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Analysis of the First 100 Patients From the Syrian Civil War Treated
in an Israeli District Hospital
Seema Biswas, FRCS,  Igor Waksman, MD,y Shay Baron, BSc,z David Fuchs, BA, RN,
Hagai Rechnitzer, PhD, Najib Dally, MD,jj Shokrey Kassis, MD,  and Amram Hadary, MD 

the Israeli Defence Force (IDF) and receive medical treatment in

Objective: An analysis of the injuries and treatment of the first 100 patients
hospitals in the north of Israel.
from the Syrian civil war was conducted to monitor quality of care and
Ziv Medical Center, a 320-bed district hospital that serves as a
regional level 2 trauma center in Safed, Upper Galilee, is less than 20
Summary Background Data: As reports of the collapse of health care
miles by road from the Israel-Syria border (the closest hospital to the
systems in regions within Syria reach the media, patients find themselves
border) and has treated more than 440 Syrian patients over the last 20
crossing the border into Israel for the treatment of war injuries. Among these
months. The outcome data of the first 100 patients are presented here.
patients are combatants, noncombatants, women, and children. Treatment,
Although anecdotal reports indicate that the cooperation in health
that is free at the point of care, is a humanitarian imperative for war wounded,
care between Israel and Syria might be improving, patients who seek
and this paper reports the care in an Israeli district hospital of the first
treatment in Israel have crossed a closed border and are treated in a
100 patients received.
nation considered an enemy of Syria. Written referrals from health
Methods: With ethics committee approval, data from the Trauma Registry
professionals in Syria to colleagues in Israel remain rare. Every care
and electronic patient records were collected and analyzed. No identifying
is taken, therefore, to protect the identities of patients and not enquire
data are presented.
beyond their immediate medical history.
Results: Most patients (94) were male. Seventeen patients were younger than
the age of 18 years; 52 patients were in their twenties. Most injuries were the
results of gunshot or blast injury (50 and 29 patients, respectively). METHODS
Two multiple-trauma patients died, 8 were transferred for specialist care, Data were obtained from the hospital trauma registry and
and 90 patients returned from Ziv Hospital to Syria after discharge. electronic patient files for the first 100 patients admitted to the Ziv
Conclusions: The experience of the care of patients across a hostile border Medical Center between February and October 2013. Institutional
has been unprecedented. Hospital protocols required adjustment to deliver ethics committee approval was granted for data collection and
quality clinical and social care to patients suffering from both the acute and analysis. No patients were asked to provide personal information
chronic effects of civil war. as their security is a priority. No identifiable data were collected.
Keywords: blast injury, civil war, gun shot wound, humanitarian, surgery, Patients not admitted to hospital, or with nontrauma diagnoses, are
war wounded not included in the trauma registry. Data for all patients were
collected from electronic patient files. The hospital trauma coordi-
(Ann Surg 2016;263:205209) nator maintained a record of every Syrian patient assessed and treated
in Ziv Medical Center.

