War Surgery and the ICRC

(15B-68)

 

War surgery and care of the wounded is actually only a very small part of the work of the Medical Division.

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There is always a much greater need for clean water, adequate nutrition and protection of access to pre-existing health structures, so the ICRC rightly concentrates its resources on these needs (15B).

Nevertheless, over the last fifteen years the ICRC has established seven independent hospitals for war-wounded near or within the border of the country where conflict is occurring, and it has placed surgical teams in 18 pre-existing facilities in conflict zones. Up to 18,000 war casualties have thus been cared for each year, by hundreds of civilian surgeons and anaesthetists on 3-6 month contracts with the ICRC or with their National Societies.

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As a result, the ICRC has accumulated a wealth of experience in dealing with war wounds, experience which has shown the efficacy and necessity of management by well-applied basic principles of war surgery. These principles are not new and have been known and practised by generations of military surgeons (16-18), though they often have had to be relearned by surgeons new to war.

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Over the last five years the ICRC has run an annual War Surgery Conference at Cartigny near Geneva to impart this experience to surgeons and anaesthetists about to embark on missions in ICRC hospitals.

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The valuable lessons learnt by the ICRC through its unrivalled experience of war surgery have been increasingly well documented over the last few years. These lessons cover aspects such as first aid, triage, wound classification, wound excision and delayed primary closure, penetrating head injuries, blood transfusion, Surgery and anaesthesia, vascular and abdominal injuries, limb injuries, amputations and antipersonnel mine injuries - all of direct relevance to military surgeons.

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First Aid (19)

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Two major problems of war casualties are firstly that they seldom receive adequate first aid and secondly that their access to hospital is either non-existent or delayed and hazardous. The Medical Division of the ICRC therefore, strives to improve first-aid training for combatants and civilians and to provide transport for the wounded. It has also established first aid posts near conflict areas, where wounds are dressed, fractures are splinted, intravenous infusion is started, and antibiotics

and analgesics are given, prior to transport to ICRC hospitals (19).

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Triage (20-24)

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The ICRC hospitals have often been inundated by large numbers of both civilian and combatant war injured, such that the available surgical facilities are overwhelmed. The ICRC has documented its practical, well-tried system (20-23) for the benefit of anyone, including military medical personnel, who may have to deal with large numbers of war wounded with limited resources.

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The triage categories (22) used in ICRC hospitals are:

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Category I, requiring urgent surgery and with a good chance of reasonable survival;

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Category Il, who do not require surgery. (This includes both patients with very slight wounds and those so severely injured as to be unlikely to survive);

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Category Ill, who can wait for non-urgent surgery. This triage system was used effectively by the Saudi Arabian teaching hospital which treated the majority of American soldiers wounded in the Al-Khobar Scud missile disaster of 25 February 1991 during the recent Gulf War (24).

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Wound Classification (25-30)

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"Treat the wound not the weapon". Recognition that wound management is determined by the wound severity (i.e., both by the structures involved and more importantly by the overall size of the wound) rather than by the weapon or presumed missile velocity has led to the formulation of the Red Cross Classification of War Wounds (25).

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In this system certain features of the wound are scored: the size of Entry and exit wounds; whether there is a Cavity, Fracture or Vital structure injured; and whether Metallic foreign bodies are present. Subsequent analysis allows the wound to be graded according to the amount of tissue damage.

 

Grade I signifies low energy transfer,

 

Grade 2 high energy transfer,

 

and

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Grade 3 a massive wound. The wounds can also be typed according to structures injured, Soft Tissue, F, V, or VF. Grading and typing place any regional wound into one of 12 categories of comparable clinical significance.

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This provides a new means of understanding, communicating, and gathering information about war

wounds and their management (25-26A). For instance, it has shown that certain small uncomplicated Soft Tissue fragment wounds can be treated initially without surgery (26B).

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Red Cross and Red Crescent Movement

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An important application of this Classification is in assessing whether one or both sides of a conflict are using ammunition that contravenes the Hague Declaration of 1899, which specifically forbids the use of small arms ammunition that disrupts in the body after impact to cause unnecessarily severe wounds (27-28).

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Since its inception the Red Cross Classification has been used in all ICRC hospitals. It has also proven its worth in the evaluation of civilian shotgun wounds in the United Kingdom (29) and in the assessment of wounded military personnel treated in a British field hospital in the 1991 Gulf War (30).

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