D Surgery in the Camps

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D

Surgery in the Camps

Pauline A. Cutting

585 In the late 1980s, I worked for 18 months as a surgeon in the Bourj al Borajneh Palestinian refugee camp in Beirut, Lebanon, during the 15-year- long Lebanese Civil War. We were caring for more than 1200 war-injured patients during two periods of ﬁghting—one of six weeks and one of six months.¹During this time, the camp was attacked and surrounded. These circumstances presented various issues including:

1. Limited resources, no special tests, and no specialists;

2. Availability of blood;

3. Working extremely close to the front ﬁghting line;

4. Austere conditions.

Limited Resources, No Special Tests, and No Specialists

To manage victims of ballistic trauma, one would ideally like to have the support of modern medical facilities with I.T.U., computed tomography, magnetic resonance imaging (MRI), image intensiﬁers, laboratory support, and specialist opinions, as described in the Royal College of Surgeons document, Better Care for the Severely Injured (see Further Reading).

However, in war, this is rarely the case, and many wars are fought where the medical services are, at best, basic, inaccessible, or at a distance—sometimes several days travelling from the ﬁghting line. War injured may be of any age, from the very young to the very old, and any or all body areas may be injured. Even in less-than-ideal conditions with limited resources and no specialists, much can be done and good surgical care provided by a surgeon with general surgical and trauma experience if sound surgical principles are followed.²

In the Palestinian refugee camp in Beirut, I worked in a small war- damaged ﬁeld hospital that functioned as a general and emergency medical and surgical hospital. It was situated inside the refugee camp, staffed by a small team of local doctors and nurses, with a few Europeans like myself recruited by nongovernmental organizations (NGOs).

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The basement and ground ﬂoor had been converted into an emergency care complex consisting of:

– an emergency room;

– a small operating theater with one anesthetic machine and one table;

– a pharmacy;

– an X-ray room with a portable machine, which worked intermittently;

– a laboratory with facilities limited to hematocrit, blood group, and crossmatch (on a tile), and occasionally urine and stool microscopy, depend- ing upon the availability of slides; and

– wards housing 30 to 40 beds.

Surgery was performed with a general surgical set. There were some orthopedic instruments, including a Gigli saw for amputation, vascular instruments, skin graft knives, and craniotomy burrs. Usually, one operation was carried out at a time, or on occasions with many seriously injured, we squeezed in another couch, brought in a desk lamp, and operated in two teams in cramped conditions, sometimes cleaning and sharing instruments.

General anesthetics were nitrous oxide and Fluothane with or without intubation and muscle relaxation, or intravenous anesthetics with patients manually ventilated on air; Ketamine in combination with Diazepam was used often.

In these circumstances, 1276 war injured were managed—all injured by conventional weapons (Table D-1), age range 2 months to 100 years, 55% men, 45% women and children with a whole spectrum of injuries from patients with serious multi-system injury to minor soft tissue wounds (Table D-2).

Injuries operated on (Table D-3) were mostly soft tissue, following the traditional time-tested treatment of primary wound excision followed by Table D-1. Wounding missiles %

Missile World War II Vietnam Northern Ireland Bourj al Barajneh

Bullets 10 52 55 20

Fragments 85 44 25 60

Other or unclassiﬁed 5 4 20 20

Table D-2. Distribution of missile wounds (%)

Location World War II Vietnam Northern Ireland Bourj al Barajneh

Head and neck 4 14 20 11.5

Chest 8 7 15 16

Abdomen 4 5 15 18

Limbs 75 54 50 45.5

Other 9 20 — 9

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delayed primary closure at about ﬁve days or left open to close by secondary intention.

There were no specialists and it was not possible to evacuate patients.

I was the only doctor with a surgery qualiﬁcation (F.R.C.S.), but had no war surgery experience. Amongst the Palestinian doctors, two were surgeons in training, with little formal training, but much experience. The other doctors were juniors and generalists who assisted in theater, and we trained them to put in chest drains and perform primary wound excision. None of us were orthopedic surgeons, nor did we have cardiothoracic or neurosurgical experience.

