ORIGINAL ARTICLE
Analysis of the First 100 Patients From the Syrian Civil War Treated
in an Israeli District Hospital
Seema Biswas, FRCS,  Igor Waksman, MD,y Shay Baron, BSc,z David Fuchs, BA, RN,
Hagai Rechnitzer, PhD, Najib Dally, MD,jj Shokrey Kassis, MD,  and Amram Hadary, MD 
Objective: An analysis of the injuries and treatment of the first 100 patients
from the Syrian civil war was conducted to monitor quality of care and
outcome.
Summary Background Data: As reports of the collapse of health care
systems in regions within Syria reach the media, patients find themselves
crossing the border into Israel for the treatment of war injuries. Among these
patients are combatants, noncombatants, women, and children. Treatment,
that is free at the point of care, is a humanitarian imperative for war wounded,
and this paper reports the care in an Israeli district hospital of the first
100 patients received.
Methods: With ethics committee approval, data from the Trauma Registry
and electronic patient records were collected and analyzed. No identifying
data are presented.
Results: Most patients (94) were male. Seventeen patients were younger than
the age of 18 years; 52 patients were in their twenties. Most injuries were the
results of gunshot or blast injury (50 and 29 patients, respectively).
Two multiple-trauma patients died, 8 were transferred for specialist care,
and 90 patients returned from Ziv Hospital to Syria after discharge.
Conclusions: The experience of the care of patients across a hostile border
has been unprecedented. Hospital protocols required adjustment to deliver
quality clinical and social care to patients suffering from both the acute and
chronic effects of civil war.
Keywords: blast injury, civil war, gun shot wound, humanitarian, surgery,
war wounded
(Ann Surg 2016;263:205209)
A s the Syrian civil war continues for a fourth year, more than
190,000 people have been killed,1 more than 500,000 have been
wounded,2 and at least 9 million people have fled their homes.3
Although most have fled to neighboring Arab countries, Israels
border remains closed, and there are no refugees in Israel. A state of
war still exists between the 2 countries with intermittent hostile
activities from time to time despite disengagement in 1967. Since
February 2013, more than 1300 people have, however, made their
way to the border fence, where they are retrieved by paramedics of
From the Department of Surgery, Ziv Medical Center, Safed, Galilee, Israel;
yDepartment of Surgery, Western Galilee Hospital, Nahariya, Isreal; zBar Ilan
University Medical School, Safed, Galilee, Israel; Emergency Department,
Ziv Medical Center, Safed, Galilee, Israel; Department of Microbiology, Ziv
Medical Center, Safed, Galilee, Israel; jjDepartment of Haematology, Ziv
Medical Center, Safed, Galilee, Israel; and Department of Plastic Surgery,
Ziv Medical Center, Safed, Galilee, Israel.
Disclosure: All authors confirm that no support, financial or otherwise, was
received in the preparation of the manuscript or the work described. All
authors confirm that there is no conflict of interest. This manuscript is original,
and although this work has been presented in part at a number of scientific
conferences, this manuscript has not been submitted or published elsewhere.
Reprints: Seema Biswas, FRCS, Department of Surgery, Ziv Medical Center,
Safed, Galilee, 13100, Israel. E-mail: seemabiswas@msn.com.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/14/26105-0821
DOI: 10.1097/SLA.0000000000001230
Annals of Surgery  Volume 263, Number 1, January 2016
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
the Israeli Defence Force (IDF) and receive medical treatment in
hospitals in the north of Israel.
Ziv Medical Center, a 320-bed district hospital that serves as a
regional level 2 trauma center in Safed, Upper Galilee, is less than 20
miles by road from the Israel-Syria border (the closest hospital to the
border) and has treated more than 440 Syrian patients over the last 20
months. The outcome data of the first 100 patients are presented here.
Although anecdotal reports indicate that the cooperation in health
care between Israel and Syria might be improving, patients who seek
treatment in Israel have crossed a closed border and are treated in a
nation considered an enemy of Syria. Written referrals from health
professionals in Syria to colleagues in Israel remain rare. Every care
is taken, therefore, to protect the identities of patients and not enquire
beyond their immediate medical history.
METHODS
Data were obtained from the hospital trauma registry and
electronic patient files for the first 100 patients admitted to the Ziv
Medical Center between February and October 2013. Institutional
ethics committee approval was granted for data collection and
analysis. No patients were asked to provide personal information
as their security is a priority. No identifiable data were collected.
Patients not admitted to hospital, or with nontrauma diagnoses, are
not included in the trauma registry. Data for all patients were
collected from electronic patient files. The hospital trauma coordi-
nator maintained a record of every Syrian patient assessed and treated
in Ziv Medical Center.
Patients receiving initial emergency care at the Syrian-Israeli
border fence were brought by IDF ambulances to the trauma room in
the emergency department. In hospital, they were treated in the
critical care units (adult and pediatric), general surgery, vascular,
orthopedic, plastic surgery, pediatric, and ophthalmology depart-
ments. Length of stay in hospital was from 1 to 78 days (average
length of stay was 14 days compared with the 4-day length of stay for
the average Israeli inpatient).
RESULTS
Of the 100 patients, 94 were male and 6 were female. The age
range was from 2 to 51 years, and the average age was 23 years (17
patients were younger than the age of 18 years; 52 patients were in
their twenties). The time from injury to arrival in the trauma room at
Ziv Medical Center was estimated for all patients from what the
patients, their companions, and ambulance crew described. Accord-
ing to their description, only 24 patients arrived within 24 hours of
their injury.
Table 1 shows the nature and causes of injury (100 patients),
and Figure 1 shows the sites of injury (100 patients).
Trauma Room
All patients were assessed in accordance with Advanced
Trauma Life Support guidelines in the trauma room (a separate area
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Biswas et al Annals of Surgery  Volume 263, Number 1, January 2016

