WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE VOLUME 1 SECOND EDITION, 2019 C. GIANNOU M. BALDAN REFERENCE WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE VOLUME 1 SECOND EDITION, 2019 C. GIANNOU M. BALDAN PREFACE Many things change in a decade; many things stay the same. Despite advances in the management of severely injured patients, the challenge of providing timely, adequate and appropriate care for the victims of armed conflict remains. In the ten years since War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence was first published, it has become a basic reference text for surgeons facing the challenge of managing the war wounded – both civilians and combatants – in difficult and austere circumstances. Our surgical colleagues considered it useful to bring certain chapters up to date to reflect new knowledge. In addition to the ICRC-sponsored translations into French, Russian and Spanish, local initiatives now include versions in Arabic, Chinese, Japanese and Turkish, which is a testament to the relevance of ICRC surgical experience. The challenges are not confined to medical care. In 2019, 70 years after the four Geneva Conventions were signed, disregard for the lives of those providing medical treatment remains all too common. The International Committee of the Red Cross, colleagues from the International Red Cross and Red Crescent Movement and other humanitarian organizations have all made it clear that health care during armed conflict is in danger, despite the requirements of international humanitarian law – the law of war. The ICRC remains vigilant in guarding against the erosion of international humanitarian law and works with States to correct harmful behaviour. For we know that compliance with international humanitarian law saves lives, keeps hospitals and schools open, maintains electricity and water supplies and allows markets to function. Fewer people are displaced, development efforts are preserved and stability is enhanced. The Conventions remain as relevant and applicable today as they were in 1949, for even in armed conflict, at the worst of times, the core of our common humanity must be preserved. The care and protection of the sick and wounded during war remains fundamental to the identity of the ICRC and forms the basis of the very first Geneva Convention of 1864. This updated edition of War Surgery attempts to share the expertise of ICRC medical professionals in providing a little bit of humanity in situations which, in a better world, would not exist. Peter Maurer ICRC President TABLE OF CONTENTS INTRODUCTION 11 Chapter 1 SPECIAL CHARACTERISTICS OF SURGERY IN TIMES OF CONFLICT 19 1.1 Differences between surgery in times of conflict and civilian practice 21 1.2 How war surgery differs 22 1.3 “Surgeries” for victims of war 27 1.4 Differences between military and non-military war surgery: the ICRC approach 29 ANNEX 1. A ICRC criteria for introducing a new technology 33 Chapter 2 APPLICABLE INTERNATIONAL HUMANITARIAN LAW 35 2.1 Historical introduction 37 2.2 International humanitarian law: basic principles 38 2.3 The distinctive emblems 40 2.4 The International Red Cross and Red Crescent Movement and its Fundamental Principles 41 2.5 Rights and duties of medical personnel according to IHL 41 2.6 Responsibility of States 43 2.7 Reality check: some people do not follow the rules 45 2.8 The neutrality of a National Red Cross/Red Crescent Society 46 2.9 The role and mandate of the ICRC in situations of armed conflict 47 ANNEX 2. A The distinctive emblems 50 ANNEX 2. B The International Red Cross and Red Crescent Movement 52 Chapter 3 MECHANISMS OF INJURY DURING ARMED CONFLICT 55 3.1 The various mechanisms of injury 57 3.2 Ballistics 61 3.3 Terminal ballistics 65 3.4 Wound ballistics 72 3.5 Wound dynamics and the patient 80 Chapter 4 RED CROSS WOUND SCORE AND CLASSIFICATION SYSTEM 83 4.1 Applications of the RCWS and classification system 85 4.2 Principles of the Red Cross Wound Score 86 4.3 Grading and typing of wounds 90 4.4 Wound classification 90 4.5 Clinical examples 91 4.6 Conclusions 93 Chapter 5 THE EPIDEMIOLOGY OF THE VICTIMS OF WAR 95 5.1 Introduction: purpose and objectives 97 5.2 Public health effects of armed conflict 97 5.3 Epidemiology for the war surgeon 100 5.4 General questions of methodology 102 5.5 Aetiology of injury 106 5.6 Anatomic distribution of wounds 108 5.7 Fatal injuries 112 5.8 The lethality of context: delay to treatment 117 5.9 Hospital mortality 119 5.10 ICRC statistical analysis of hospital workload 120 5.11 Conclusions: lessons to be gained from a study of epidemiology 123 ANNEX 5. A ICRC surgical database 125 ANNEX 5. B Setting up a surgical database for the war-wounded 127 Chapter 6 THE CHAIN OF CASUALTY CARE 131 6.1 The links: what kind of care, and where? 