Wartime urologic injuries require different mindset

Injuries to the bladder, ureters, kidneys and external genitalia often require complex surgical treatment, said Dr. Arthur Smith, an MCG urologist. But during wartime, when those wounds are often combined with other life-threatening injuries, their treatment becomes secondary to lifesaving tactics.

Smith made his comments at a lecture, Revised Management Strategies for Urologic Injuries During Wartime, at the Warrior Health Symposium in Canberra, Australia Oct. 30. The symposium is co-sponsored by the Australian Military Medical Association and the Australian Defense Force Joint Health Command.

"Most urological injuries occurring in the civilian setting result from blunt trauma, but they are far fewer in occurrence and their treatment is generally implemented in a straightforward way with an organized and well-supported health care system," he said. "During wartime, though, penetrating injuries are more common and rarely occur in isolation, because victims often receive multiple injuries concurrently. Treatment options must change and be prioritized."

Treating multiple injuries is only part of the problem.

"Other variables," Smith said, "commonly affect surgical intervention: the status of resources, the number of other casualties and, of course, the overall tactical situation."

Advanced weapons such as improvised explosive devices and multiple fragmentation munitions that cause a wide spectrum of injuries also complicate matters, he added. Because treating urologic injuries is a lower priority, complications often arise. In some cases, injuries are discovered later or missed altogether.

"During wartime, casualties are all managed through echelons of care," Smith said. "When someone is injured, he may be treated on the battlefield, at a field hospital, at an evacuation hospital and then transferred to a more permanent location."

All of those echelons require different treatment strategies, he explained. On the battlefield, treatment is most likely focused on stopping the bleeding; field hospital treatment may include early life-saving amputations; at an evacuation hospital, there may be surgery to repair wounds -- and urologic injuries, especially those to the kidneys and internal organs -- may not be discovered until then.

"What we have to realize is that it's a very fluid situation often comprised of variable facilities, austere conditions and limited logistics support and evacuation staff. We often have to treat with a damage-control mentality."