TABLE 1. Nature and Causes of Injury (100 Patients) TABLE 2. Operative Procedures According to Surgical Spe-
Percentage of Patients
cialty (100 Patients)
Injury Causes (n 100) Surgical Specialty No. Procedures
Gunshot 42% Orthopedic 89
Blast 24% General surgery 78
Gunshot and blast 8% Plastic 19
Flying missiles 9% Vascular 8
Burn 2% Ophthalmology 5
Road traffic crash in conflict 7% Head and neck 3
Other 8% Oral Maxillo-Facial 1

Includes other combinations of injuries (8%).
Urology 1
Cardiothoracic 1

TABLE 3. Outcome DataAll Patients

spine Percentage of patients

head and neck

Discharged 91%
Transferred 8%
eyes Deaths 2%
Injury sites


lower limb One patient was transferred back to Ziv Medical Center after drainage of lung
abscess in Rambam Hospital (level 1 regional trauma center).
upper limb

pelvis

chest
TABLE 4. Outcome DataComplications (n 24)
abdomen
Percentage Mean Length Mean Length
0 5 10 15 20 25 30 35 40 of Patients of Stay in of Stay in
Number of patients ICU (Days) Hospital
Surgical site infection 12 10 32
FIGURE 1. Sites of injury (100 patientsmost patients had Pulmonary 10 10 26
multiple injuries). Venous thromboembolism 1 3 7
Skin graft necrosis 1 5 17

Pulmonary embolism and deep vein thrombosis confirmed at duplex and CT
pulmonary angiogram at day 1 and day 2, respectively, after nailing of femoral fracture.

from the rest of the Emergency Department and resuscitation area) to

facilitate rapid transfer from IDF paramedic teams and rapid assess-
ment, and as a routine infection control measure for patients trans-
ferred from other health facilities.
All but 2 patients (who were transferred immediately to the
operating room (OR) for laparotomy for intra-abdominal hemor-
rhage) underwent radiological assessment in the trauma room. This
included chest x-ray and focused abdominal sonography for trauma
(FAST) scan performed by a radiologist, as per the hospital trauma
resuscitation protocol. Conscious patients with isolated limb inju-
ries then underwent x-ray in the radiography emergency depart-
ment. Computed tomographic (CT) scan was performed in all
hemodynamically stable patients with head and torso injuries
(78%). Of the patients who underwent CT scan, 61 had associated
limb injuries.
Ninety-nine percent of patients underwent surgery on the day
of admission. Sixty-five patients were transferred from the trauma
room directly to the OR or underwent CT scan en route to the OR.
Thirty-three patients went to the surgical ward and then to the OR.
One patient went directly to the intensive care unit (ICU) and then to
the OR. Table 2 lists operative procedures in all 100 patients by
surgical specialty.
Complications
Tables 36 list outcomes including complications, transfers,
and deaths in the 100 patients.
DISCUSSION
Surgery
Thirteen patients underwent primary damage control laparot-
omy. Relook laparotomy was performed after 24 or 48 hours (3
patients underwent relook laparotomy 3 times, 2 patients twice). Six
patients required colectomy, 5 patients small bowel resection, and
splenectomy was performed in 2 patients, distal pancreatectomy in 1
patient, and liver laceration sutured in 1 patient. Two patients were
left with ventral hernias after initial surgery and laparostomy. Mesh
hernia repairs were performed after the resolution of sepsis approxi-
mately 2 weeks after primary laparotomy in both cases.
Orthopedic patients returned to the OR for multiple debride-
ments (up to 7 times) as the majority of wounds were heavily
contaminated, patients arrived wrapped in soiled blankets, or, before
transfer, traumatic wounds had been primarily closed in the field (in
Syria possibly) to control hemorrhage. These wounds were all
reopened, cleaned, and managed with negative pressure wound
therapy for, on ave, 10 days; indeed, the hospital purchased 6
additional vacuum-assisted closure systems (a 300% increase). Daily
dressings employing Milton solution (an aqueous solution of sodium
hypochlorite and sodium chloride) were incorporated into standard
wound care. Patients were only discharged after wounds had healed
or had been successfully grafted.