Orthopedic injuries were managed with plaster of paris and splintage, and occasionally, external ﬁxators were used for lower leg fractures and associated extensive soft tissue loss. Fractured femurs were managed with Steinman pin traction with sandbag weights or skin traction for young children. Even patients with orthopedic injuries and requiring vascular repair were treated in this way. For non-orthopedic surgeons, I believe this approach has been supported by the work of Professor Rowley, who has shown that in similar conditions good, if not better, results can be achieved with these methods of treatment than those achieved with more interven- tion and use of external ﬁxation.³ However, that is not to say that fully trained orthopedic surgeons could not achieve better results.

All penetrating chest injuries were treated with a wide-bore basal chest tube that was connected to an underwater sealed drain and inserted in the ﬁfth or sixth intercostal space anterior to the mid axillary line. No thora- cotomies were performed.

All those with abdominal injuries suspected to be penetrating underwent laparotomy. The most devastating and difﬁcult to deal with were those produced by multiple large fragments, and these were often associated with injuries to other body areas and with a high mortality. High-velocity bullet injuries were often complicated as expected and injured organs were removed or repaired. Mortality was related to the number of injured organs.

Survivors averaged 2.1 injured organs while non-survivors averaged 3.7 injured organs.

Craniotomies for penetrating brain injuries were performed by enlarg- ing the skull defect with bone nibblers, extracting bone fragments, acces-

Table D-3. Types of injury operated on

Injury No.

Soft tissue 900

Chest, penetrating 67

Abdomen, penetrating 69

Peripheral, vascular 21

Orthopedic 112

Brain 5

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sible metal fragments, and pulped brain with low-pressure suction. There was no ventilator for postoperative ventilation. Tackling these patients with no senior or specialist opinion was daunting. Advice came from the theater nurse, who had worked in neurosurgery and gave tips on exposure and hemostasis.

There was no rearward evacuation of patients after initial surgery. The management of patients with postoperative complications was particularly difﬁcult, with no back-up services, such as laboratory investigations, ultra- sound, CT, or MRI. Even ﬂuid balance charts were not reliable, as some nurses had little or no training. However, clinical assessment of patients took place every morning. Thus, in these conditions with limited equipment, a great deal can be done and good care provided by a surgeon with sound surgical training adhering to time-tested surgical principles.²

Availability of Blood

One crucial factor in caring for the patients with serious multiple injuries is the availability of blood. It is hopeless to operate on such patients without any blood. We were lucky that the population, family, and friends were ready and willing to donate blood. There was a large supply of citrated blood bags. Crossmatch was performed on a white tile. As the camp was surrounded and the whole population nearby and many people living in the hospital, there was on most occasions a ready supply of fresh blood for transfusion. This did not always help the triage decisions, and I believe we made some naive decisions and took patients to the operating theater with a poor prognosis. However, the effect on morale of labeling patients hopeless is signiﬁcant, and with a short evacuation time, good initial assessment and resuscitation, and the availability of fresh blood, you get a “few good saves.” Patients can recover fully, which lifts morale amongst patients, care givers, and the community alike.

Operating Very Near the Front Line

Medical facilities situated very close to or in the front line result in patients arriving alive with severe complicated multi-system injury, including major vessel injury. These patients consume a great deal of resources and only a few survive. The hospital—Haifa Hospital—was inside the Palestinian refugee camp of Bourj al Barajneh. The camp was on a slope measuring about 400 by 500 meters and housed 9000 people. During the periods of ﬁghting, the camp was surrounded and attacked on all sides with guns, rocket-propelled grenades, mortars, and tanks. The wounded were all carried to the hospital on stretchers, and the distance from the place of wounding to the hospital was no more than a few 100 meters in any direc-

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tion. The evacuation time for most was extremely short—only minutes. One patient arrived alive with a fragment injury transecting his spinal cord at C2.

