Specificities of Surgery inTime 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

First AidDressing

40-60 %No surgery

10-15% Head10-12% Chest8-10% Abdomen60-70% Limbs

90% Surgery

Small woundsParaplegiaTetraplegia

Observation

10% NO Surgery

40-60 %Hospital care

WW in the field(GSW, mine, blast)

100 wounded

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

0102030405060708090

100

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

Everyday work

MCI

MAD

Triage

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