A s the Syrian civil war continues for a fourth year, more than
190,000 people have been killed,1 more than 500,000 have been
wounded,2 and at least 9 million people have fled their homes.3
Patients receiving initial emergency care at the Syrian-Israeli
border fence were brought by IDF ambulances to the trauma room in
the emergency department. In hospital, they were treated in the
Although most have fled to neighboring Arab countries, Israels critical care units (adult and pediatric), general surgery, vascular,
border remains closed, and there are no refugees in Israel. A state of orthopedic, plastic surgery, pediatric, and ophthalmology depart-
war still exists between the 2 countries with intermittent hostile ments. Length of stay in hospital was from 1 to 78 days (average
activities from time to time despite disengagement in 1967. Since length of stay was 14 days compared with the 4-day length of stay for
February 2013, more than 1300 people have, however, made their the average Israeli inpatient).
way to the border fence, where they are retrieved by paramedics of
From the Department of Surgery, Ziv Medical Center, Safed, Galilee, Israel; Of the 100 patients, 94 were male and 6 were female. The age
yDepartment of Surgery, Western Galilee Hospital, Nahariya, Isreal; zBar Ilan range was from 2 to 51 years, and the average age was 23 years (17
University Medical School, Safed, Galilee, Israel; Emergency Department, patients were younger than the age of 18 years; 52 patients were in
Ziv Medical Center, Safed, Galilee, Israel; Department of Microbiology, Ziv their twenties). The time from injury to arrival in the trauma room at
Medical Center, Safed, Galilee, Israel; jjDepartment of Haematology, Ziv
Medical Center, Safed, Galilee, Israel; and Department of Plastic Surgery, Ziv Medical Center was estimated for all patients from what the
Ziv Medical Center, Safed, Galilee, Israel. patients, their companions, and ambulance crew described. Accord-
Disclosure: All authors confirm that no support, financial or otherwise, was ing to their description, only 24 patients arrived within 24 hours of
received in the preparation of the manuscript or the work described. All their injury.
authors confirm that there is no conflict of interest. This manuscript is original,
and although this work has been presented in part at a number of scientific Table 1 shows the nature and causes of injury (100 patients),
conferences, this manuscript has not been submitted or published elsewhere. and Figure 1 shows the sites of injury (100 patients).
Reprints: Seema Biswas, FRCS, Department of Surgery, Ziv Medical Center,
Safed, Galilee, 13100, Israel. E-mail: Trauma Room
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/14/26105-0821 All patients were assessed in accordance with Advanced
DOI: 10.1097/SLA.0000000000001230 Trauma Life Support guidelines in the trauma room (a separate area

Annals of Surgery  Volume 263, Number 1, January 2016 | 205

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Biswas et al Annals of Surgery  Volume 263, Number 1, January 2016

TABLE 1. Nature and Causes of Injury (100 Patients) TABLE 2. Operative Procedures According to Surgical Spe-
Percentage of Patients
cialty (100 Patients)
Injury Causes (n 100) Surgical Specialty No. Procedures
Gunshot 42% Orthopedic 89
Blast 24% General surgery 78
Gunshot and blast 8% Plastic 19
Flying missiles 9% Vascular 8
Burn 2% Ophthalmology 5
Road traffic crash in conflict 7% Head and neck 3
Other 8% Oral Maxillo-Facial 1

Includes other combinations of injuries (8%).
Urology 1
Cardiothoracic 1

TABLE 3. Outcome DataAll Patients

spine Percentage of patients

head and neck

Discharged 91%
Transferred 8%
eyes Deaths 2%
Injury sites

lower limb One patient was transferred back to Ziv Medical Center after drainage of lung
abscess in Rambam Hospital (level 1 regional trauma center).
upper limb


TABLE 4. Outcome DataComplications (n 24)
Percentage Mean Length Mean Length
0 5 10 15 20 25 30 35 40 of Patients of Stay in of Stay in
Number of patients ICU (Days) Hospital
Surgical site infection 12 10 32
FIGURE 1. Sites of injury (100 patientsmost patients had Pulmonary 10 10 26
multiple injuries). Venous thromboembolism 1 3 7
Skin graft necrosis 1 5 17

Pulmonary embolism and deep vein thrombosis confirmed at duplex and CT
pulmonary angiogram at day 1 and day 2, respectively, after nailing of femoral fracture.

