Mine Injury Casualties Report from the Iraq-Kuwait DMZ
by Dr. B.M. Schneider, V. Ehmann, M. Gebler, M. Pohlers, J. Bronnert, M. Schneider, V. Bartke, H. Woltering and B. Domres, WADEM Landmine Task Force
This article is dedicated to the victims we were unable to help in spite of all our efforts.
After the implementation of the UN Iraq-Kuwait Observation Mission (UNIKOM) at the end of the first Gulf War in 1990, a medical team was set up in 1991 to support the UN troops in their difficult tasks in the demilitarised zone (DMZ), a remote desert area between Kuwait and Iraq.1 The medical team was designed to take care of the medical treatment for the UNIKOM members and the nomadic people living in the DMZ as pointed out in UN Secretary-General reports S/2001/287 and S/2001/913 on the official UN website.2
Despite the continuing mine clearance and the UN Mine Awareness Program on both sides of the DMZ, the management of mine injuries remained a challenging task for our medical teams.3 In addition to these major problems, the usual day-to-day outpatient department (OPD) visits for the military and local staff personnel, dehydrations, scorpion bites, infectious diseases and road traffic accidents also had to be managed.4 During the first few years, the medical duties and responsibilites for the troops from 33 nations were carried out by an Austrian and later a Norwegian Medical Team (NORMED). In October 1995, this role was given to Germany, and since then, 15 voluntary German Medical Teams (GERMED 1 to 15), equipped and managed by the Foreign Service of the Knights of Malta from Cologne, were responsible for providing the emergency medical service (EMS) in the desert of the DMZ between Kuwait and Iraq until the second Gulf War began in March 2003.5
Mine Injury-Related Experiences During the Missions From 1996 to 2002
The rescue area included 3,800 sq km of the DMZ and the remote desert surroundings. Five ambulances from three rescue stations with seven paramedics equipped with necessary supplies provided 24-hour service for the 1,200 UN personnel and the nearby nomadic population. During 2001, there were about 4,000 regular OPD visits and about 50 calls for casualty evacuations (CASEVACS). Forty percent of the CASEVACs were mine-related and most of these injuries happened on the Iraqi side of the DMZ.
Therefore, this problem was greater than the road accident problem and had a political component as well because the injuries happened in the Iraqi territories to the south of the DMZ where no domestic help was available for the victims. In many cases, the victims had to be transported to the southern paramedics rescue station to get access to the medical service carried out from the United Nations within this area.
The mine clearing was always carried out by the Argentenian Engineering (ARGENG) demining specialists. During each of the 75 mine blasting days, ARGENG had to be accompanied by our paramedics.
To prepare the medical teams for their new tasks, mine injury treatment guidelines and the International Committee of the Red Cross (ICRC) classification of the mine-injured patients were discussed and compared with the regional mine injury epidemiology of previous missions. These basic preparations for the medical teams were usually accompanied by weekly concurrent medical education based on the advice of R. Coupland from ICRC as well as M. King and P. Bewes in their handbook Primary Surgery (on the web at www.meb.uni-bonn.de/dtc/primsurg).6 The basic preparations also included training for special situations as well as some research about possible telemedicine support for medical treatment in these remote areas.7 The medical challenges in this remote area required the strict cooperation of the medical team members with representatives of different disciplines within the multinational UN-peacekeeping military environment.
The chain of rescue from the two forward medical posts out in the desert to the UN level one hospital was equipped with rescue equipment nearly approaching the European Standard (EN), and the equipment had to be maintained within the extreme climatic circumstances, which included dust and temperatures up to 50 degrees Celsius. Long rescue times had to be managed in certain instances in the difficult environment of the desert. To achieve the minimal rescue times, two helicopters from Banair, a company that specializes in testing equipment, or one of the three available ambulances had to be coordinated in the most efficient manner. Unfortunately, sometimes the road conditions of the DMZ were not easily manageable.
The UN level one hospital was located in the UNIKOM headquarters. Therein basic life support could be provided and emergency operations could be done under emergency anesthesia—both with limited resources. No X-ray, computerized tomography (CT) or intensive care units (ICUs) from known EN were available. Due to political reasons, the well-equipped Kuwaiti Health System was not available for the Iraqi patients. After the emergency treatment by the United Nations, those patients had to be referred to their country. Based on the reports of the former medical teams, the figures of the missions were as shown in Table 2.
It is interesting to note that the number of mine incidents increased within the years of interest in spite of the improving mine clearance conducted by the ARGENG demining teams.
Rescue Times During GERMED 12
According to M. Helm, the chance of survival in these severe injuries lowers by one percent for every three minutes of rescue time. The Injury Severity Score (ISS) for the mine- injured patients from GERMED 12 varied from 50 to 2. According to the Trauma Injury Severity Score (TRISS), the survival probabilities resulting from these and other necessary parameters had to be calculated between 9.5 percent and 96.8 percent mostly depending on the complexity of the injuries described in Table 4.
In spite of the large number of injuries in the lower extremities, some individual patients' injury patterns with injuries only in the upper part of the body gave evidence that some of the patients had been handling UXO or mines before the explosions of Hazards No. III.220.127.116.11
These figures extracted from the official UN documents are to be seen as minimal figures. Some dead-on-the-scene patients from accidents from outside the DMZ didn't get access to the help from the UN medical teams in time. The follow-up for patients mostly referred to care from the Basra hospitals with limited resources, which at that time were not accessible to UNIKOM authorities.
From the end of the first Gulf War (1991) until the beginning of the second Gulf War in March 2003, UNIKOM attempted to guarantee the stability of this post-conflict area between Kuwait and Iraq. Mine-related injuries remained the major problem for the EMS services. Most victims were young Iraqi civilians who had been entering through the southern part of the former DMZ to get basic medical support from the different UN medical teams provided in the UN level one hospital in the former UNIKOM headquarters near Umm Qasr.
The lessons learned have been used to establish the World Association for Disaster and Emergency Medicine (WADEM) Landmine Task Force to formulate an update of WADEM's 1997 declaration on the mine hazard situation of the world at the beginning of the new millennium (preliminary URL: www.dismedmaster.de. Further work has to be done to learn more about the outcome and the rehabilitation of the surviving victims. For this purpose, contacts have been established to the teaching ICRC's Superfluous Injury or Unnecessary Suffering (SIrUS) Project Team from Geneva, the UN Portfolio of Mine Action Projects Team in New York11 as well as the Journal of Mine Action and surrounding institutions. We are hoping that these contacts will help to improve the living conditions of the survivors of landmines.
WADEM Landmine Task Force