Resource
Prehospital
Hospital
After discharge
Equipment
Tourniquets
Topical hemostatic agents
Splints
Beds/mattresses
Sterile attire
Sutures
Surgical instruments
X-ray machines
Vascular shunts
Anesthesia machine
Prosthetic limbs
Walking aids
Wound care supplies
Facility
–
Temporary or permanent structure
Electricity
Water supply
OR suite
Wards
Outpatient clinic
Acute rehabilitation
Skilled nursing facility
Hospice facility
Personnel
Paramedics
Local healthcare workers
Nurses
Ancillary staff
Cleaners
Cooks
Are supportive family available?
Language/dialect
Communication between first responders and patients
Communication between healthcare providers and patients
Communication between healthcare providers and family
Medications
Home remedies
Analgesics
Narcotics
Sedatives
Paralytics
Antibiotics
Blood products
Oral analgesics
Oral antibiotics
Community sources (i.e., pharmacy, local herbalist)
Nutrition
Baseline nutritional status of local population
Secure food source for patients (i.e., meal tray, tube feeds, infant formula)
Secure food source at home
Oral nutrition supplements
Local expertise
Understand scope of practice of local healthcare workers and “health givers” (i.e., shaman, herbalists, bonesetters)
Local healthcare workers to orient and assist visiting healthcare workers with provision of culturally appropriate care
Visiting healthcare workers to orient and assist local healthcare workers with recognition and treatment of common complications
Specialty and subspecialty care
–
Presence of in-house teams (i.e., medicine, ortho, neurosurgery, plastics)
Outside facilities to which you can refer
Outpatient follow-up
Transportation
Ambulance
Taxi
On foot
Gurneys
Wheelchairs
Stairs
Elevators
System for transporting debilitated patients to aftercare facility or home
A good example of this comes from the US military with their forward surgical teams that were deployed widely in Iraq and Afghanistan, equipped with limited supplies and personnel. In spite of these constraints, damage control laparotomy became a standard practice due to the presence of an extensive onward transportation network. In-flight critical care resources allowed for the safe transfer of these patients to more liberally equipped field hospitals where definitive care could take place. Such care would not be feasible at a hospital in rural Africa, for example, where referral centers are not immediately accessible.
This highlights the importance of identifying accessible resources that may be outside of the austere environment as well as transportation options. Once an accurate assessment of the available resources has been made, it is possible to outline realistic care plans with your support staff and your patients.
76.2 What Do I Really Need?
In a resource-limited environment, it is critical to determine what you, as a surgeon, can and cannot do without. We work in a technologically advanced world with easy access to computed tomography, laboratory testing, and readily available subspecialty consultants. When preparing to operate under austere conditions, you must understand that the resources available in your normal daily practice will not be present. In spite of this, it is clear that with a modicum of improvisation, good surgery can be performed without our favorite #1 PDS suture or a Bookwalter retractor. Consider the following examples:
76.2.1 Peripheral Vascular Reconstruction
If you are performing complex vascular surgery in an industrialized nation, then you will want the ability to perform angiography, balloon thrombectomy, and IV heparinization. However, providing vascular surgery in an austere environment may involve only shunting of injured vessels and transferring them to a facility that can provide definitive care, if available. In this instance, IV tubing or small-bore chest tubes can make for acceptable conduits.
76.2.2 Split-Thickness Skin Grafting
You will probably have had experience with an electric dermatome and a mesher, but in an austere environment, you may be faced with only a Humby knife or Weck blade for the very first time. To obtain a large, uniform graft with one of these instruments is an acquired skill. Furthermore, meshing will need to be done by hand by making small incisions in the skin graft, a time-consuming and tedious but necessary process. This seemingly simple procedure takes on a whole new complexity under these conditions. If you are able to familiarize yourself with less commonly used instruments at your home institution, your adaptation to an austere environment will be much easier.
