v o l u m e 1 Ww o ra k i nr g W iS t hU war l i mr i tg e d re e sr o uy SUrgery r c e s i n a r m e d c Working With limited resources o n f in armed conflict l i c t and other situations of violence a n d volume 1 o t h e r s i t u a t i o n s o f v i o l e n c e 0973/002 03.2009 3,000 war SUrgery Working With limited resources in armed conflict and other situations of violence volume 1 C. Giannou M. Baldan International Committee of the Red Cross 19 Avenue de la Paix 1202 Geneva, Switzerland T + 41 22 734 60 01 F + 41 22 733 20 57 E-mail: [email protected] www.icrc.org © ICRC, March 2009 Cover photos: A. Bakkour/ICRC; A. Bakkour/ICRC; V. Louis/ICRC. Preface In 1863, a small group of Swiss citizens founded the International Committee of Geneva for the Relief of Wounded Soldiers. A year later, an international diplomatic conference negotiated the first Geneva Convention for the Amelioration of the Condition of Wounded Soldiers in the Field, which to this day is one of the cornerstones of international humanitarian law, and gave the International Committee of the Red Cross its definitive name. International humanitarian law – the law of war – has developed since, and the mandate, role and activities of the ICRC have expanded to include both protection and assistance for all the victims of armed conflict and other situations of violence. Assistance and relief programmes are now run according to a public health approach and aim to be holistic regarding human needs while respecting the dignity of each and every one. War surgery – the care of the wounded in armed conflict and other situations of violence – remains a pillar of the ICRC’s identity. Over the years, ICRC hospital teams have unfortunately been witness to a great deal of physical and mental suffering in this world. Through caring for the sick and wounded in so many different conflict zones, the ICRC and its partners in the International Red Cross and Red Crescent Movement have developed an expertise they are keen to share, and created a pool of human resources ever willing and prepared to help alleviate some of the suffering. This new manual presents some of this expertise, gained at great human cost, in the hope that one day it will no longer be required. Jakob Kellenberger President International Committee of the Red Cross taBle of contents INTRODUCTION 9 Chapter 1 SPECIAL CHARACTERISTICS OF SURGERY IN TIMES OF CONFLICT 17 1.1 Differences between surgery in times of conflict and civilian practice 19 1.2 How war surgery differs 20 1.3 “Surgeries” for victims of war 25 1.4 Differences between military and non-military war surgery: the ICRC approach 27 Annex 1. A ICRC criteria for introducing a new technology 31 Chapter 2 APPLICABLE INTERNATIONAL HUMANITARIAN LAW 33 2.1 Historical introduction 35 2.2 International humanitarian law: basic principles 36 2.3 The distinctive emblems 38 2.4 The International Red Cross and Red Crescent Movement and its Fundamental Principles 39 2.5 Rights and duties of medical personnel according to IHL 39 2.6 Responsibility of States 41 2.7 Reality check: some people do not follow the rules 43 2.8 The neutrality of a National Red Cross/Red Crescent Society 44 2.9 The role and mandate of the ICRC in situations of armed conflict 45 Annex 2. A The distinctive emblems 48 Annex 2. B The International Red Cross and Red Crescent Movement 50 Chapter 3 MECHANISMS OF INJURY DURING ARMED CONFLICT 53 3.1 The various mechanisms of injury 55 3.2 Ballistics 59 3.3 Terminal ballistics 63 3.4 Wound ballistics 70 3.5 Wound dynamics and the patient 78 Chapter 4 RED CROSS WOUND SCORE AND CLASSIFICATION SYSTEM 81 4.1 Applications of the RCWS and classification system 83 4.2 Principles of the Red Cross Wound Score 84 4.3 Grading and typing of wounds 88 4.4 Wound classification 88 4.5 Clinical examples 89 4.6 Conclusions 91 3 Chapter 5 THE EPIDEMIOLOGY OF THE VICTIMS OF WAR 93 5.1 Introduction: purpose and objectives 95 5.2 Public health effects of armed conflict 95 5.3 Epidemiology for the war surgeon 98 5.4 General questions of methodology 101 5.5 Aetiology of injury 104 5.6 Anatomic distribution of wounds 106 5.7 Fatal injuries 110 5.8 The lethality of context: delay to treatment 114 5.9 Hospital mortality 117 5.10 ICRC statistical analysis of hospital workload 118 5.11 Conclusions: lessons to be gained from a study of epidemiology 121 Annex 5. A ICRC surgical database 123 Annex 5. B Setting up a surgical database for the war-wounded 125 Chapter 6 THE CHAIN OF CASUALTY CARE 129 6.1 The links: what kind of care, and where? 