from the rest of the Emergency Department and resuscitation area) to

facilitate rapid transfer from IDF paramedic teams and rapid assess-
ment, and as a routine infection control measure for patients trans- DISCUSSION
ferred from other health facilities.
All but 2 patients (who were transferred immediately to the Surgery
operating room (OR) for laparotomy for intra-abdominal hemor- Thirteen patients underwent primary damage control laparot-
rhage) underwent radiological assessment in the trauma room. This omy. Relook laparotomy was performed after 24 or 48 hours (3
included chest x-ray and focused abdominal sonography for trauma patients underwent relook laparotomy 3 times, 2 patients twice). Six
(FAST) scan performed by a radiologist, as per the hospital trauma patients required colectomy, 5 patients small bowel resection, and
resuscitation protocol. Conscious patients with isolated limb inju- splenectomy was performed in 2 patients, distal pancreatectomy in 1
ries then underwent x-ray in the radiography emergency depart- patient, and liver laceration sutured in 1 patient. Two patients were
ment. Computed tomographic (CT) scan was performed in all left with ventral hernias after initial surgery and laparostomy. Mesh
hemodynamically stable patients with head and torso injuries hernia repairs were performed after the resolution of sepsis approxi-
(78%). Of the patients who underwent CT scan, 61 had associated mately 2 weeks after primary laparotomy in both cases.
limb injuries. Orthopedic patients returned to the OR for multiple debride-
Ninety-nine percent of patients underwent surgery on the day ments (up to 7 times) as the majority of wounds were heavily
of admission. Sixty-five patients were transferred from the trauma contaminated, patients arrived wrapped in soiled blankets, or, before
room directly to the OR or underwent CT scan en route to the OR. transfer, traumatic wounds had been primarily closed in the field (in
Thirty-three patients went to the surgical ward and then to the OR. Syria possibly) to control hemorrhage. These wounds were all
One patient went directly to the intensive care unit (ICU) and then to reopened, cleaned, and managed with negative pressure wound
the OR. Table 2 lists operative procedures in all 100 patients by therapy for, on ave, 10 days; indeed, the hospital purchased 6
surgical specialty. additional vacuum-assisted closure systems (a 300% increase). Daily
dressings employing Milton solution (an aqueous solution of sodium
Complications hypochlorite and sodium chloride) were incorporated into standard
Tables 36 list outcomes including complications, transfers, wound care. Patients were only discharged after wounds had healed
and deaths in the 100 patients. or had been successfully grafted.

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Annals of Surgery  Volume 263, Number 1, January 2016 Injuries and Treatment of Patients From the Syrian Civil War

TABLE 5. Outcome DataTransfers (n 8)

Mean Time to
Percentage Mean Transfer From
Destination of Patients ISS Reason for Transfer Ziv (Days)
Neurosurgery (Western Galilee Hospital, 5 20 Neurosurgical management after general surgical Same day
Nahariya) and orthopedic surgery (all patients)
Cardiothoracic Unit (Rambam Hospital) 2 26 Lung abscess 38
26 Hemodynamically stable but mediastinal and Same day
cardiac fragments from blast
Vascular Unit (Rambam Hospital) 1 13 No vascular cover in hospital. Transferred after Same day
pelvic and bilateral lower limb fixation

