Abstract
Surgical care for the weapon wounded and sick in conflict and disaster zones is clearly defined with internationally accepted guidelines for clinical care, the provision of resources, and infrastructure. This chapter outlines priorities in the organization and delivery of surgical care, with real-life examples of surgical activity in the field and ICRC experience of field hospital surgery. ICRC hospital programmes and surgical standards are summarized.
The Global Burden of Surgical Disease
The global burden of surgical disease may be estimated to be as high as 30%[1]; yet less than 5% of all surgery is performed in the poorest regions of the world[2]. Low- and middle-income countries, with almost 50% of the world’s population, have only 20% of the global surgical workforce. While high-income regions of the globe have approximately 14 operating theaters per 100 000 people, low-income regions have fewer than two theaters per 100 000 people[3]. The need for overseas surgical assistance in elective and emergency conditions, the development of surgical training programs, and building relationships with local health-care personnel and health ministries are crucial. Field hospitals are designed to fulfill each of these priorities and, while this chapter focuses on the resources needed to deliver surgical services in the most austere of environments, in particular where there is conflict and/or disaster, surgical care in the field may be delivered by military and civilian international organizations (including charities and nongovernmental organizations [NGOs] working independently or integrated within local health services.
Field Surgery
Modern field surgery describes long- and short-term missions for disaster relief, the treatment of war wounded, and the support and development of surgical services in low and middle countries. Shrime[1] developed a taxonomy for overseas charitable surgical missions, classifying temporary surgical platforms, the most common form of surgical assistance, in terms of short-term surgical disease specific trips with long-term follow-up left to local clinicians (typically plastic surgery – Operation Smile, for example, craniofacial surgery, orthopedics and ophthalmology missions); self-contained surgical platforms involving longer missions with organizations bringing with them their own infrastructure, such as Mercy Ships; and specialty surgical hospitals establishing a specialist service within local health-care or community infrastructure – the Addis Ababa Fistula Hospital as an exemplary model.
The World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care and the Global Burden of Surgical Disease working group further describe surgical needs that surgeons in these field hospitals are likely to encounter. These may be prioritized in terms of surgical conditions with a high prevalence; those easily amenable to surgical treatment such as trauma interventions, exploratory laparotomy for acute abdominal emergencies, external fracture fixation, caesarian section, and hernia repair; conditions with a moderate public health burden, which are moderately amenable to surgical intervention such as vascular trauma, open reduction and internal fixation of fractures; surgery related to the complications of pregnancy; surgery for common malignancies such as breast or colon cancer; and, finally, surgical conditions that exert a relatively low public-health burden, requiring specialized interventions or procedures, which may not result in successful control of disease such as surgery for advanced malignancy or transplantation[4]. This last category, comprising surgical procedures of advanced complexity, is not within the domain of field surgery. Indeed, the more complex the procedure, the more the unsatisfactory the surgical outcome[5,6]. Field surgery is, therefore, recommended for the simpler surgical interventions, which may be performed safely within the environment of a field hospital and with a high probability of successful short- and long-term outcomes.
Surgical assistance programs of large humanitarian organizations such as the International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF) deploy in conflict zones. The ICRC functions under a unique mandate provided by the states involved. The International Federation of Red Cross and Red Crescent Societies (IFRC) deploys emergency response units (ERUs) in response to disasters[7]. This chapter focuses on typical surgical field hospitals supported or established by these organizations, describing the unique mandate, the surgical needs met, and the surgical resources necessary to initiate and maintain field surgery operations.
The Medical ERU of the IFRC
The IFRC comprises 190 National Red Cross and Crescent Societies. The IFRC deploys in disasters and health emergencies through medical ERUs. Each medical ERU includes a team of trained specialists, prepared for deployment at short notice in basic health-care ERUs or in rapid deployment or referral hospital ERUs. Urgent mobilization and deployment are made possible through the organization and preparation of prepacked sets of standardized equipment. ERUs work with field assessment coordination teams and are designed to be self-sufficient for one month, although they can operate for up to four months, and longer if the emergency continues. The ERUs are much like the emergency medical teams (EMTs) of WHO or MSF. Types of deployment are described below.
Basic Health-Care ERU
The basic health-care ERU is designed to provide immediate basic curative, preventive and community health care for up to 30 000 people. The ERU uses a modular approach adjusting to local needs and the WHO basic protocols. The unit deploys with the interagency emergency health kit (a standardized kit of essential medicines, supplies, and equipment deployed by UN agencies and WHO in response to emergencies where the local supply has become disrupted). One kit is designed to meet the basic health needs of 10 000 people for approximately three months. The approximate weight is 18 metric tons. The unit can deliver basic outpatient clinic services, maternal and child health (including uncomplicated deliveries), community health outreach, immunization, and nutritional surveillance. There is no surgical capacity; thus, there must be a mechanism for referral of more serious cases for hospitalization within a reasonable distance with transportation (ambulance) facilities. Although the basic health-care unit does not function as a hospital, there are 10–20 overnight beds for observation. There are 5 to 8 staff and the ERU requires the availability of local health staff and interpreters to support services with the agreement of the local ministry of health (MoH).
