C
Conflict Surgery
David J. Williams
579 The difficulties that any surgeon encounters in the management of a surgi- cal case in the well-equipped situation of a first-world hospital will also be experienced in the environment of a conflict zone, but additionally, they are compounded by a combination of environmental, logistical, and cultural factors unique to the geographical area where one is working.
The following “tips”—some clinical, some not—may help. The most important, though, is not to put yourself in a situation where you are iso- lated from senior support and expected to deal with an array of problems unless you are happy to do so.
Pre Deployment
Research the country to which you are being sent regarding the tempera- ture range, weather patterns, and range of local diseases/parasites. Purchase appropriate clothing and ancillaries to increase your comfort and reduce the chance of becoming a thermal casualty, but most importantly to ensure that you are as comfortable as possible. Ensure all immunizations have been administered and malaria prophylaxis (if needed) has been commenced in a timely fashion. If the water supply locally is of unknown quality, take enough sterilizing tablets to easily see you through the duration of your stay.
Liaise with the team with whom you are to be deployed; discuss poten- tial scenarios and iron out any disagreements in management well before any casualties arrive. Check the kit list and make sure you are happy with all the items to be taken—once you are deployed, it is too late to rectify any deficiencies. Decide who is the lead clinician in the case of a clinical dilemma.
Deployment
Stay happy! Integrate with all the tasks, especially if they are mundane, physically hard, and dirty (such as digging latrines). You earn an infinite amount of respect if you are seen to be doing crap jobs as readily as every- one else.
Share any luxury items with everyone—we had a “comfort box” where one put in anything that was nice, and then it would be opened intermit- tently and shared out. This is fantastic for morale after a bad day.
Nip any disagreements in the bud, clear the air and start fresh the next day; several weeks of festering animosity is likely to lead to major dys- function in the team.
Look out for colleagues; the most unlikely people can prove to be the most robust, while those whom one imagines to be tough may break down after a short while.
Debrief wherever possible after a case; be constructive with the aim of increasing everyone’s knowledge, improving the care of the next casualty, and (in case of a poor outcome) ensuring that no team member feels that they are to blame.
Scenarios—Routine Traffic Accidents
Even in a war, people crash vehicles!
Road Traffic Accident 1
Twenty-year-old male, driving, left-sided impact resulting in # left humerus, ruptured spleen, # femur (open), # tib/fib (open).
Investigations—blood count, U&E, X match, X-ray, ultrasound scan (USS),
Treatment—cast for # humerus, tibial traction pin, and Thomas splint post debridement and washout for # femur, ex fix post debridement, and washout for tib/fib and laparotomy/splenectomy.
Discussion
1. The above case showed the value of portable ultrasound. Clinically, this man’s abdomen was not one that required a laparotomy, and without the FAST USS we would not have explored it, with the likelihood that he would have continued to bleed and have had a poorer outcome.
2. Bottled mineral water was used for washouts rather than intravenous (IV) fluids. The rationale for this was that the IV fluids were at a premium while drinking water was continually replaced and so we could be more liberal with the irrigation.
3. Traction pins and Thomas splints are rarely used in modern health ser- vices, but they are fantastic in austere environments and allow for pain
relief, hemorrhage control, and easier transfer of the patient. In combina- tion with skeletal traction, they are life- and limb-saving devices.
4. The modern treatment of splenic injury by serial USS, High Depen- dency Unit care, and a wait-and-see policy does not apply to the conflict area. The patient must not be allowed to bleed for long periods otherwise hypothermia, coagulopathy, and potential for renal dysfunction will occur.
Additionally, the opportunity to do a laparotomy may not occur again due to factors such as more casualties arriving or the need to move the medical facility.
5. At laparotomy, save the patients life and only commit them to another operation if absolutely necessary. An injured spleen can be wrapped and left in situ in a modern hospital where the patient can be monitored and returned to the theater if required; in the middle of a war, do a splenec- tomy and thereby complete the treatment. Ensure this fact is documented, commence prophylactic antibiotics, and arrange immunization against encapsulated organisms.
Road Traffic Accident 2
Twenty-eight-year-old male ejected from a vehicle at a speed of approxi- mately 30 miles per hour. Admitted with open-book pelvic fracture (Figure C-1) and hemorrhagic shock. Ascending urethrography demonstrated dis- rupted urethra/bladder. Patient was treated by external fixation of pelvis with initial transient response. Clinically, he had ongoing bleeding, so
Figure C-1. X-ray demonstrating open book pelvic fracture.
laparotomy performed. No clotting factors held in forward facility, so unit members donated nine pints of whole fresh blood.
