Letter to the Editor
Coordination of emergency medical teams in a conflict zone
La coordinación de los equipos médicos en una zona en conflicto
Alberto Hernández-Tejedor
, Víctor Sainz Ruiz de León
Corresponding author
SAMUR-Protección Civil, Madrid, Spain
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class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Víctor" "apellidos" => "Sainz Ruiz de León" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "SAMUR-Protección Civil, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La coordinación de los equipos médicos en una zona en conflicto" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">On 7 October 2023, Israel suffered a massive terrorist assault launched from Gaza. Its medical teams came under attack and, once security had been guaranteed, a medical care response was launched that also included psychological care.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The terrorist attack was followed by an Israeli military response that is affecting the population of Gaza and the aid response of the international teams.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the face of a humanitarian catastrophe, the response needs to be adequately coordinated for it to be efficient, without posing a burden for the affected country, and adjusted to the real needs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The World Health Organization (WHO) has established an Emergency Medical Team Coordination Cell (EMTCC) for the organization of medical care in a catastrophe or conflict zone. For the first time, in order to coordinate the response in Gaza, the WHO has requested the support of experts from the European Civil Protection Mechanism (UCPM). To date, seven experts (including two Spanish experts) have been deployed in different rotations to integrate the EMTCC.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The work of an EMTCC is always complex, though in a conflict zone, it proves especially difficult due to the inherent risks and limitations imposed by the intervening parties. An example is the severe restriction placed upon elements that are essential for an adequate humanitarian response in general and a medical care response in particular. Field hospital structures, power generators, communication or localization systems, chemical products, etc., are elements that cannot be introduced into the zone due to the dual uses that could be made of them.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The coordination of the emergency medical teams (EMTs) in a conflict zone is crucial. The security of the installations housing the equipment must be guaranteed; casualty evacuation (including critical cases) to centers where they can be taken care of must be facilitated, even outside the zone if necessary (CASEVAC); medical evacuation means (MEDEVAC) must be made available; a supply system must be established, etc.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The WHO has established three types of medical teams according to their characteristics.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Types 2 and 3 have admission, surgical, intensive care, blood transfusion, radiology and laboratory test capabilities, among others. The role of the emergency care physicians and intensivists in these teams is fundamental for guaranteeing quality treatment under difficult conditions.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Thirteen EMTs with different capabilities are deployed at different points in the south of the Gaza Strip: surgical teams supporting hospitals, teams able to conduct admission, surgery and intensive care, first care teams, etc. Over 2000 patients are attended daily. Trauma conditions predominated at first, though with the passing weeks chronic disorders that become destabilized were increasingly seen, along with infectious-contagious diseases such as hepatitis A, diarrhea syndromes and respiratory infections, since the zone lacks sanitation infrastructures and adequate waste management resources for such an extremely high population density.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The medical teams contact the EMTCC to manage the rotations of their personnel, which must be authorized by the parties involved in the conflict and the country of entry; difficulties with the supply lines; medical evacuations; serious incidents requiring an immediate response, etc. Likewise, many teams interested in being deployed contact the EMTCC and need to receive detailed information, given the special characteristics of this emergency.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We collect daily information on the characteristics of the patients that are attended, the disease conditions, procedures, referrals and deaths, so that the resources can be coordinated and risks and changes in the care needs of the population can be identified. Such adequate management of the information in the field has very positive consequences for the affected population, since it allows adjustment of the responses to their needs.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We have developed contingency plans for different scenarios that might occur during the conflict, such as the need to evacuate certain medical care points; the creation of additional care zones in the event of massive population displacements; or the securing of evacuation routes with the best means available.</p><p id="par0055" class="elsevierStylePara elsevierViewall">On a daily basis, we have first-hand experience with especially complex cases of patients that cannot be treated, cuts in supplies that especially affect the intensive care units and operating theatres, operations performed in corridors, as well as malnutrition or a lack of basic products for the population, including the families of the local medical care workers. In many cases, all aspects of life take place in the hospital: work, hygiene, food, nighttime rest, and seeing the sun rise again the next morning. No words can adequately describe the commitment of these intervening persons.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In this context, it is essential to know the ethical implications of working temporarily in a country with a different culture, other capacities and a different legislation. The team members must adapt to the local uses and customs referred to both social aspects and medical care. Procedures must be followed to legalize births and certify deaths; establish a protocol for sexual violence or violence against children; manage requests for information from relatives in accordance with their culture; to know their way of dealing with mourning, etc.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We are healthcare professionals, workers in logistics or managers that take no party in the conflict but who nevertheless live it from within. We express our appreciation for all those people who selflessly commit themselves to help improve the miserable living conditions of a population in a conflict zone, and we pray for the end of the hostilities and the facilitation of entry for medical teams.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The ultimate aim of the efforts of so many professionals is none other than to provide relief from the suffering of those people who are in a situation of maximum vulnerability, and where all the basic human references (water, food, housing, medical care, hygiene, safety, etc.) have been taken away from them.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">The present study has received no financial support.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p><p id="par0085" class="elsevierStylePara elsevierViewall">No use has been made of AI in preparing the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mental health volunteers after the Oct 7 Gaza border crisis in Israel: silent warriors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Z. Elyoseph" 1 => "D. Hadar-Shoval" 2 => "T. Angert" 3 => "N. Yitshaki" 4 => "E. Hol" 5 => "O. Asman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S2215-0366(23)00369-3" "Revista" => array:6 [ "tituloSerie" => "Lancet Psychiatry." "fecha" => "2024" "volumen" => "11" "paginaInicial" => "10" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/38101869" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "World Health Organization. Classification and minimum standards for emergency medical teams. [Accessed 7 Mar 2024]. Available from: <a target="_blank" href="https://www.who.int/publications/i/item/9789240029330">https://www.who.int/publications/i/item/9789240029330</a>." ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conflicts in Gaza and around the world create a perfect storm for infectious disease outbreaks" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.E. Kearney" 1 => "N. Thiel" 2 => "A. El-Taher" 3 => "S. Akhter" 4 => "D.A. Townes" 5 => "I. Trehan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pgph.0002927" "Revista" => array:3 [ "tituloSerie" => "PLOS Glob Public Health." 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