133 6.2 Surgical hospital treating the war-wounded 135 6.3 Transport 136 6.4 Forward projection of resources 137 6.5 The reality: common war scenarios 138 6.6 Conflict preparedness and implementation 139 6.7 The pyramid of ICRC surgical programmes 140 ANNEX 6. A Initial assessment of a surgical hospital treating the war-wounded 143 ANNEX 6. B Strategic assessment of a conflict scenario 149 ANNEX 6. C Humanitarian action for the sick and wounded: typical settings 151 Chapter 7 FIRST AID IN ARMED CONFLICT 155 7.1 First aid: its crucial importance 157 7.2 First aid in the chain of casualty care 158 7.3 First-aiders: an important human resource 159 7.4 Essential elements of the first-aid approach and techniques 159 7.5 Setting up a first-aid post 161 7.6 ICRC involvement in first-aid programmes 163 7.7 Debates, controversies and misunderstandings 163 7.8 Disability: the AVPU system 167 7.9 Evacuation: a risk to take 168 Chapter 8 HOSPITAL EMERGENCY ROOM CARE 171 8.1 C-ABCDE priorities 173 8.2 Initial examination 173 8.3 Catastrophic haemorrhage 174 8.4 Airway 175 8.5 Breathing and ventilation 178 8.6 Circulation 179 8.7 Blood transfusion where supplies are limited 184 8.8 Disability 187 8.9 Environment/exposure 188 8.10 Complete examination 188 Chapter 9 HOSPITAL TRIAGE OF MASS CASUALTIES 193 9.1 Introduction 195 9.2 Setting priorities: the ICRC triage system 197 9.3 How to perform triage 200 9.4 Triage documentation 202 9.5 Emergency plan for mass casualties: disaster triage plan 203 9.6 Personnel 204 9.7 Space 206 9.8 Equipment and supplies 207 9.9 Infrastructure 208 9.10 Services 208 9.11 Training 208 9.12 Communication 208 9.13 Security 209 9.14 Summary of triage theory and philosophy: sorting by priority 210 ANNEX 9. A Sample triage card 212 ANNEX 9. B Hospital emergency plan for a mass influx of wounded 213 7 Chapter 10 SURGICAL MANAGEMENT OF WAR WOUNDS 215 10.1 Introduction 217 10.2 Complete examination 218 10.3 Preparation of the patient 219 10.4 Examination of the wound 220 10.5 Surgical treatment 220 10.6 Retained bullets and fragments 225 10.7 Final look and haemostasis 226 10.8 Wound excision: the exceptions 227 10.9 Leaving the wound open: the exceptions 228 10.10 Dressings 229 10.11 Anti-tetanus, antibiotics, and analgesia 230 10.12 Post-operative care 230 Chapter 11 DELAYED PRIMARY CLOSURE AND SKIN GRAFTING 233 11.1 Delayed primary closure 235 11.2 Skin grafting 237 11.3 Full-thickness grafts 242 11.4 Healing by secondary intention 244 Chapter 12 NEGLECTED OR MISMANAGED WOUNDS 247 12.1 General considerations 249 12.2 Chronic infection: the role of biofilm 251 12.3 Surgical excision 252 12.4 Antibiotics 254 12.5 To close or not to close? 255 Chapter 13 INFECTIONS IN WAR WOUNDS 257 13.1 Contamination and infection 259 13.2 Major bacterial contaminants in war wounds 260 13.3 Major clinical infections of war wounds 261 13.4 Antibiotics 267 ANNEX 13. A ICRC antibiotic protocol 269 Chapter 14 RETAINED BULLETS AND FRAGMENTS 271 14.1 The surgeon and the foreign body 273 14.2 Early indications for removal 273 14.3 Late indications 276 14.4 Technique for the removal of a projectile 277 Chapter 15 BURN INJURIES 279 15.1 Introduction 281 15.2 Pathology 281 15.3 Burn management 284 15.4 Burns presenting late 287 15.5 Nutrition 288 15.6 Care of the burn wound 288 15.7 Closure of the burn wound 291 15.8 Scar management and rehabilitation 295 15.9 Electrical burns 295 15.10 Chemical burns 296 ANNEX 15. A Nutrition in major burns: calculating nutritional requirements 299 8 Chapter 16 LOCAL COLD INJURIES 301 16.1 Physiology of thermal regulation 303 16.2 Types of local cold injuries 303 16.3 Management 304 Chapter 17 ANAESTHESIA AND ANALGESIA IN WAR SURGERY 307 17.1 Introduction 309 17.2 Anaesthesia methods 310 17.3 Local and regional anaesthesia 311 17.4 Dissociative anaesthesia with ketamine 312 17.5 Post-operative pain management 314 ANNEX 17. A Fasting rules for non-emergency surgeries, including delayed primary closure 317 ANNEX 17. B Standard ICRC anaesthetic equipment 318 ANNEX 17. C ICRC recommendations for choice of anaesthetic techniques 319 ANNEX 17. D Ketamine delivery regimes 320 ANNEX 17. E ICRC pain management protocols 321 Chapter 18 DAMAGE CONTROL SURGERY AND HYPOTHERMIA, ACIDOSIS AND COAGULOPATHY 327 18.1 Introduction to damage control 329 18.2 Hypothermia, acidosis and coagulopathy 330 18.3 Damage control protocol 335 ACRONYMS 341 SELECTED BIBLIOGRAPHY 345 9 INTRODUCTION INTRODUCTION Our common goal is to protect and assist the victims of armed conflict and to preserve their dignity.