How to use the book

Do not let the size of this book intimidate you. Let it be your companion in the war zone. It has to be comprehensive, since it might be the only book you can afford.

We also know many of you have only very basic medical education. We therefore spend time explaining things.

The book is in three parts

The first part of the book is about Primary Trauma Care and it is marked by the black strip on the top of the pages. Most fatalities occur outside the reach of hospital surgons. This section explains how deaths can be avoided by life support given by trained non-graduate health workers. This is the section that everyone interested in helping survivors have to study, whether you are a graduate or non-graduate.

The next part of the book concentrates on surgical and anesthetic techniques.

Those who are not keen to work inside the operating theatre can be excused from reading it. It is marked with the black strip at the bottom of the page. We know from experience that many doctors in the third world do not have the luxury of a lengthy surgical and anaesthetic training, and indeed many surgical training programmes in the high-income countries are not suited to the situation in poverty stricken third world countries attacked by sophisticated weapons.

We write surgical techniques with them in mind. We do not think the concept of “Read One – Do One” is a good way to practise surgery, but we know there will be some of you who have no choice. For some of the authors at least that was how we started. Study the techniques well, email us with your queries and suggestions.

The last part is unmarked, and is scattered throughout the book. It is about logistics, teaching, documentation, audit and research. In the war zones of the Third World, thousands are killed and wounded. Their medical attendants have continually developed better and more efficient methods of dealing with the wounded.

Yet very rarely is their voice heard in established medical and surgical literature.

Eg. you can hardly find one word in the “classic” textbooks on post-injury malaria Falciparum, a threat to a population of 400 million people around the globe.

Therefore we have paid much attention to documentation, audit, and research, and communication. It is the duty of all to report and share experience and new techniques, to encourage each other, to constructively critique each other so that we are no longer alone. This is the culture of enabling survival – the forum for survival.

There is one more book to study. Surgeons often consider the job done when the patient is carried out of the operating theatre – and definitely so when he is discharged from the hospital. Thirty years of surgery in the war zones in the South has taught us that they are wrong: a lot of survivors in poor communities suffer

from chronic pain and a sense of worthlessness, so much that they cannot carrty an artifical limb, and much less provide for their family. In fact, poverty is as much a trauma as the injury itself. So, the end-point where you should measure success or failure of treatment is not the operating theatre – but the village and the urban slum, months and years after injury. Lizz Hobbs’ beautiful rehabilitation manual, Life After Injury, helps you find ways to cope in the long term, see reference list, see p. 849.

There is a pocket folder at the back cover. It helps you keep the head cool in difficult situations, especially when treating child victims.

Foreword to the First Edition

War Surgery, field manual is written for health workers and doctors in the front line, how-to-do-it-yourself, and teach others to do it. It is on life- and limb-saving procedures, and on organizing war medical services in the field. We also hope it is useful to the experienced surgeon faced with mass casualties under difficult conditions

with few resources.

There are other books on war surgery, mainly written for well-equipped armies and hospitals. This manual looks at surgery from a different angle – from the standpoint of deprived Third World communities caught in wars they did not ask for.

As surgeons working with Afghan peasants, the Palestinians in refugee camps, querrillas in rural areas in South-east Asia – people caught in wars they did not start and are unable to stop – we should be truly depressed by the injustice of the situation:

Poorly equipped local medical services in poverty-stricken areas and paramedics with little formal education are made to cope with injuries from the most advanced weapons of modern warfare. Logic would say that when a village or refugee camp is “blanket” bombed to saturation level, the people being injured there would stand no chance of survival.

But the reverse is true. We learn from our fellow health workers a whole new way of looking at problems. We should not simply look at the wounded in the way surgical textbooks have taught us – dividing the patient into systems. Because resources are so scarce, we have to look at the enormous healing capacity of the

human body as our best “ally” – and look at surgery as a total supportive strategy to assist that healing capacity. And we should look at the injured person as someone who is not a passive recipient of medical attention. The patient is actively trying

to help himself, and so are his family and friends. The patient and his community therefore become part of the medical team, as operation assistants, blood donors, nurses and physiotherapists. They also teach us how to use local food resources for nutrition, and how to improvise and “pirate” equipment which would otherwise be beyond their reach.

