ICRC surgical activities
31-10-1991 Article, International Review of the Red Cross, No. 284, by Rémi Russbach, Robin Charles Gray, Robin Coupland
Note: this article has been revised as of August 1995.
Dr. Robin Charles Gray was born in 1942 in Epsom, England. He studied medicine in Great Britain, receiving an M.A. in 1966 and becoming a Fellow of the Royal College of Surgeons in 1972. In 1979, he obtained a Certificate of Higher Surgical Training in general surgery. He has been a surgical tutor for the Royal College of Surgeons, Chairman of the Department of Surgery at Brook General Hospital, Consultant in General and Urological Surgery at Gama Hosital in Riyadh, Saudi Arabia and Consultant General Surgeon for the South-East Thames Regional Health Authority. His first secondment to the ICRC by the British Red Cross in 1983 was followed by many others for missions to ICRC surgical hospitals in Thailand and Pakistan. He has been an ICRC medical co-ordinator since 1988 and in 1989 was made the institution's Co-ordinator for War Surgery.
Dr. Robin Michael Coupland was born in 1957 and studied medicine in Great Britain. He received his M.A. in 1982 and became a Fellow of the Royal College of Surgeons in 1985. From 1985 to 1987 he worked as Registrar for general gastro-intestinal, urological and cardio-thoracic surgery at the University College Hospital and Middlesex Hospital. He was then seconded by the British Red Cross for several missions to ICRC surgical hospitals in Pakistan (Peshawar and Quetta), Thailand (Khao-I-Dang) and Angola. He has been a surgical co-ordinator at the ICRC since November 1989.
The surgical activities of the International Committee of the Red Cross stem from the institution's general mandate to protect and assist the victims of armed conflict.
The war wounded are thus only one category of the victims included in the ICRC's terms of reference.
The ICRC's main role in relation to the war wounded is not to treat them, for this is primarily the responsibility of the governments involved in the conflict and hence their army medical services. The task of the ICRC is first and foremost to ensure that the belligerents are familiar with the provisions of the Geneva Conventions and apply them, that is, care for members of the enemy armed forces as well as their own and afford medical establishments and personnel the protection to which they are entitled.
Nevertheless, local medical services are often completely overwhelmed in conflict situations and the ICRC is then compelled to step in to help the war wounded. When supplying hospitals with medical equipment and medicines is not enough, the ICRC has to set up its own surgical facilities to offer the wounded the care that the authorities cannot provide.
There was a sharp increase in conflict situations calling for direct ICRC assistance in the 1980s and the institution's surgical activities showed an unprecedented expansion. The number of wounded admitted to ICRC hospitals rose from 4,000 in 1987 to 23,000 in 1994.
These various surgical units have developed along different lines, depending on the constraints imposed by the local context.
In certain situations, the ICRC surgical hospitals are entirely autonomous. They are housed in ICRC premises and are staffed by expatriate personnel, backed up by local employees who work under ICRC supervision.
In such cases, the ICRC has complete control over the system of treatment and can compile reliable statistics.
In other situations, the ICRC's teams have to work in govermnent-run hospitals and are limited to performing surgery, while the government retains responsibility for other services and for most of the nursing staff.
The ICRC has to ensure that in hospitals not under its control certain basic principles are respected so as to win the trust of the adverse party (no weapons or political activity in the hospital, no discrimination against enemy wounded).
ICRC surgical hospitals differ considerably from army medical units in that the ICRC has no control over the system to evacuate the wounded and has no referral facilities. Each ICRC hospital therefore, serves as both first-aid and final referral centre, thus forming an entity that has little in common with a military surgical unit.
The ICRC does, however, try to extend its activities to the prehospitalization phase and to organize adequate first-aid and transport.
It is not usually possible for ICRC staff to have access to the actual scene of the fighting, so arrangements for the prehospitalization phase have to be made through intermediaries.
With this in mind, the ICRC has set up several programmes to train first-aid workers belonging to groups involved in the fighting. The basic first-aid training given (dressing wounds, immobilizing fractures, stopping bleeding, rehydration, administration of antibiotics) is accompanied by an introduction to the elementary principles of international humanitarian law (ban on killing wounded enemies and prisoners, respect for civilians, etc.).
ICRC hospitals are designed to receive a large number of casualties at the same time. In the admissions area the patients undergo triage and resuscitation and are prepared for theatre. The patient's condition determines whether he or she requires haemoglobin estimation, cross-matching or radiography.
A blood bank is important when managing major injuries. In the situations in which the ICRC is working, blood for transfusion is often scarce. Donation of blood is encouraged among the local population and the patients'relatives; collection sessions are used as opportunities to disseminate the basic principles of the Red Cross and Red Crescent.
