The International Committee of the Red Cross, ICRC, has extensive experience with health care in areas of conflict in austere, remote environments, and they have an excellent book on the subject. War Surgery – working with limited resources in armed conflict and other situations of violence. It is also available as a free PDF download.
Today, April 9th, is the remeberance day for Norway being invaded by the Nazis in 1940, during their Operation Weserübung. After WWII we’ve been lucky enough to live in a peaceful and prosperous part of the world. Not everybody is that fortunate. The International Red Cross is one of the organizations that has a big involvement in many of these areas, and therefore a huge expertise in dealing with the consequences of war and disaster, often in austere environments. So it seemed appropriate to make a post on war surgery and war medicine today. It turns out we too can gain from lessons learned in these environments.
The book contains valuable insight, and also lots of MacGyver tips that can be useful in a setting with minimal equipment and personnel. Something you could encounter in rural areas in developed countries, remote prehospital missions or for expedition wilderness medicine.
Ketamine Infusion Anaesthesia.
This is the preferred technique in ICRC practice. It is not only more economical of ketamine, but allows for a longer operation without re-injections. It can be used either after i.v. bolus induction of anaesthesia or as an induction method on its own.
A solution is made of ketamine in normal saline and placed in a different vein from that used for fluid replacement. The rate of infusion is titrated against the patient’s response, both for induction and as maintenance of anaesthesia.
Ketamine infusion anaesthesia can be combined with muscle relaxants and endotracheal intubation. This is standard ICRC procedure where muscle relaxation is necessary (abdominal or thoracic surgery). As mentioned previously, the absence of mechanical ventilators means that the paralysed patient must be bagged manually.
The standard ketamine drip is be made by injecting 500 mg of Ketamine into a 1000 mL bag of Saline, making a Ketamine 0.5 mg/mL solution. Easily and roughly adjusted to effect through a standard giving set with a roller clamp and drop counter.
In the book you’ll also find anecdotes of impressive thinking and improvisation by local doctors with minimal equipment and resources available:
Afghan colleagues working with ICRC surgical teams in the Jalalabad Teaching Hospital in 1993 developed a simple protocol for dealing with patients severely injured by anti-personnel landmines. Many patients had suffered a traumatic amputation of one leg and severe injuries to the other and succumbed, exsanguinated, by the time the debridement of the second leg had been performed.
Our Afghan colleagues then decided to divide the surgical procedure into two parts: the first operation was on the traumatic amputation, the other leg was simply washed and dressed, and the operation ended. Fresh whole blood was sought from family members and the patient fully resuscitated and given penicillin. Forty-eight hours later, another operation to debride the second leg was performed. This was Afghan “damage control surgery”, locally invented, to face the situation of a lack of blood for transfusion.
Shortly after a war surgery seminar in Kinshasa, two young Congolese general practitioners belonging to the military medical services, with limited surgical expertise, told the ICRC surgeon of one of their experiences and asked a simple question. While working in a field hospital in the bush, they received a comrade with a bullet injury to the abdomen. Evacuation to another hospital was impossible. They operated and found a severe wound to the liver, and had no blood for transfusion.
“We couldn’t stop the bleeding, and not knowing what to do, we packed the liver and stopped the operation”, they recounted. They then managed to persuade some other soldiers to donate several units of blood, and re-operated the patient after 48 hours; the patient survived. “Did we do the right thing?” they asked. The ICRC surgeon replied that they had discovered on their own what was now standard practice in many parts of the world when faced with exsanguinating haemorrhage.
Impressive and humbling stories. Have the pdf version available on your iPhone or iPad for reading – just to emphasize the gap in avaliable resources and technology. But obviously not in clinical observation and thinking.
Djebel Mara region, Sudan. A medical group based in Nyala performs an emergency operation in a field clinic. ©ICRC / B. Heger
Along a similar vein, is the Update in Anaesthesia from the World Federation of Societies of Anaesthesiologists. Both the web page and the pdf updates gives great tips to providing safe quality health care with a minimum of equipment and expertise.
From the International Committee of the Red Cross, you can download the full pdf version
War Surgery – working with limited resources in armed conflict and other situations of violence, ICRC, 2009.