131 6.2 Surgical hospital treating the war-wounded 133 6.3 Transport 134 6.4 Forward projection of resources 135 6.5 The reality: common war scenarios 136 6.6 Conflict preparedness and implementation 137 6.7 The pyramid of ICRC surgical programmes 138 Annex 6. A Initial assessment of a surgical hospital treating the war-wounded 140 Annex 6. B Strategic assessment of a conflict scenario 146 Annex 6. C Humanitarian intervention for the wounded and sick: typical settings 148 Chapter 7 FIRST AID IN ARMED CONFLICT 153 7.1 First aid: its crucial importance 155 7.2 First aid in the chain of casualty care 156 7.3 First aiders: an important human resource 157 7.4 Essential elements of the first-aid approach and techniques 157 7.5 Setting up a first-aid post 159 7.6 ICRC involvement in first-aid programmes 161 7.7 Debates, controversies and misunderstandings 161 Chapter 8 HOSPITAL EMERGENCY ROOM CARE 169 8.1 ABCDE priorities 171 8.2 Initial examination 171 8.3 Airway 172 8.4 Breathing and ventilation 175 8.5 Circulation 177 8.6 Blood transfusion where supplies are limited 181 8.7 Disability 184 8.8 Environment/exposure 185 8.9 Complete examination 185 4 Chapter 9 HOSPITAL TRIAGE OF MASS CASUALTIES 189 9.1 Introduction 191 9.2 Setting priorities: the ICRC triage system 193 9.3 How to perform triage 196 9.4 Triage documentation 198 9.5 Emergency plan for mass casualties: disaster triage plan 199 9.6 Personnel 200 9.7 Space 202 9.8 Equipment and supplies 203 9.9 Infrastructure 204 9.10 Services 204 9.11 Training 204 9.12 Communication 204 9.13 Security 205 9.14 Summary of triage theory and philosophy: sorting by priority 206 Annex 9. A Sample triage card 207 Annex 9. B Hospital emergency plan for a mass influx of wounded 208 Chapter 10 SURGICAL MANAGEMENT OF WAR WOUNDS 211 10.1 Introduction 213 10.2 Complete examination 214 10.3 Preparation of the patient 215 10.4 Examination of the wound 216 10.5 Surgical treatment 216 10.6 Retained bullets and fragments 221 10.7 Final look and haemostasis 222 10.8 Wound excision: the exceptions 223 10.9 Leaving the wound open: the exceptions 224 10.10 Dressings 225 10.11 Anti-tetanus, antibiotics, and analgesia 226 10.12 Post-operative care 226 Chapter 11 DELAYED PRIMARY CLOSURE AND SKIN GRAFTING 229 11.1 Delayed primary closure 231 11.2 Skin grafting 233 11.3 Full-thickness grafts 238 11.4 Healing by secondary intention 240 Chapter 12 NEGLECTED OR MISMANAGED WOUNDS 243 12.1 General considerations 245 12.2 Chronic sepsis: the role of biofilm 247 12.3 Surgical excision 248 12.4 Antibiotics 250 12.5 To close or not to close? 251 Chapter 13 INFECTIONS IN WAR WOUNDS 253 13.1 Contamination and infection 255 13.2 Major bacterial contaminants in war wounds 256 13.3 Major clinical infections of war wounds 257 13.4 Antibiotics 263 13.5 Neglected or mismanaged wounds 265 Annex 13. A ICRC Antibiotic protocol 266 5 Chapter 14 RETAINED BULLETS AND FRAGMENTS 269 14.1 The surgeon and the foreign body 271 14.2 Early indications for removal 271 14.3 Late indications 274 14.4 Technique for the removal of a projectile 275 Chapter 15 BURN INJURIES 277 15.1 Introduction 279 15.2 Pathology 279 15.3 Burn management 282 15.4 Burns presenting late 286 15.5 Nutrition 286 15.6 Care of the burn wound 286 15.7 Closure of the burn wound 289 15.8 Scar management 293 15.9 Electrical burns 294 15.10 Chemical burns 294 Annex 15. A Nutrition in major burns: calculating nutritional requirements 297 Chapter 16 LOCAL COLD INJURIES 299 16.1 Physiology of thermal regulation 301 16.2 Types of local cold injuries 301 16.3 Management 302 Chapter 17 ANAESTHESIA AND ANALGESIA IN WAR SURGERY 305 17.1 Introduction 307 17.2 Anaesthesia methods 308 17.3 Local and regional anaesthesia 309 17.4 Dissociative anaesthesia with ketamine 310 17.5 Post-operative pain management 312 Annex 17. A ICRC pain management protocols 314 Chapter 18 DAMAGE CONTROL SURGERY AND HYPOTHERMIA, ACIDOSIS, AND COAGULOPATHY 319 18.1 Resuscitative surgery and damage control surgery 321 18.2 Hypothermia, acidosis, and coagulopathy 322 ACRONYMS 329 SELECTED BIBLIOGRAPHY 333 6 7