At laparotomy, resuscitative aortic cross-clamping was performed to arrest uncontrollable pelvic bleeding. The pelvis was packed, large volume transfusion was given to replace losses, and the aortic clamp was released after twenty minutes. Further bleeding occurred and so the aortic clamp was reapplied, followed by selective dissection and clamping of the common iliacs; this demonstrated the source of the bleeding to be on the right. The right internal and external iliac were dissected and right internal iliac tied off with Nylon.
Post operatively the patient was in a coagulopathy but after a delay of 4 hours from time of request, clotting factors including recombinant activated factor VII arrived at our location and were administered.
Discussion
1. Most pelvic fractures will be adequately treated by an external fixator, but if one has to perform a laparotomy, it is difficult because the fixator remains in place and blocks access; in addition, there is a very large pelvic hematoma (similar to a pregnant uterus) distorting tissue planes. Addi- tionally, there is the anxiety of an exsanguinating patient. Make a generous laparotomy, if necessary, up to the xiphisternum because good access will speed the surgery.
2. STAY CALM. Pack the pelvis and apply pressure, usually the bleed- ing is venous and this should reduce it dramatically. If this does not work, do not spend further time on fruitless exploration in a large hematoma/
fracture site; dissect out the abdominal aorta and apply a vascular clamp.
3. Having obtained control, leave the packs in situ and check the rest of the abdomen for signs of injury.
4. TALK TO THE ANESTHETISTS AND DO NOT REMOVE THE CLAMP UNTIL THEY HAVE CAUGHT UP WITH LOSSES, RECLAMP IF THEY ASK YOU TO.
5. At clamp release, there will be two events, little bleeding or much bleeding. The latter indicates major vessel disruption and may require arte- rial ligation as above. If you are not an experienced arterial surgeon, the safest way to dissect out the iliacs is to remain on the surface of the aorta and slowly move down to the bifurcation, do not migrate off into other tissue planes otherwise injury to ureters, bowel, or pelvic veins may occur.
6. Fresh blood was, in this case, donated by members of our unit, but it can be obtained from friends or relatives of the patient; it has the advan- tage of being warm, of normal biochemistry, platelet- and clotting-factor rich, and with a normal 2,3-diphosphoglycerate (2,3-DPG) content.
7. If another facility has items you require, ask for them as early as pos- sible due to the logistical problems with delivery.
Scenarios—Pediatrics
Children do not know the difference between toys and munitions, and they play with them. Modern munitions are often scattered during a conflict and may find their way into areas where children play or work. Do not let the fact that the patient is a child change your management from the basic prin- ciples of dealing with the war wounded; their outcome is likely to be wors- ened by inappropriate treatment.
Pediatric 1
Fourteen-year-old boy, picked up unexploded ordnance with non-dominant hand, leading to a hemi-amputation (Figure C-2). Intravenous antibiotics and tetanus immunoglobulin given. The patient was taken to theater post X-ray, where debridement and washout was performed. Although having a vascular supply, the extensive skin loss and exposure of bone and tendon meant that the chance of keeping the hand was slight. Transfer to Plastics team arranged for attempt at flap.
Discussion
1. The definitive treatment of this injury was beyond the skills contained in our facility. If we had not had a Plastics unit available, we would have treated the wound by the same initial procedure, but at second look at 48 hours would have prepared the family for an amputation.
Figure C-2. Traumatic hemi-amputated hand in a child.
2. Desire to keep soft tissues must be tempered with the need to remove all debris and nonviable areas.
3. If there had be a lack of vascular supply or gross contamination, a primary amputation would have been performed (see Pediatric 2).
Pediatric 2
Seven-year-old boy playing with his brother encountered unexploded ord- nance which he kicked, resulting in traumatic amputation of his foot, shrap- nel damage to his remaining foot, and bilateral open tib/fib fractures for his brother, who was standing next to him at the time. Both children were taken to theater that night; the child with the traumatic amputation received a below-knee amputation, which was left open to be re-inspected and closed in three to five days time, with debridement and washout of the remaining foot. His brother had debridement and washout for his open fractures fol- lowed by application of plaster of paris because the external fixators were not appropriate for a child.
Discussion
1. The decision to remove a child’s leg is not one that is made easily, but leaving a child with a non-healing severely injured limb is inappropriate.
2. At completion of amputation, one might be tempted to close the wound primarily if it looked clean to avoid the need for a second opera- tion; this would almost certainly lead to deep infection and the requirement for revision amputation.
3. The child with open fractures lost large fragments of his tibia; these had periosteal stripping and were devitalized; if left in situ, they would become a focus for infection. Removal leaves a cavity that, when clean, can be bone grafted and covered with a muscle flap at a further operation.