A short lag time between injury and definitive surgery increases the overall mortality within the medical facilities, but improves the outcome for the individual.¹At the other end of the scale, as the hospital was so close by, many patients came with relatively minor wounds and some with multiple superficial soft tissue wounds—sometimes tens or even hundreds of small fragment wounds. There was not much in the literature concerning these so-called “pepper pot” wounds, but it was clear that it was neither fea- sible, nor practical, nor necessary to perform a wound excision on all these wounds. These “pepper pot” wounds were given tetanus prophylaxis, penicillin if available and felt to be necessary, and the wounds themselves cleaned, sometimes with not much more than a good wash. A few devel- oped focal infection, but there were no deaths in the patients whose only wounds were uncomplicated soft tissue wounds. I believe there is now supporting literature for this approach, using the International Committee of the Red Cross (ICRC) wound classification, these being the small-grade VO fragment wounds. It also has been shown that fragments transfer the maximum amount of their energy at or very close to the surface,⁴such that if the entry wound is small, there will be no hidden area of damage due to temporary cavitation.

Being very close to or in the ﬁghting zone raises issues of safety and secu- rity of patients and health care personnel. Although the Geneva Conven- tion sets out the rights and duties of the health care personnel in war and that hospitals and ambulances should be respected, this is not always adhered to and medical facilities may be damaged by inadvertent or intended bombardment.

Haifa Hospital, initially a five-story building, was hit hundreds of times by bombs and mortars and the two top floors were demolished piecemeal (Figure D-1). The emergency care complex was situated in the basement and there were wards in the basement and on the ground floor. Medical and nursing personnel ventured out of the hospital rarely or not at all during periods of fighting, sometimes lasting weeks on end.

One may have to face the decision of whether (as foreign personnel) to be evacuated or not. In our position, evacuation would have been extremely difﬁcult and, in any case, we chose to remain.

Austere Conditions

There are certain basic essentials for the provision of surgical care for the victims of war. “The wounded need access to a safe place, supplied with water and power, where they can receive competent surgical treatment, backed up by good nursing care, within a well organised system, which

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receives adequate supplies.”⁵The surgeon and the anesthetist may not be the most important aspect of providing care, and if the infrastructure breaks down, then proper surgical care may no longer be possible. During the six- month period of ﬁghting around Bourj al Barajneh, the camp was under siege. There was no evacuation of patients and no replenishing of supplies, requiring rationing of resources. Disposable items were reused after cleaning. Many wounds were left open after primary wound excision, to be closed by secondary intention, thus preserving anesthetic and suture material for life- and limb-saving surgery. Patients managed their own wounds by keeping them mechanically clean by washing and applying dressings, if necessary. The increased morbidity of leaving wounds open was difﬁcult to quantify, but no patient died whose only injury was soft tissue. Antibiotics were used sparingly. Gas gangrene was seen when we had run out of penicillin.

“The hospital will not function without water and electricity.”⁵The electricity was cut off from the camp early. The generators at the hospital were used and run only for emergency use. The water tank on the roof was damaged and had to be resituated on the ﬁrst ﬂoor behind reinforced walls.

Fatigue and exhaustion were eventually compounded by hunger and starvation when food stores ran low. Under-nourished patients had more complications. The future looked bleak and “burnout” was seen amongst hospital staff. One doctor disappeared from the hospital for several days

Figure D-1. The hospital after the battles.

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after a particularly difficult case and returned to work, but remained a recluse. These were not military personnel, who might be more disciplined, but civilians. Generally, the hospital staff worked well as a team, importantly supporting each other through difficult times. Small acts of generosity, such as families bringing in food for the staff from their own meager stores, were vitally important for morale when faced with hunger. Battlefields and conditions change rapidly, and just when everything appeared hopeless with starvation and threat of mass slaughter, the overall political situation changed; the Syrian Army intervened and the fighting ended, allowing for replenishing of supplies and eventual evacuation of patients still requiring further care.

References

1. Cutting PA, Agha R. Surgery in a Palestinian refugee camp. Injury. 1992;

23:405–409.

2. Jackson DS, Batty CG, Ryan JM, McGregor WSP. The Falklands War; Army ﬁeld surgical experience. Ann R Coll Surg Engl. 1983;65:281–285.

3. Rowley DI. War Wounds with Fractures: A Guide to Surgical Management.

Geneva: International Committee of the Red Cross; 1996.

4. Bowyer GW, Cooper GJ, Rice P. Management of small fragment wounds in war:

Current research. Ann R Coll Surg Engl. 1995;77:131–134.

5. Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H. Hospitals for War-wounded.

Geneva: International Committee of the Red Cross; 1998.