Rapid Deployment Hospital
The rapid deployment hospital is a specifically modified and lighter version of the referral hospital ERU, which can deploy within 48 hours of alert and offers medical and surgical interventions such as triage, first aid, medical evacuation, and limited medical and surgical care. There is 10-bed inpatient capacity and an outpatient department.
The rapid deployment hospital can function up to 10 days pending assessment and arrival of a more complete hospital or basic health-care ERU. The hospital has 8 to 10 staff and the equipment weighs approximately 10 metric tons. Being flexible and mobile, requiring no loading equipment, the team works with limited equipment and resources. The Rapid Deployment Hospital can also be used as mobile clinic if required at a later phase of an emergency deployment.
Referral Hospital ERU
The Referral Hospital ERU is a first level field hospital, providing multidisciplinary care to a population of up to 250 000 people. The inpatient capacity ranges from 75–150 beds, providing surgery, limited traumatology, anesthesiology, internal medicine, gynecology, obstetrics, and pediatrics. Prepacked equipment weighs approximately 60 metric tons.
The hospital typically has one or two operating theaters, a delivery room, inpatient wards and treatment areas, X-ray facilities, and a laboratory for blood and urine examinations. There is an outpatient department and an emergency room.
The referral hospital ERU is designed in a modular way to be adaptable to a given situation in the field and to best integrate into the existing local health system and structures. This type of ERU needs to be self-sufficient and, therefore, includes supporting modules such as administration, IT networks and communication, a water and power supply, and staff accommodation and vehicles. The setup may be in tents or move partly or entirely into existing buildings and the unit works based on an agreement with the local MoH. The referral hospital ERU comprises 15 to 20 staff members working with local health staff who receive in-service training in the ERU and work in an integrated way alongside expatriate staff.
Surgery in a Field Hospital
Surgical field hospitals must be equipped to deal with both direct and indirect surgical pathology resulting from conflict and disaster. It is, in fact, indirect injury and illness that results in greater morbidity and mortality in conflict zones, and in the long term, in disaster-affected areas[8]. The minimal capabilities of the surgeon must, therefore, include basic trauma care (visceral and orthopedic), comprising airway management, tube thoracostomy, emergency thoracotomy, the management of bleeding, laparotomy for bowel injury and hemoperitoneum, stoma formation, wound coverage and closure (including skin graft), fracture management (especially debridement, external fixation, fasciotomy and amputation), decompressive craniotomy, obstetric emergencies, and the management of general surgical and urological emergencies such as bowel obstruction, peritonitis, testicular torsion, and complications of hernia.
The Operation Theater and Essential Equipment for Safe Surgery
Equipment and furnishings in the operating theater vary according the facilities available. Both the ICRC and MSF may set up operations in existing health facilities or support well-established surgical units. Figure 16.1 shows what would be considered to be a well-equipped operating theater, but even more basic facilities should enable surgeons to safely perform laparotomy, orthopedic, and debridement procedures. Although, whenever possible, procedures are performed under regional or ketamine anesthesia, general anesthesia with manual and, less commonly, mechanical ventilation is possible. Battery-operated pulse oximetry and manual sphygmomanometry permit perioperative monitoring.
The delivery of oxygen requires an oxygen concentrator, which, in turn, requires an electricity supply, usually from a portable generator powered by gasoline. The operating light, fan, and, rarely, air conditioner, also depend on electricity. A battery-operated headlight is of huge potential assistance to the surgeon. The operating table may be tilted or broken, but usually has no special adaptation for the treatment of fractures, nor for obstetric procedures. Arm rests, however, grant the surgeon and anesthetist important access. Intravenous fluids may be warmed in a bucket of hot water[9]. At 42°C, the water becomes cool enough to touch, and thus warmed crystalloid is available for intravenous administration or irrigation and lavage. Blood transfusion facilities are not available in a basic setup such as this. Blood tests, other than MalariaSpot tests, HIV tests, and syphilis serology (as per the WHO standards) are not performed in these basic surgical hospitals. Clinical assessment and decision-making, therefore, must be sharp and fast. Treatment of hemorrhage relies on hemorrhage control with damage control resuscitation and surgery. Triage and judicial surgical decisions are necessary in dealing with an influx of wounded patients as a basic surgical facility is potentially overwhelmed without planning for mass-casualty scenarios.
Increasingly, ICRC field deployments take the form of mobile surgical teams working in tented facilities or ideally a makeshift building with solid floors, walls, and ventilation. One surgical team includes a surgeon, an anesthetist, scrub nurse, ward nurse, and physiotherapist. An operating theater assistant may be recruited locally and is invaluable not simply in the running of the surgical theater but in translation as the team communicates with each patient. A fully functional surgical setup should allow the team to perform up to 10 operations in 24 hours (60 per week including a rest day, comprising approximately 30 new patient admissions and 30 follow-up operations)[10].