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Annals of Surgery  Volume 263, Number 1, January 2016
TABLE 5. Outcome DataTransfers (n 8)
Percentage Mean
Destination of Patients ISS
Neurosurgery (Western Galilee Hospital, 5 20
Nahariya)
Cardiothoracic Unit (Rambam Hospital) 2 26
26
Vascular Unit (Rambam Hospital) 1 13
TABLE 6. Outcome DataDeaths (n 2)
Mean Length
Percentage Age of Stay in
of Patients (yr) Diagnosis ISS ICU (Days)
1 25 Multiple-trauma, 34 2 Two patients (mother and daughter) reported the collapse of their
hemorrhage,
organ failure
1 27 Multiple-trauma, 50 27
bile leak,
pneumonia
A special effort was made to preserve limbs as it was
considered crucial to the long-term survival of patients returning
to the personal and familial devastation and limited resources of
Syria as civil war continues. A specialist orthopedic surgeon at the
hospital has led the treatment of complex fractures with damage
control orthopedic surgery and limb salvage (which comprises
aggressive debridement and excision of bone fragments in neuro-
vascular intact limbs, shortening and angulation of the limb, external
fixation, and, finally, the application of an Ilizarov frame followed by
gradual limb lengthening).4 Seven patients, including the children in
this series, underwent this program of limb salvage, all of whom have
functionally viable limbs. Where amputation was necessary (in 4
patients), donors were located within Israel for prostheses that the
patients would be able to take back with them.
Critical Care
Twenty-two patients were admitted to the ICU. Thirteen
ventilated patients were extubated after an average of 9.5 days
(range: 265 days; mode 10 days). Eight patients required inotrope
support. Nine patients were admitted for postoperative monitoring
and were not ventilated. Three patients were extubated within
24 hours.
Mechanisms of Injury as Related to Conflict
Standard precepts of blunt and penetrating trauma are not
easily applied in war surgery. Military surgeons in the recent
Afghanistan and Iraq conflicts5 describe a significant number of
the injuries they encountered as multiple penetrating trauma, often
the result of roadside improvised explosive devices.
The mix of civilians and combatants in this series of patients
from Syria who presented with diverse causes of injury, wounds
secondary to military ammunition and improvised weapons and
injuries related to the collapse of buildings and road traffic crashes,
presents difficulties in injury classification. The combatants might be
better described as a militia rather than an organized military force
equipped with standard issue body armor. Delays in transfer and
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Injuries and Treatment of Patients From the Syrian Civil War
Mean Time to
Transfer From
Reason for Transfer Ziv (Days)
Neurosurgical management after general surgical Same day
and orthopedic surgery (all patients)
Lung abscess 38
Hemodynamically stable but mediastinal and Same day
cardiac fragments from blast
No vascular cover in hospital. Transferred after Same day
pelvic and bilateral lower limb fixation
infection compounded injuries, and, in many cases, determining
whether civilians had been injured in blasts (through primary,
secondary, or even tertiary blast injury resulting from hand grenades,
shells, mortars, mines, or aerial bombardment) or by flying missiles,
debris, and the collapse of their homes, were difficult to understand.
shelter after an explosion. Both had complex leg injuriesfractures,
extensive soft tissue loss, and multiple wounds from flying missiles.
Even after repeated enquiry, it was never clear what the exact
mechanism of injury had been.
Similarly, of the 11 patients who had road traffic crashes, only
4 patients reported the vehicular crash as a result of coming under fire
or a blast. The remaining 7 patients had a combination of injuries
ranging from blunt trauma expected after a motor vehicle crash to
injuries resulting from being dragged behind their car.
Determinants of Clinical Course
The clinical course in multiple-trauma is determined usually
by the severity of injury,6 the extent of blood loss,7 coagulopathy,8
acidosis,9 underlying physiology (including level of nutrition) and
the molecular response to trauma,10 and hypothermia. Civil war adds
confounding determinants of clinical course, not least, the premorbid
physiology of patients under- or malnourished, the time taken to
initial treatment and stabilization, the quality of that treatment and, of
course, the delay in transfer for definitive care.
Over the last 20 months Ziv Medical Center has received
civilians, women and children, people with chronic diseases, and
even a handful of patients with referral letters from Syrian doctors,
but this series of the first 100 patients (all trauma) comprised
predominantly young men (Figure 2). Of these, the patients who
suffered complications or died had extensive injuries and presented
after a delay or after initial stabilization treatment was undertaken in
Syria. It remains unclear how each patient came to be transferred to
Israel for care, but the injuries indicate that they were initially
survivable, and, other than 1 case of exsanguination, sepsis (due
to delayed definitive wound care) was the main determinant in
clinical course, evidenced by the instances of complicationsmost
of which were in patients with established severe sepsis or sepsis in
nonaccessible compartments. Patients transferred with wounds that
had been closed primarily before definitive care in our center all
underwent reopening of the wounds and debridement. A policy of
administration of tetanus immunization (active and passive) was
routinely practiced from the outset. No patients developed tetanus.
Although only 76 patients presented with a delay of more than
24 hours after injury, no correlation was found between time from
injury to arrival in the trauma room and the incidence of septic
complications. Of the 24 patients who presented within 24 hours,
only 4 presented within 12 hours of injury.
In general, injury severity score (ISS) was low for isolated
limb injuries (ISS 8). As expected, patients with torso trauma had a
www.annalsofsurgery.com | 207
Biswas et al
FIGURE 2. A patient in the trauma room. This patient had
extensive facial burns, traumatic amputation of the right fore-