infection compounded injuries, and, in many cases, determining

TABLE 6. Outcome DataDeaths (n 2)
whether civilians had been injured in blasts (through primary,
Mean Length secondary, or even tertiary blast injury resulting from hand grenades,
Percentage Age of Stay in shells, mortars, mines, or aerial bombardment) or by flying missiles,
of Patients (yr) Diagnosis ISS ICU (Days) debris, and the collapse of their homes, were difficult to understand.
1 25 Multiple-trauma, 34 2 Two patients (mother and daughter) reported the collapse of their
hemorrhage, shelter after an explosion. Both had complex leg injuriesfractures,
organ failure extensive soft tissue loss, and multiple wounds from flying missiles.
1 27 Multiple-trauma, 50 27 Even after repeated enquiry, it was never clear what the exact
bile leak, mechanism of injury had been.
Similarly, of the 11 patients who had road traffic crashes, only
4 patients reported the vehicular crash as a result of coming under fire
or a blast. The remaining 7 patients had a combination of injuries
ranging from blunt trauma expected after a motor vehicle crash to
A special effort was made to preserve limbs as it was injuries resulting from being dragged behind their car.
considered crucial to the long-term survival of patients returning
to the personal and familial devastation and limited resources of Determinants of Clinical Course
Syria as civil war continues. A specialist orthopedic surgeon at the The clinical course in multiple-trauma is determined usually
hospital has led the treatment of complex fractures with damage by the severity of injury,6 the extent of blood loss,7 coagulopathy,8
control orthopedic surgery and limb salvage (which comprises acidosis,9 underlying physiology (including level of nutrition) and
aggressive debridement and excision of bone fragments in neuro- the molecular response to trauma,10 and hypothermia. Civil war adds
vascular intact limbs, shortening and angulation of the limb, external confounding determinants of clinical course, not least, the premorbid
fixation, and, finally, the application of an Ilizarov frame followed by physiology of patients under- or malnourished, the time taken to
gradual limb lengthening).4 Seven patients, including the children in initial treatment and stabilization, the quality of that treatment and, of
this series, underwent this program of limb salvage, all of whom have course, the delay in transfer for definitive care.
functionally viable limbs. Where amputation was necessary (in 4 Over the last 20 months Ziv Medical Center has received
patients), donors were located within Israel for prostheses that the civilians, women and children, people with chronic diseases, and
patients would be able to take back with them. even a handful of patients with referral letters from Syrian doctors,
but this series of the first 100 patients (all trauma) comprised
Critical Care predominantly young men (Figure 2). Of these, the patients who
Twenty-two patients were admitted to the ICU. Thirteen suffered complications or died had extensive injuries and presented
ventilated patients were extubated after an average of 9.5 days after a delay or after initial stabilization treatment was undertaken in
(range: 265 days; mode 10 days). Eight patients required inotrope Syria. It remains unclear how each patient came to be transferred to
support. Nine patients were admitted for postoperative monitoring Israel for care, but the injuries indicate that they were initially
and were not ventilated. Three patients were extubated within survivable, and, other than 1 case of exsanguination, sepsis (due
24 hours. to delayed definitive wound care) was the main determinant in
clinical course, evidenced by the instances of complicationsmost
Mechanisms of Injury as Related to Conflict of which were in patients with established severe sepsis or sepsis in
Standard precepts of blunt and penetrating trauma are not nonaccessible compartments. Patients transferred with wounds that
easily applied in war surgery. Military surgeons in the recent had been closed primarily before definitive care in our center all
Afghanistan and Iraq conflicts5 describe a significant number of underwent reopening of the wounds and debridement. A policy of
the injuries they encountered as multiple penetrating trauma, often administration of tetanus immunization (active and passive) was
the result of roadside improvised explosive devices. routinely practiced from the outset. No patients developed tetanus.
The mix of civilians and combatants in this series of patients Although only 76 patients presented with a delay of more than
from Syria who presented with diverse causes of injury, wounds 24 hours after injury, no correlation was found between time from
secondary to military ammunition and improvised weapons and injury to arrival in the trauma room and the incidence of septic
injuries related to the collapse of buildings and road traffic crashes, complications. Of the 24 patients who presented within 24 hours,
presents difficulties in injury classification. The combatants might be only 4 presented within 12 hours of injury.
better described as a militia rather than an organized military force In general, injury severity score (ISS) was low for isolated
equipped with standard issue body armor. Delays in transfer and limb injuries (ISS 8). As expected, patients with torso trauma had a

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Biswas et al Annals of Surgery  Volume 263, Number 1, January 2016