There may be cultural and practical obstac les to the collection of blood, and often widespread chronic anaemia in the local population is a further complication. Judicious use of the available blood is therefore essential. The general guideline is not to transfuse patients with a haemoglobin level above 7 g/dL. Before transfusion, each unit of blood is cross-matched and tested for malaria, syphilis, hepatitis B and HIV. The quantity of blood needed for war surgery has been established from experience; the average requirement in ICRC hospitals is 45 units per 100 patients admitted; this rises to 60 units if the patients are admitted within six hours of being wounded and to 100 if antipersonnel mines are widely used in the conflict concerned.
The radiographic service is limited to plain films, which are sufficient for preoperative assessment.
In an ICRC hospital, the operating theatre, postoperative ward, blood bank, laboratory and radiography unit are housed in permanent structures (brick, corrugated iron) with a concrete floor. The surgical wards and triage areas may be simple shelters or tents if the security situation permits. Thus bed capacity can be increased easily and rapidly.
The surgical equipment, drugs and nursing materials used are standardized. The standard list, drawn up by the ICRC Medical Division, ensures uniform management throughout the institution's hospitals; it avoids problems arising from different expectations and preferences on the part of medical personnel. This is particularly important in situations where the surgical teams rotate on a three-month basis. The standard list is regularly reviewed. The principle on which it is based is to provide only items essential for managing war wounds, such as basic instrument sets and equipment for safe anaesthesia.
The ICRC hospitals also provide a physiotherapy service, outpatient review and, later, rehabilitation. The hospitals are run by both expatriate and local staff. The medical personnel are recruited through National Red Cross and Red Crescent Societies; each surgical team consists of a surgeon, an anaesthetist and an operating theatre nurse.
The capacity to deal with a large number of patients admitted within a short period may be limited by the operative facilities. In such circumstances it is necessary to determine which patients have high priority for treatment. The triage officer should preferably be an experienced doctor; it can be difficult to come to terms with the concept that the most severely wounded may not have top priority. Category I comprises those who need urgent surgery but who have a good chance of survival. Category II includes both patients who do not require surgery for their wounds and those who are so severely wounded that surgery would not help and would take up excessive surgical resources. Category III comprises those who can safely await surgery. Frequent reassessment is necessary, as inevitably some patients with hopeless prognoses improve while others may deteriorate. Rational triage is of paramount importance to achieve " the best for the most " .
4. Wound management
Wounds from fragments or bullets may be sma ll, requiring little or no surgery. Those with significant tissue damage, however, are usually heavily contaminated and pieces of clothing or skin are pushed or sucked into the wound. With mine injuries, the victim may suffer traumatic leg amputation while stones, mud and bone fragments are blown up into the thighs, buttocks or genitals.
The surgical aims are to remove all the foreign materials and loose bone fragments, to excise the devitalized tissue and to decompress the viable tissue that remains. The wounds are then left open and dressed with sufficient quantities of loose gauze to absorb the blood and serum exudate. The dressing remains undisturbed until the date for delayed primary closure (four to five days), unless the general condition of the patient indicates that the wound has been incompletely excised. Delayed closure may be by direct suture, skin graft or reconstruction. For limb wounds, correct wound management has a higher priority than the method of fracture fixation; external -skeletal fixation has proved popular with surgeons but there is growing recognition of the efficacy of simpler rneans such as plaster of Paris.
5. Training of civilian surgeons for war surgery
The ICRC Medical Division recognizes that the transition from specialized civilian surgical practice to the management of war wounds may be difficult for many surgeons. They are faced with different working conditions, equipment, pathology and patient expectations. Moreover, they are working outside the speciality for which they have been trained.
A course for surgeons is held ev ery year and has proved a popular forum for exchanging information and experience. Surgical briefing material has been distributed to all National Red Cross and Red Crescent Societies that recruit surgeons. There have been many publications documenting the ICRC's experience in war surgery (see bibliography), the aim of which is to establish a process of internal evaluation to improve professional performance. Such publications are proving a valuable means of contact between the Medical Division and professional bodies, National Red Cross and Red Crescent Societies and armed forces medical services which could benefit from ICRC experience.
In addition, there is growing recognition that the experience gained by individual surgeons on ICRC missions is beneficial to their civilian practice and, in the case of younger surgeons, it is an asset for their curriculum vitae. Indeed, in modern surgical training there is little opportunity to experience true general surgery; the ICRC provides that opportunity.
The ICRC Medical Division, while continuing to expand its surgical activities, is at the same time endeavouring to retrieve this field experience for the benefit of others who have to manage war-wounded patients.