arm, pneumothorax, intestinal perforation, liver injury, and
multiple skin wounds resulting from blast injury. He had
received initial treatment in Syria (including primary laparot-
omy and closure of traumatic wounds) before transfer for
further care in Israel. After intubation, chest drain insertion,
and fluid resuscitation, he underwent full body CT and relook
laparotomy (with bowel resection, liver suture, and extensive
abdominal lavage). The orthopedic team reopened infected
wounds and performed debridement procedures. He under-
went 8 further surgical procedures in total before recovery and
discharge.
mean ISS of 16 and those with combined limb and torso injuries had a
mean ISS of 18. Damage control surgery, staged care with relook
laparotomy and repeated debridement, and aggressive treatment of
infection produced favorable outcomes in the majority of patients
further evidence that this cohort of patients had survivable injuries
and were able to tolerate a delay in treatment and the journey
to Israel.
The policy of the trauma unit is to take venous blood gas
samples and fibrinogen in every trauma patient, but in practice most
patients with isolated limb injuries did not have fibrinogen measured.
Fibrinogen levels were not used to guide fluid therapy and did not
correlate with ISS. Clinical and biochemical evidence indicates that
physiological status was a function of sepsis in addition to injury and
blood loss.11,12
Most patients with severe head or spinal injuries were triaged
and transferred directly from the border to a level 1 trauma center
with a Neurosurgery Service in western Galilee, Nahariya. Patients
with neurological injury managed in Ziv were assessed by the
hospital neurosurgeon and transferred to the neurosurgical unit in
Nahariya immediately after surgery for life-threatening hemorrhage
(5 patients within this cohort; Table 5).
Anecdotal evidence indicated a level of undernutrition and
malnutrition, particularly among children, but within the first 100
patients formal assessments of nutrition were not documented. This
has been addressed directly for the patients since the collection of this
initial data, and in one instance vitamin B replacement was crucial in
the treatment of a child with severe chronic undernutrition presenting
with metabolic encephalopathy.
208 | www.annalsofsurgery.com
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Annals of Surgery  Volume 263, Number 1, January 2016
Impact on Hospital Services
Two departments were heavily impacted by the influx of
Syrian wounded. Almost two-thirds of the patients had orthopedic
injuries and the 8-bed ICU was at least half full of Syrian wounded at
any time between February and October 2013. Every year, approxi-
mately 8500 operations are performed at Ziv Medical Center (1000
of which are for trauma). Orthopedic surgery saw an increase from
22% to 26%. Spending in orthopedic surgery rose from NIS 3.6
million to NIS 5.5 million in a year. General surgery expenses rose
from NIS 17 million to NIS 22 million, including an increase in
vascular surgery expenses from NIS 300,000 to NIS 500,000.
Elective procedures are performed daily between 8 AM and 3
PM. The impact of emergency surgery required for the Syrian patients
was, therefore, mainly to out-of-hours operating (32% patients
admitted between 8 AM and 3 PM, 50% admitted between 3 PM and
midnight, and 18% admitted between midnight and 8 AM). Additional
operating theaters were opened in the afternoons, and day staff
covered the extra work with on-call staff. For the duration of care
of this cohort of 100 Syrian patients, all elective surgery cancelled on
the day was rescheduled the next morning. No major cases booked in
advance were cancelled.
Although busier, the impact on nursing and medical staff of
managing life-threatening trauma has increased interest and confi-
dence, especially as staffing issues have warranted nurses from other
departments, such as the Intensive and Coronary Care Units, attending
to patients in the trauma room. They attend monthly practice sessions
in the trauma room (which we record and feedback) to improve
trauma skills.
Special Considerations
Evidence is emerging that a number of patients from Syria
have resistant bacteria as a result of over the counter purchase of
antibiotics.13,14 Further research into the origins of this resistance and
serotyping of resistant bacteria is underway,15 but infection control
measures have necessitated routine microbiological swabs on admis-
sion, the use of the trauma room rather than the general emergency
department for immediate resuscitation (this is reflected in the data
for length of stay for patients awaiting surgery in the trauma room, as
patients were not transferred to the main emergency department after
initial resuscitation), isolation bays on the wards (rather than separate
wards), and protocols in the OR for the preparation and recovery of
patients and cleaning of theaters. The hospital computer system has
been updated so that bacterial resistance is flagged.
Children who arrive alone or with a relative are kept together
and undergo medical procedures at the same time, as far as possible,
to ensure that anxiety levels are low.
The Arabic-speaking social worker who worked part-time
now has a full-time post as his work in communicating with the
patients and helping them become orientated and acclimatized to a
foreign hospital environment is invaluable. He now has the assistance
of Arabic-speaking social work students from the local college who
work as volunteers in the hospital. There is just 1 Arabic-speaking
medical clown. He spends as much time with the patients as possible,
but anxiety levels among the patients remain high and addressing
mental health needs is also a priority. It is now 4 years since the
children were last at school.
All discharge summaries are typed in English and anonymized
as appropriate.
SUMMARY
Less than half an hours drive south from the Lebanon border,
Ziv Medical Center was a civilian-receiving hospital during the
second Israel-Lebanon war in 2006.16 A number of articles report
the experiences of civilian hospitals in the treatment of war
2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 263, Number 1, January 2016 Injuries and Treatment of Patients From the Syrian Civil War