Impact on Hospital Services

Two departments were heavily impacted by the influx of
Syrian wounded. Almost two-thirds of the patients had orthopedic
injuries and the 8-bed ICU was at least half full of Syrian wounded at
any time between February and October 2013. Every year, approxi-
mately 8500 operations are performed at Ziv Medical Center (1000
of which are for trauma). Orthopedic surgery saw an increase from
22% to 26%. Spending in orthopedic surgery rose from NIS 3.6
million to NIS 5.5 million in a year. General surgery expenses rose
from NIS 17 million to NIS 22 million, including an increase in
vascular surgery expenses from NIS 300,000 to NIS 500,000.
Elective procedures are performed daily between 8 AM and 3
PM. The impact of emergency surgery required for the Syrian patients
was, therefore, mainly to out-of-hours operating (32% patients
admitted between 8 AM and 3 PM, 50% admitted between 3 PM and
midnight, and 18% admitted between midnight and 8 AM). Additional
operating theaters were opened in the afternoons, and day staff
covered the extra work with on-call staff. For the duration of care
of this cohort of 100 Syrian patients, all elective surgery cancelled on
FIGURE 2. A patient in the trauma room. This patient had the day was rescheduled the next morning. No major cases booked in
extensive facial burns, traumatic amputation of the right fore- advance were cancelled.
arm, pneumothorax, intestinal perforation, liver injury, and Although busier, the impact on nursing and medical staff of
multiple skin wounds resulting from blast injury. He had managing life-threatening trauma has increased interest and confi-
received initial treatment in Syria (including primary laparot- dence, especially as staffing issues have warranted nurses from other
omy and closure of traumatic wounds) before transfer for departments, such as the Intensive and Coronary Care Units, attending
further care in Israel. After intubation, chest drain insertion, to patients in the trauma room. They attend monthly practice sessions
and fluid resuscitation, he underwent full body CT and relook in the trauma room (which we record and feedback) to improve
laparotomy (with bowel resection, liver suture, and extensive trauma skills.
abdominal lavage). The orthopedic team reopened infected Special Considerations
wounds and performed debridement procedures. He under- Evidence is emerging that a number of patients from Syria
went 8 further surgical procedures in total before recovery and have resistant bacteria as a result of over the counter purchase of
discharge. antibiotics.13,14 Further research into the origins of this resistance and
serotyping of resistant bacteria is underway,15 but infection control
measures have necessitated routine microbiological swabs on admis-
sion, the use of the trauma room rather than the general emergency
mean ISS of 16 and those with combined limb and torso injuries had a department for immediate resuscitation (this is reflected in the data
mean ISS of 18. Damage control surgery, staged care with relook for length of stay for patients awaiting surgery in the trauma room, as
laparotomy and repeated debridement, and aggressive treatment of patients were not transferred to the main emergency department after
infection produced favorable outcomes in the majority of patients initial resuscitation), isolation bays on the wards (rather than separate
further evidence that this cohort of patients had survivable injuries wards), and protocols in the OR for the preparation and recovery of
and were able to tolerate a delay in treatment and the journey patients and cleaning of theaters. The hospital computer system has
to Israel. been updated so that bacterial resistance is flagged.
The policy of the trauma unit is to take venous blood gas Children who arrive alone or with a relative are kept together
samples and fibrinogen in every trauma patient, but in practice most and undergo medical procedures at the same time, as far as possible,
patients with isolated limb injuries did not have fibrinogen measured. to ensure that anxiety levels are low.
Fibrinogen levels were not used to guide fluid therapy and did not The Arabic-speaking social worker who worked part-time
correlate with ISS. Clinical and biochemical evidence indicates that now has a full-time post as his work in communicating with the
physiological status was a function of sepsis in addition to injury and patients and helping them become orientated and acclimatized to a
blood loss.11,12 foreign hospital environment is invaluable. He now has the assistance
Most patients with severe head or spinal injuries were triaged of Arabic-speaking social work students from the local college who
and transferred directly from the border to a level 1 trauma center work as volunteers in the hospital. There is just 1 Arabic-speaking
with a Neurosurgery Service in western Galilee, Nahariya. Patients medical clown. He spends as much time with the patients as possible,
with neurological injury managed in Ziv were assessed by the but anxiety levels among the patients remain high and addressing
hospital neurosurgeon and transferred to the neurosurgical unit in mental health needs is also a priority. It is now 4 years since the
Nahariya immediately after surgery for life-threatening hemorrhage children were last at school.
(5 patients within this cohort; Table 5). All discharge summaries are typed in English and anonymized
Anecdotal evidence indicated a level of undernutrition and as appropriate.
malnutrition, particularly among children, but within the first 100
patients formal assessments of nutrition were not documented. This SUMMARY
has been addressed directly for the patients since the collection of this Less than half an hours drive south from the Lebanon border,
initial data, and in one instance vitamin B replacement was crucial in Ziv Medical Center was a civilian-receiving hospital during the
the treatment of a child with severe chronic undernutrition presenting second Israel-Lebanon war in 2006.16 A number of articles report
with metabolic encephalopathy. the experiences of civilian hospitals in the treatment of war

