Organization of evacuation of the wounded in wartime: the impact of patient routing on treatment outcomes and infection risks

Abstract

Combat-related limb injuries in modern warfare are characterised by high-energy tissue destruction, extensive soft-tissue defects, and a high risk of infectious complications. Evidence from previous military conflicts in Iraq and Afghanistan, as well as civilian trauma centres, indicates that optimal management of such patients requires not only appropriate surgical tactics but also timely routing to specialised orthoplastic centres. Early radical debridement and definitive wound coverage within the orthoplastic «fix and flap» concept and BOAST standards are associated with reduced infection rates, fewer reoperations, and avoidance of delayed amputations. Despite the central role of evacuation pathways, quantitative data on how different evacuation models influence clinical outcomes in contemporary war conditions remain limited.

Objective – to assess the effectiveness of two medical evacuation models – mass (stepwise) and targeted (selective) – in patients with combat-related injuries based on the length of hospital stay and surgical burden.

Materials and methods. A retrospective cohort study was conducted among patients admitted to a specialised orthoplastic centre. Patients were stratified into two groups: targeted evacuation (direct transport to the reconstructive centre ≤ 72 hours post-injury) and mass evacuation (stepwise transfer through ≥ 2 intermediate hospitals). The primary endpoints included the length of hospital stay and the number of surgical procedures per patient. Time from injury to admission was analysed as a key factor. Statistical methods included descriptive analysis and intergroup comparison using the t-test/Mann-Whitney U test (p < 0.05).

Results. The mean time from injury to hospital admission in the targeted evacuation group was 1.77±0.32 days (range: 0 – 6), compared with 11.84±1.45 days (range: 3 – 53) in the mass evacuation group – a sevenfold increase. Mean length of hospital stay was significantly longer in the mass group: 37.03±3.68 vs. 27.27±2.47 days in the targeted group (p=0.03). The average number of surgical procedures per patient was 2.78±0.33 vs. 2.36±0.38, respectively (p=0.41), excluding prior operations performed before referral. No delayed amputations related to infectious complications or reconstruction failure were observed in either group.

Conclusions. Targeted evacuation enables a significantly shorter time to specialised surgical care, leading to reduced hospital stay and a more predictable clinical course. Although differences in surgical burden were not statistically significant, a consistent trend toward fewer interventions was observed with targeted routing. Optimising medical evacuation systems is a critical determinant in the management of limb combat injuries and may be scaled to healthcare systems operating in wartime or resource-limited environments.