casualties,17,18 but at the time of the Arab Spring, few could have
predicted that Israeli district hospitals would be treating Syrian
wounded. This experience, across a hostile border, has been unpre-
cedented. It has inspired the notion that necessity of medical
intervention and the humanitarian imperative transcend regional
and cultural differences.
CONCLUSIONS
Surgical and nonsurgical staff have benefitted from the learn-
ing opportunities in managing patients with complex injuries and
challenging physiology. The incidence of complications within this
cohort of patients has been surprisingly low, considering the delay to
definite treatment and level of nutrition. As a result of the study of
their care, greater attention has been paid to hospital protocols for
massive transfusion, infection control, and nutrition assessment, and
to theater utilization, training in trauma management, and morbidity
and mortality analysis.
ACKNOWLEDGMENTS
The authors thank Shlomit Dahan and her team in the hospital
Trauma Registry for their invaluable help in retrieving trauma data
and Mira Zelig for her unfailing efficiency in obtaining patient
records. This article reports the work of clinical and hospital staff
across a number of disciplines; the authors acknowledge their
dedication to the care of the Syrian, indeed, all trauma, patients.
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ERRATUM

Randomized Multicenter Trial Comparing Glue Fixation,

Self-gripping Mesh, and Suture Fixation of Mesh in
Lichtenstein Hernia Repair (FinnMesh Study): Erratum

In the November 2015 issue of Annals of Surgery in the article by Ronka et al, Randomized Multicenter Trial
Comparing Glue Fixation, Self-gripping Mesh, and Suture Fixation of Mesh in Lichtenstein Hernia Repair
(FinnMesh Study), the following sentence was printed incorrectly: Recurrence of hernia was confirmed by a
clinical or ultrasound examination and ensures or at re-operation. The sentence should read: Recurrence of
hernia was confirmed by a clinical or ultrasound examination or ensured at re-operation.

REFERENCE
Ronka K, Vironen J, Kossi J, et al. Randomized multicenter trial comparing glue fixation, self-gripping mesh,
and suture fixation of mesh in Lichtenstein hernia repair (FinnMesh Study). Ann Surg. 2015;262:714720.

2015 Wolters Kluwer Health, Inc. All rights reserved. www.annalsofsurgery.com | 209

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