medical personnel deployed to CHN L2 delivered a high standard of care that, in most areas, equals or surpasses the recommendations for good civilian trauma care in China. This most likely can be attributed to an efficient coordination of care in both the prehospital and in-hospital setting.
Funding This study was funded by Logistics science and technology project of PLA (CSY15J001).
Competing interests None declared.
Patient consent Not required.
Ethics approval This study was conducted under the supervision of the Ethics Committee of General Hospital of Shenyang Military Command.
Provenance and peer review Not commissioned; internally peer reviewed.
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