A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare

Sherry M. Wren*, Hannah B. Wild, Jennifer Gurney, Mohana Amirtharajah, Zachary W. Brown, Eileen M. Bulger, Frederick M. Burkle, Eric A. Elster, Joseph D. Forrester, Kent Garber, Richard A. Gosselin, Reinou S. Groen, Gary Hsin, Manjul Joshipura, Adam L. Kushner, Ian Norton, Inga Osmers, Heather Pagano, Tarek Razek, Jesús Manuel Saénz-TerrazasLilli Schussler, Barclay T. Stewart, Abd Al Rahman Traboulsi, Miguel Trelles, John Troke, Christopher A. Vanfosson, Paul H. Wise

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


Importance: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective: To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants: An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures: The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results: Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance: Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

Original languageEnglish
Pages (from-to)114-121
Number of pages8
JournalJAMA Surgery
Issue number2
StatePublished - Feb 2020
Externally publishedYes


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