INTRODUCTION

When war breaks out, any existing health care system is rapidly disrupted and overwhelmed. Resources may be in short supply. Qualified medical and nursing staff may have left or be simply insufficient in numbers. The hospital infrastructure may be damaged. The water supply may be cut off. The power supply may be unreliable. Fuel may be difficult to obtain.

Surgical units are particularly susceptible to disruption because they depend on a basic minimum of infrastructure (secure buildings, water and electricity) expertise in surgery, anaesthesia, nursing and technical matters, an organized system of patient management and the regular provision of supplies. The additional burden of casualties, both military and civilian, arrives just when the hospitals are most likely to be in difficulty; the necessary minimum of infrastructure and expertise is rarely available. Assistance for such hospitals must be considered in terms of both materials and expertise. Both can be supplied by aid agencies. In the absence of any functioning hospital, a new surgical facility has to be set up; this an expensive commitment. The needs are long-term and do not disappear with the end of the fighting.

An independent hospital run by an aid agency can employ - and dismiss - its own staff. It has control over the distribution and use of supplies, and can thus ensure accountability. It can also provide free treatment; this reaffirms the role of the hospital as an independent, neutral place where the wounded may be treated in safety whatever their allegiance.

The organizational structure and system of patient management described in this book is that adopted in independent ICRC hospitals. It may seem to be an “ideal recipe”. However, it not only provides for a realistic and achievable standard of care but also constitutes a tried and tested system that works. Details of management structure may differ, but the principle of a standardized, team approach to patient management under clear leadership can be applied to any hospital which admits large numbers of war-wounded. Flexibility of approach is important but, whatever the circumstances, the wounded patients must be managed according to properly applied basic surgical principles. This book is about providing the means for such management.

Medical and nursing staff working in hospitals for war-wounded tend to come from different countries, with variable training and experience. Aid agency staff are also likely to have short contracts; this leads to a rapid turnover of experienced staff. Locally employed staff rarely have nursing experience. This book offers practical advice to the key people (see Chapter 1.3) involved in setting up or running a hospital for war-wounded: the field director of a medical aid agency, the director of an existing hospital, the head nurse, the hospital administrator, the operating theatre nurse, the surgical ward nurses and the nurse responsible for staff training.

Chapter 1 outlines how to set up a hospital in a difficult and potentially dangerous environment and gives checklists of essential points. Chapter 2 focuses on the administrative details involved in the daily running of the hospital. It covers all aspects of hospital organization, including personnel management, organizing supplies, and running the kitchen, laundry and other support services. Chapter 3 addresses patient management from admission to discharge, nursing care and organizational aspects of triage. Chapter 4 explains how to set up and run the operating theatre. Chapter 5 proposes a framework for a training programme for unqualified staff. The appendices comprise lists of standard materials and drugs.

Although the nursing guidelines focus specifically on the management of war-wounded patients, the general guidelines on hospital infrastructure and organization may be applied to any hospital set up in an emergency or disaster situation.