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Annals of Surgery  Volume 263, Number 1, January 2016 Injuries and Treatment of Patients From the Syrian Civil War

casualties,17,18 but at the time of the Arab Spring, few could have 4. Lerner A, Soudr M. Armed Conflict Injuries to the Extremities: A Treatment
Manual. Springer 2011. Available at:
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wounded. This experience, across a hostile border, has been unpre- 5. Nessen SC, Lounsbury DE, Hetz SP. War Surgery in Afghanistan and Iraq: A
cedented. It has inspired the notion that necessity of medical Series of Cases, 2003-2007 (Textbooks of Military Medicine). Borden Insti-
intervention and the humanitarian imperative transcend regional tute/ US Army office of Surgeon General. Available at: http://www.abebooks.-
and cultural differences. Published 2008.
Accessed March 31, 2015.
CONCLUSIONS 6. Champion HR, Sacco WJ, Hunt TK. Trauma severity score to predict
mortality. World J Surg. 1983;7:411.
Surgical and nonsurgical staff have benefitted from the learn- 7. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome:
ing opportunities in managing patients with complex injuries and an overview of epidemiology, clinical presentations, and therapeutic consider-
challenging physiology. The incidence of complications within this ations. J Trauma. 2006;60:S3S11.
cohort of patients has been surprisingly low, considering the delay to 8. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma.
definite treatment and level of nutrition. As a result of the study of 2003;54:11271130.
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trauma patients: the rationale for damage control surgery. Acta Chir Belg.
massive transfusion, infection control, and nutrition assessment, and 2002;102:313316.
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11. Hagemo JS, Stanworth S, Juffermans NP, et al. Prevalence, predictors and
ACKNOWLEDGMENTS outcome of hypofibrinogenaemia in trauma: a multicentre observational study.
The authors thank Shlomit Dahan and her team in the hospital Crit Care. 2014;18:R52.
Trauma Registry for their invaluable help in retrieving trauma data 12. Inaba K, Karamanos E, Lustenberger T, et al. Impact of fibrinogen levels on
and Mira Zelig for her unfailing efficiency in obtaining patient outcomes after acute injury in patients requiring a massive transfusion. J Am
Coll Surg. 2013;216:290297.
records. This article reports the work of clinical and hospital staff
13. Otoom SA, Sequiera RP. Health care providers perceptions of the problems
across a number of disciplines; the authors acknowledge their and causes of irrational use of drugs in two Middle East countries. Int J Clin
dedication to the care of the Syrian, indeed, all trauma, patients. Prac. 2006;60:565570.
14. Al Assil B. Resistance trends and risk factors of extended spectrum-lactamases
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Randomized Multicenter Trial Comparing Glue Fixation,

Self-gripping Mesh, and Suture Fixation of Mesh in
Lichtenstein Hernia Repair (FinnMesh Study): Erratum

In the November 2015 issue of Annals of Surgery in the article by Ronka et al, Randomized Multicenter Trial
Comparing Glue Fixation, Self-gripping Mesh, and Suture Fixation of Mesh in Lichtenstein Hernia Repair
(FinnMesh Study), the following sentence was printed incorrectly: Recurrence of hernia was confirmed by a
clinical or ultrasound examination and ensures or at re-operation. The sentence should read: Recurrence of
hernia was confirmed by a clinical or ultrasound examination or ensured at re-operation.

Ronka K, Vironen J, Kossi J, et al. Randomized multicenter trial comparing glue fixation, self-gripping mesh,
and suture fixation of mesh in Lichtenstein hernia repair (FinnMesh Study). Ann Surg. 2015;262:714720.

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