The wounded start dying at the time of injury, and can only survive if he recieves life support and surgery immediately. In the war zones of the Third World, who are the surgeons? We ourselves have to come to terms with the traditional hangup that only qualified surgeons can do life-saving operations. One of us had an

Afghan peasant as a fellow surgeon, and the other a nurse as chief orthopaedic resident surgeon. And it is our belief that if the “copyright and patent” on surgical knowledge are broken, then many more talented people will come forward.

With an experience drawn from 15 years working in various war-fronts, and always under the constant teaching of the people we work with, we feel ready to synthesize what we learnt in the field, teaching materials from training courses we conducted, and our scientific medical background into this manual. Our book is written for and about the “little man” struggling under enormous odds, with very little to fall back upon. We can only admire his strength. His survival proves the effectiveness of his methods.

This manual is dedicated to him.

1994

Hans Husum

Foreword to the Second Edition

Much has happened since the first edition of War Surgery, written a decade and a half ago. We quoted Joseph Trueta, the English surgeon who worked in the Spanish Civil War, in the front cover of that edition: “What are the defensive mechanisms which the body sets in motion to repair wound damage and to protect the whole system from the consequent dangers? This is a vital question to which we should know the answer before undertaking any kind of treatment”.

Dr. Trueta is still with us; his warning to trauma care providers, made in 1938, has become even more relevant today. The close of the twentieth century and the dawn of the new millennium have seen

massive advancement in weapon technology. Moreover there is much readiness to use these weapons with impunity. Modern warfare seems no longer about conquest and rule – it is about deconstruction, fragmentation and destruction of entire communities and even countries. Freed from the need to restore stability after conquest, modern wars are simply about destruction – just lay waste and leave.

More importantly, they have the ability to carry it out, and within a short time frame. Targets are no longer limited to combatants but intentionally include large number of civilians. Neither is war confined to fire-power only; starvation and hunger, economic embargo have all been mobilised in the service of the powerful

in their attempts to break down those their weapons failed to kill. Manipulation of public opinion and the media ensure that truth becomes a casualty of such wars. They seek to destroy life, but also hope, aspiration, and truth.

So what do we do at the receiving end? We have to strengthen our defence force against these aggressions. Firstly, we have to keep abreast of the latest advancement in weapon technology and understand the special effects they create. For instance, to effectively treat the casualties we have to know how the newly developed DIME – Dense Inert Metal Explosives. Secondly, our knowledge of how the body works in response to injury has also advanced. Our understanding of physiology has improved, and concepts such as hypotensive resuscitation and damage control surgery develop as a result. Better understanding of microbiology such as bacterial biofilms has reinforced our practise of meticulous debridement as infection control rather than depend on antibiotics. Perforator soft tissue flaps make us heal open fractures in a better way. These are but a few examples.

The first edition of War Surgery is doing well, and has found its way into clinics and hospitals all over the world. In this second edition we updated the chapters on prehospital care with guidelines from the handbook “Save Lives, Save Limbs” (see books recommended for further studies, see p. 846). Also the information on modern weaponry and the physiological responses to injury are brought up to date. We now know that surgery is conceived by the injured body as another traumatic event, that it may be devastating if carried out wrongly. A protocol for staged life-saving surgery is therefore included in the revised edition.

The Foreword to the First Edition of War Surgery resounds with our respect and confidence in the abilities of health workers in Third World war zones. Since then, we have seen the publication of solid reports documenting improvement in survival rates in the Third World through the implementation of low-tech chain-ofsurvival

trauma systems. Our confidence in our colleagues – graduate and nongraduate – in the South is therefore well founded. Facing the atrocities of the 4th Generation War we should not be intimidated, but go on to heal the wounds, rebuild the broken societies, and teach new generations better strategies for survival.