Although mobile surgical teams work under basic conditions, the operating theater is supervised by the scrub nurse and remains clean and kept free of insects as far as possible. Sterile conditions are maintained in surgery through the use of disposable sterile drapes. Sterile disposable consumables are stored in clean, dry conditions, stocks monitored, and waste collected in large plastic bags within waste baskets. Sharps are collected in sharps bins and incinerated with clinical waste at a safe distance from the hospital buildings or tents.
Surgical instruments are cleaned in accordance with international standards including rinsing, disinfection, cleaning, drying, and autoclaving. Typical instrument packs include a basic surgical set with self-retaining retractor and bone nibblers used for minor procedures, debridements, and as an adjunct to external fixator kits; and split skin graft sets, which include a free-hand modified Humby-type knife; amputation sets; laparotomy sets; thoracotomy sets; vascular sets; and craniotomy sets. All surgery is open surgery.
Chest drainage is performed in the operating theater rather than the ward and employs a closed drained underwater-seal system. Major dressing changes (especially if sedation or morphine analgesia is required) are also performed in the operating theater. Dressings comprise gauze and bandages. Occlusive plastic dressings are not included in the standard list of consumables. Silver sulfadiazine covered with gauze and bandages are the dressings of choice for burns. Skin coverage is achieved with split skin grafts as soon as possible where appropriate. Plaster of Paris splints and casts are employed where limb immobilization is required. Debrided wounds remain bandaged until wound closure is performed two to five days after radical debridement and lavage under antibiotic cover. Steinmann pins for the management of femoral fractures in traction are inserted in the operating theater.
Surgical Care: The Realities in the Field: Dorein, South Sudan
As a field surgeon with ICRC, you find yourself with the mobile surgical team in a small field hospital. There are tents to sleep, to perform surgery, and care for your patients. It is raining: a lot. The mud is everywhere.
Life has not been easy since your arrival a week ago. Hot nights in a semiflooded tent prevented a good sleep. An ant attack did not help. However, the team spirit is good. You are the only surgeon. You have an anesthetist, a scrub nurse, and a ward nurse. You have no X-ray, and only simple laboratory tests (rapid malaria antigen test and hemoglobin spot tests), and pulse oximetry handled by the anesthetist.
The reason to deploy here was an outbreak of fighting in the region and the presence of wounded with no local treatment facilities. There are no roads. Airplanes cannot take off or land as all areas that can serve as landing strips are flooded. The only access is via helicopter.
Your tented hospital has a limited number of beds, and they are all occupied. There are more patients outside the hospital compound. The wounded are waiting with local patients and patients who have traveled for days on foot as news of an ICRC field hospital has spread. Expectations are high. Patients with a wide variety of pathologies are demanding elective procedures. You are feeling a little overwhelmed: the project specifies limiting your work to weapon-wounded patients and patients with other life-threatening conditions.
This morning you do a ward round, see new cases, documenting your findings as you go (Figure 16.2), and prioritize cases for theater:
Surgical debridements for patients with infected gunshot wounds of the limbs, several days old, due to the delay in reaching the hospital. They will also need fracture fixation with plaster, traction, or external fixation.
Drainage of an infected hemothorax.
Laparotomy for a patient who survived an abdominal gunshot wound, and who has developed a colonic fistula.
One patient has been the subject of discussion within the team. This boy has a cerebral gunshot wound. The entrance of the gunshot wound is through the eye. There is no exit. The neurological prognosis is dubious. As he is still alive, with a Glasgow Coma Scale of 11, and the wound is purulent, he is now scheduled for debridement.
The next patient has osteomyelitis of the mandible months after a gunshot wound. He is drooling, cannot eat, and is losing weight. You plan to refer him to a specialist working in the capital, but he needs to fly there and planes have not been able to land near the field hospital since you arrived,
Several patients are ready for delayed primary closure. It is now five days since initial debridement of their wounds. ICRC protocol is to perform a radical initial debridement, bandage the wound, continue antibiotics (usually penicillin), and perform delayed primary closure of a clean wound, usually on the second to fifth postoperative day. Hopefully, these patients have clean wounds, otherwise they will undergo re-debridement. If the wounds can be closed, most of them will require a split skin graft. The battery-powered dermatome has just arrived.
One patient with an exposed proximal tibia will require a muscle flap. This has to be scheduled for a quiet moment – you are not used to performing this procedure.
Halfway during the morning, a patient with closed head injury and signs of lateralization is brought to the hospital. There is no CT scan, and the decision for craniotomy must be taken on clinical grounds.
There may be a caesarian section to do. More women in advanced pregnancy seem to be coming to the hospital.
The team is tired, because last night they worked on a woman with postpartum hemorrhage.
Figure 16.2a The ICRC patient history sheet. Clinical and operative findings and postoperative instructions are documented
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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