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 First Aid Dressing % No surgery 10-15% Head 10-12% Chest 8-10% Abdomen 60-70% Limbs 90% Surgery Small wounds Paraplegia Tetraplegia Observation 10% NO Surgery % 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

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, O 2 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