Surgery with limited resources: a handbook for Colombia
A handbook for the treatment of war wounds has recently been released in Bogotá jointly by the ICRC and the Colombian Ministry of Social Protection. This 700-page specialized guide is the culmination of nearly two years’ work and draws on the expertise of both Colombian and ICRC doctors. We asked Julio Guibert, ICRC war surgeon, and Ricardo Uribe, Colombian specialist trauma surgeon, to tell us more about it.
Julio Guibert, what is this handbook for and how is it going to help Colombian doctors improve their treatment of casualties of armed conflict?
The Colombian Ministry of Social Protection was keen for the ICRC to help produce a manual about war wounds that was broad enough to encompass all levels of treatment in the country. We worked alongside Colombian doctors for more than a year, introducing international standards of surgery developed over the ICRC’s 30 years of experience of armed conflicts. The handbook is easy to use and offers detailed and practical advice, which we hope will help to improve the overall treatment of conflict victims in Colombia.
What are the ICRC’s standards of war surgery, contained in the handbook?
The ICRC recommends thoroughly cleaning the wound, removing dead tissue, foreign bodies and bone fragments, and leaving the wound open for between five and seven days. Then, if the wound is clean, we put in stitches – a practice known as “late primary suturing,” which has proved highly effective and is accepted as standard procedure by most armed forces across the world. The ICRC has a very particular approach to fighting infection, but we also maintain that surgery is the best option in this regard.
The ICRC already has an international handbook on war surgery. What is different about this new one?
The Colombian handbook draws not only on ICRC expertise but also on the experiences of local doctors. As a result, it includes chapters on technical procedures such as x-rays and blood tests, applicable to the treatment of patients in cities, where more resources are available. The international handbook does not encompass such procedures, since the majority of the ICRC’s work is carried out in situations where resources are limited. For surgery to be a success, however, the same basic principles should be applied universally, regardless of the availability of resources.
What are the most common wounds encountered within the context of the armed conflict in Colombia?
Due to the frequent use of improvised explosive devices in place of mines, the wounds we see are often contaminated with all sorts of material waste, and are therefore at risk of serious infection. This particular type of wound is not so common elsewhere in the world, where industrial mines are more typically used.
One of the most important challenges addressed by the handbook is how to provide prompt and comprehensive treatment within technical constraints and in difficult conditions. What are the key recommendations given in this regard?
After resuscitating the patient, we recommend applying certain principles to limit collateral damage, if necessary. We advise doctors not to be deceived by external appearances: a bullet, for example, may have caused a very small entry wound on the surface, but a catastrophe inside. Of course, with this kind of wound, surgery is the best option. Doctors who are not trained surgeons should simply stabilize the patient and refer him or her on to someone who is, rather than attempt to undertake surgery themselves: heroism can never be a replacement for high-quality surgery.
Ricardo Uribe, what was it like working with the ICRC on this handbook?
We all put in a lot of hard work, both the Colombian specialists and the ICRC team: we wanted to create a handbook that was practical, simple and suitable for use in any scenario. Our common aim was to improve the overall quality of treatment for trauma victims – not only the quality of the surgical procedures themselves, but also of our approach to international humanitarian law and of psychotherapy provision, to facilitate the reintegration of patients into society, work and the family.
In your opinion, what is the main benefit of having the handbook?
The handbook serves as a quick reference point for surgeons, equipping even those who are not trained in war surgery to deal with emergencies. It also represents a first step towards incorporating the treatment of war wounds into postgraduate programmes for surgical and orthopaedic interns. It is important to understand that war wounds are different from those encountered in everyday situations.
What is the main difference between these two types of wounds?
The main difference lies in the way the wounds are caused: the high-velocity weapons used in armed conflict cause significant tissue damage. Furthermore, in situations of armed conflict, there is often a delay in reaching the injured, followed by a long journey to a medical facility. This delay, coupled with the severity of the wounds, makes casualties of armed conflict unique: they often suffer haemorrhagic shock and hypothermia, and since their wounds have long been left untreated, they are also at greater risk of infection.
What makes war surgery in Colombia different from elsewhere in the world?
The armed conflict in Colombia has very special characteristics. Medical teams are not universally respected, so doctors and paramedics struggle to reach casualties in certain areas. Hospitals are generally located far from where armed conflict takes place. In addition, the delivery of emergency care, despite having seen some improvement, is still often complicated by issues relating to the country’s geography and climate.