|Surgery for Victims of War (ICRC, 1998, 225 p.)|
Surgery for victims of war is different from the type of surgery practised for civilian injuries. War wounds are always extremely contaminated, and missiles may cause massive destruction of soft tissues, bones and other structures.
The principles of surgery for war wounds have been known for decades but need to be relearned by each new generation of surgeons working in a war situation.
The aims of war surgery are to:
· save life;
This manual aims to provide the surgeons, anaesthetists and nursing staff working in a hospital in a war environment with basic information about the treatment of war wounds. It describes the types of operations that have proved successful, based on the experience of the ICRC and others in different countries and conflicts.
The outcome of war surgery is influenced by:
· type of injury;
All the above factors are supposed to be taken into consideration by the military.
In some countries, the organization of care is so efficient that any soldier who is wounded can count on receiving almost the same treatment as that available at home in peacetime. In developing countries, however, the health care system might already have been weak before the conflict started and may almost be non-functioning because of the conflict. Water and electricity supplies can be unreliable, trained staff often leave the area, drugs and disposable equipment cannot be replaced, and buildings can be destroyed. But even with basic technology, war wounded can be treated with good results, if doctors and nursing staff have the necessary knowledge and motivation.
The first aid provided at the point of wounding, or at the safest place near the battlefield, and rapid evacuation are of vital importance, because mortality and morbidity increase with delay between wounding and treatment. The more effective the first aid and the quicker the evacuation to a hospital, the better will be the final results. If first aid is inadequate or unavailable and the evacuation chain is long, then the outcome will be decided by nature. Some patients who might have survived will die, and the surviving patients will have established infections and other complications which lower their subsequent chances of survival. This is, unhappily, often the case where the ICRC and others are working.
Unlike a military field hospital, an ICRC hospital is responsible for all levels of medical care. It acts as a first aid post, field hospital, base hospital and referral centre. Thus, primary surgery, secondary surgery and basic reconstructive surgery are all conducted in the same facilities. Usually, there are only one or two surgeons working in each hospital. They must be able to treat all kinds of injuries, from simple soft tissue wounds to penetrating abdominal injuries, head injuries and complicated fractures. Ideally, they should be experienced general surgeons but nowadays such surgeons are difficult to find. The aim of this book is to help those who have to deal with all these injuries without having the proper training and experience.
Correct primary surgery of war wounds is the basis of success.
To be successful, surgeons should be willing to learn and should adapt their behaviour to different circumstances. The majority of wounds will be to the extremities, and the objective is to treat them so that they heal as quickly as possible without becoming infected. Treatment is not complete until the patient is rehabilitated and high quality physiotherapy is required to ensure early mobilization after surgery. In addition, orthopaedic workshops are needed to provide prostheses for amputees and other suitable devices for the disabled, such as orthoses, crutches or wheelchairs.
Basic principles of management of war wounds:
· complete wound excision;
Early and thorough wound excision:
- greatly reduces chances of death from gas gangrene or generalized infection;
- reduces the number of operations required to remove remaining infected or dead soft tissue and bone;
- allows delayed primary closure to be successful.
Correct surgery gives the patient the best chance of survival with a good quality of life and shortens the stay in hospital.
In poor countries, the level of technology is usually low before the war. In other countries, the level may go down because of the war, with disrupted communication lines, unavailability of spare parts, and lack of knowledge about repair and maintenance. Nevertheless, ICRC experience shows that it is possible to perform good quality surgery with basic technology, such as simple X-ray, but without equipment for electric monitoring in the operating theatre and the postoperative ward.
Many organizations have developed standard lists of equipment and drugs, based on experience of working under difficult conditions. These lists should take into consideration: the level of care to be provided, the standard treatment regime in the country, the directives from the local ministry of health, the level of care provided to patients in local hospitals, and the local level of resistance to drugs. Such standardization should avoid two main problems: first, the introduction of new drugs or equipment which are not available in the country and which may create new needs; and, second, the provision of surgical care which is of a higher standard and more sophisticated than that available in the host country.
Because of the war situation, some of the staff may have left the hospital. Skilled staff are difficult to replace, and their absence will of course affect daily work in the hospital.
When working in a foreign country, it is essential to have the services of reliable interpreters to facilitate communication with staff and patients, as well as local authorities.
Security is a major concern, and must be ensured for patients and staff by selecting suitable places for first aid posts and hospitals. Health facilities should be clearly marked with the protective emblem of the Red Cross or Red Crescent.
In a war situation, with few doctors and staff, and with wounded pouring in, hospital facilities may be overwhelmed. Stocks may run out, with the result that optimal treatment cannot be given. It is important to realize that surgeons also get tired and sick, and are sometimes scared. They therefore may not perform as well as usual. Cultural constraints may add to the frustrations, stopping surgeons from doing what they know is best for the patient. In many countries, amputations and laparotomies can only be performed with the consent of the family of the patient. It is hard to see young people die because necessary surgery cannot be performed.
Adaptation to the cultural, social and geographic context is essential.
Blood for transfusion is often difficult to obtain because of the religious or cultural restrictions in many countries. With the steady increase in HIV, testing must be adequate and indications for transfusion strictly limited. In some areas of the world, giving blood should probably be totally avoided. The use of blood should be restricted to vital needs and to patients with a good chance of survival. Anaemia resulting from parasitic infestations has sometimes to be accepted and should be treated with iron, folic acid and adequate food.
In a war situation most health structures will be dealing with war wounded. The wounded may, however, suffer from other diseases, such as tuberculosis, malaria, typhoid and intestinal worms, as well as malnutrition. The surgeon must therefore try to acquire some basic knowledge about the diseases specific to the area and their treatment. Local health care workers are usually familiar with these conditions and can be of great help.
Three qualities are particularly needed by personnel working in ICRC hospitals:
This manual aims to enhance knowledge of how to maintain life, reduce suffering and give the best chance of improvement in the quality of life for the victims of war.