Specificities of Surgery in
Time of Armed Conflict or
Natural Disaster
Christos Giannou
Advanced Course in the Management of Disaster Victims
Nicosia, October 2011
Understand what you are getting into
BEFORE
you go.
Natural disaster, accident, isolated explosion
One-off event:
surprise, warning
War
Successive events:
NO surprise, political build-up
1.
Rights and obligations of Medical Personnel
2.
Specific epidemiology of war (constant) / disaster (variable)
3.
Predominance of emergency surgery (especially during early
tactical field care)
4.
Surgery within a limited technical environment
5.
Limits of surgery: post-operative nursing + anaesthesia
6.
Surgery in a hostile, violent environment
7.
Mass casualties involving the principles of triage
8.
Surgery and triage in successive echelons (delayed evacuation)
9.
Specific wound pathology, qualitatively different from civilian
wounds: ballistics & blast; all are dirty and contaminated
10. Specific techniques appropriate to the context and
pathology: simplicity, security, speed
11. Importance of disease: disease is four times more common
than trauma among soldiers; disaster public health approach
1.
Rights and obligations of Medical Personnel
2.
Specific epidemiology of war (constant) / disaster (variable)
3.
Predominance of emergency surgery (especially during early
tactical field care)
4.
Surgery within a limited technical environment
5.
Limits of surgery: post-operative nursing + anaesthesia
6.
Surgery in a hostile, violent environment
Medical Ethics
Oath of Hippocrates:
International Code of Medical Ethics: WMA
1949 London, 2006 Pilanesberg S. Africa
International Humanitarian Law: laws of war
 Geneva Conventions 1949
 Additional Protocol I 1977
1.
Rights and obligations of International Humanitarian Law:
laws of war
2.
Specific epidemiology of war (constant) / disaster (variable)
3.
Predominance of emergency surgery
4.
Surgery within a limited technical environment
5.
Limits of surgery: post-operative nursing + anaesthesia
6.
Surgery in a hostile, violent environment
War wounded in the field: epidemiology
WW in the field
(GSW, mine, blast)
100 wounded
40-60 %
No surgery
First Aid
Dressing
40-60 %
Hospital care
90% Surgery
10-15% Head
10-12% Chest
8-10% Abdomen
60-70% Limbs
10% NO Surgery
Small wounds
Paraplegia
Tetraplegia
Observation
War wounded: causes of death
 Severe injury (brain, major vessels)
 Haemorrhage: peripheral
 Airway, breathing
 Coagulopathy, acidosis, hypothermia /
multiple system failure
Natural disaster: context
 Earthquake
 demographic density
 type of construction
 access: rural or urban
 Tsunami
 Storm / flooding
 Neighbourhood nuclear plant
Epidemiology of disaster wounded:
collapse of 8-storey building China
 80% of entrapped died immediately or early
 10% survived with minor injuries
 10% severe injuries
 of which 70% developed crush syndrome
Earthquake Survival Rate:
% survivors still alive without extraction
100
90
80
70
60
50
40
30
20
10
0
0.5h
24h
48h
72h
96h
120h
Earthquake: causes of death
 Immediate: severe crush of head or thorax (organ
damage + suffocation)
 Early: ABC
 Delayed: dehydration, hypothermia
 Late: crush syndrome (acute renal failure),
sepsis, multiple organ failure
1.
Rights and obligations of International Humanitarian Law:
laws of war
2.
Specific epidemiology of war (constant) / disaster (variable)
3.
Predominance of emergency surgery
4.
Surgery within a limited technical environment
5.
Limits of surgery: post-operative nursing + anaesthesia
6.
Surgery in a hostile, violent environment
Specificities of austere environments
 Damaged infrastructure (water, electricity)
 Lack of experienced human resources:
competency,
fatigue, fear
 Lack of equipment and supplies: appropriate
 Lack of blood for transfusion
 "Humanitarian circus" and military-civilian cooperation
 Culture shock
Norwegian RC field hospital: ERU post-tsunami Banda Aceh
Field Surgical Team Darfur
Recycling of a prison
Somali Red Crescent Society: No State
Shatilla refugee camp 1987
Understanding the limits

simplicity of diagnostic means available

laboratory: Hb/Hct, blood grouping & screening

anaesthesia (local, regional, ketamine)

availability of blood (no components): autotransfusion

patient monitoring (BP, P, O2 saturation)

post-operative nursing care
Heroic surgery will never replace good surgery.
Clinical skills
•
Lucky if you have X-rays
•
Chest tube & laparotomy on clinical basis alone (no DPL)
•
No place for CPR, ER thoracotomy
•
Limited- or non- use of endotracheal intubation, no
mechanical ventilation
•
Proper indications and use of damage control techniques
• Will you see your patient again?
• Category IV? supportive treatment
Always plan for alternatives:
 infrastructure
 equipment
 communications
 supplies, logistics
 human resources
1.
Rights and obligations of International Humanitarian Law:
laws of war
2.
Specific epidemiology of war (constant) / disaster (variable)
3.
Predominance of emergency surgery
4.
Surgery within a limited technical environment
5.
Limits of surgery: post-operative nursing + anaesthesia
6.
Surgery in a hostile, violent environment
Hostile, violent environment
7.
Mass casualties involving the principles of triage
8.
Surgery and triage in successive echelons (delayed evacuation)
9.
Specific wound pathology, qualitatively different from civilian
wounds: ballistics & blast; all are dirty and contaminated
10. Specific techniques appropriate to the context and
pathology: simplicity, security, speed
11. Importance of disease: disease is four times more common
than trauma among soldiers; disaster public health approach
Triage
Everyday work
MCI
MAD
7.
Mass casualties involving the principles of triage
8.
Surgery and triage in successive echelons (delayed evacuation)
9.
Specific wound pathology, qualitatively different from civilian
wounds: ballistics & blast; all are dirty and contaminated
10. Specific techniques appropriate to the context and
pathology: simplicity, security, speed
11. Importance of disease: disease is four times more common
than trauma among soldiers; disaster public health approach
Old lessons for new surgeons
War / disaster wounds are dirty and
contaminated, from the moment of injury.
The rules of septic surgery apply.
Principles of septic surgery
The best antibiotic is good surgery.
7.
Mass casualties involving the principles of triage
8.
Surgery and triage in successive echelons (delayed evacuation)
9.
Specific wound pathology, qualitatively different from civilian
wounds: ballistics & blast; all are dirty and contaminated
10. Specific techniques appropriate to the context and
pathology: simplicity, security, speed
11. Importance of disease: disease is four times more common
than trauma among soldiers; disaster public health approach