Authors and contributors

Hans Husum

is a general surgeon with thirty years of experience with popular movements in the war zones and mine fields of the Middle East, Iraq, Afghanistan, and Southeast Asia. He is a founding member of Trauma Care Foundation, an institution developing teaching aids in trauma care for low-resource communities. Hans Husum heads Tromsoe Mine Victim Resource Center, an action-research center at the University Hospital of North Norway and has published extensively on trauma systems in war with colleagues in the South.

Erik Fosse

is specialist in general and cardiothoracic surgery. He is professor of surgery at the University of Oslo and director of the Interventional Centre, which is a research and development department at Oslo University Hospital. Erik Fosse is the director of NORWAC, a humanitarian medical NGO working mainly in The Middle East and the Balkans. He worked as a surgeon with the Afghan resistance

in 1986 and in Albania during the Kosovo war in 1999. Since 1979 he has worked during several wars in Lebanon and Palestine with Palestinian organizations, including the war in Gaza in January 2009. Erik Fosse is consultant in war surgery with the Norwegian Military Medical Services.

Swee Chai Ang

is consultant trauma and orthopaedic surgeon at St Bartholomew and the Royal London Hospital, England. She and her team treated many of the major casualties of the 2005 7/7 bombings in London. Since 1982, she has worked on multiple occasions as orthopaedic surgeon to the Palestinians in the Lebanon and Gaza, with the

Palestine Red Crescent Society, the United Nations and WHO. She is co-founder and patron of the British Charity, Medical Aid for Palestinians. She has also been on several relief missions to the Pakistan Kashmir earthquake. Her publications include papers on acute care of the war wounded. She penned her survivor  eyewitness account of the 1982 Beirut Sabra Shatilla massacre in her book “From Beirut to Jerusalem”. The late Yasser Arafat awarded her the Star of Palestine for her work with his people.

List of contributors

Saeed Stroemmen-Bakhtiar, PhD

Associate Professor, Centre for Enterprise Architecture and Information Systems (SVAIS), University of Nordland, Norway.

Chapter 5

Yang Van Heng, MPH

Director, Trauma Care Foundation Cambodia.

Chapter 1 and 2

Mohamad I. Hijazi MPH

Director, Rassoul Alazam Hospital, Lebanon.

Chapter 1

Bjoern Karlsson, Orthopedic Engineer

Tromsoe Mine Victim Resource Center, University Hospital North Norway. Chapter 13 and 17

Johan Pillgram-Larsen MD

Senior Consultant, Department of Cardio-Thoracic Surgery, Ullevaal University Hospital, Norway. Chief Consultant Surgeon, Norwegian Armed Forces Medical Services.

Chapter 8

Ole-Kristian Storjord Losvik MD

Director of Research, Tromsoe Mine Victim Resource Center, University Hospital North Norway.

Chapter 4 and 6

Mudhafar Kareem Murad MD

Director, Trauma Care Foundation Iraq.

Chapter 1 and 2

Assaddullah Reha MD, PhD

Director, Mobile Emergency Medical Center, Afghanistan.

Chapter 1 and 3

Mohamad H. Sayeed MD

Consultant, Department of Surgery, Rassoul Alazam Hospital, Lebanon. Islamic Health Society, Directorate of Civil Defense.

Chapter 1 and 8

Nenad Tajsic MD, PhD

Senior Consultant, Department of Orthopedic and Plastic Surgery, University Hospital North Norway.

Chapter 13

Knut Wester MD, PhD

Senior Consultant, Department of Neurosurgery, Haukeland University Hospital, Norway. Professor, Faculty of Medicine, University of Bergen.

Chapter 8

Reiner Winkel MD

Chief, Department of Hand and Reconstructive Surgery, BGU Trauma Center, Frankfurt am Main, Germany

Chapter 13

Chapter 7 is based on the manual Save Lives, Save Limbs, Third World Network, Penang, 2000, by Hans Husum, professor Mads Gilbert, Department of Emergency Medicine, University Hospital North Norway, and professor Torben Wisborg, Department of Acute Care, Hammerfest Hospital, Norway. The authors of War

Surgery are responsible for the revision of the original text.