76.2.3 Pleural Drainage
The placement of chest tubes is another area where it is likely you will have to contend with different equipment, as you may be using the classic “three-bottle” system to drain air or blood from the thoracic cavity. The self-contained disposable systems that we use in everyday practice are usually not available in this setting. Thus, familiarity with the intricacies of a three-chamber system is important. Similarly, a Heimlich valve should be placed in the system to prevent backflow of fluid, as the bottles may not possess one-way valves. Heimlich valves may also form the primary treatment for bronchopleural fistulas under these conditions.
Keep in mind that there is no use planning an operation that cannot be successful because of the limitations placed upon you. Sometimes a short period of waiting can be beneficial for both the patient and the surgeon. For example, if a non-urgent operation is likely to result in significant blood loss, it is prudent to delay surgery until a source of compatible blood products can be found. Similarly, if a missing piece of equipment or medication can be sourced in a short period of time, temporizing surgical therapy may be appropriate. However, locating a Fogarty embolectomy catheter in the middle of a war zone is highly unlikely, and urgent surgery should not be delayed. When it comes down to it, our clinical judgment and surgical skill may be more important than suture selection and instrument availability when it comes to the care of patients in austere environments. Under these conditions, the surgeon will have little backup and needs to demonstrate creativity and composure in the face of significant resource constraints.
76.3 Improvisation
A wise orthopedic surgeon working in Africa once said, “The secret to a good surgeon is an ability to improvise,” and nowhere is this more true than a resource-limited environment. While it goes without saying that improvisation is required under these conditions, there is a substantial difference between making do with an unfamiliar brand of prosthetic mesh and performing surgery with the patient under a ketamine anesthetic without proper lighting or ventilation.
Physicians who are going to work in an austere environment should familiarize themselves with older editions of surgical textbooks including an atlas of surgical procedures, as they may find themselves performing operations which have fallen by the wayside in modern surgical era. Surgery for peptic ulcer disease would be just one example. In places that lack widespread access to proton pump inhibitors and therapy for H. pylori, complicated PUD may be more common and definitive acid-sparing procedures may be required. An older edition of Zollinger’s Atlas of Surgical Operations makes both a great reference for unfamiliar operations and a useful gift to the medical staff when you depart. The World Health Organization has a publication entitled “Surgical Care at the District Hospital” which, while very simple for the practicing surgeon, still has a number of useful tips and can be downloaded online. The International Committee of the Red Cross has also produced a downloadable book called “War Surgery” that may also be of use to the surgeon. In addition, a number of the NGOs have developed courses that are specifically designed to help broaden the expertise of surgeons to enable them to deal with the different management techniques that need to be employed for wound and burn management, orthopedic injuries, and neurological trauma.
In addition to familiarity with unconventional equipment and historical surgical procedures, a general surgeon operating in an austere environment would be wise to have knowledge of a handful of procedures that are more commonly practiced by other surgical specialists. A list of recommendations can be found in Table 76.2.
Table 76.2
Useful procedures for general surgeons working in austere environments
Cesarean section |
Hysterectomy |
Jaw wiring |
Application of external fixator |
Suprapubic catheter placement |
Vascular shunting |
76.4 Minimizing Complex Postoperative Care
Proper patient selection is an important aspect of surgical care and is heavily informed by the availability of particular resources. An important aspect of patient selection that should be carefully considered in an austere environment is the complexity of postoperative care. In many austere environments, surgeons and support staff are present for finite periods of time. As a result, patients and family members who may have very little medical background will be required to provide postoperative care without assistance. This fact should be considered before committing to a surgical plan that burdens a patient with complex and long-term postoperative care.
An example of a procedure that may result in a significant and unnecessary postoperative burden is stoma creation. The majority of patients suffering a colonic injury from trauma can be primarily repaired, and committing a patient to a stoma that you may not be around to reverse is problematic. Stoma education as well as the availability and cost of stoma supplies in an austere environment may be prohibitive. If stoma creation is required at the time of initial surgery, serious consideration should be given to early closure of a stoma during the patient’s hospital stay; this has been shown to be safe and efficacious.
In an austere environment, thought should also be given to the complexity of postoperative wound care. An open skin incision, for example, may represent an excessive burden in a place where wound VACs are not feasible and gauze dressings are scarce. Consideration might be given to lose primary closure of contaminated wounds with a brief period of daily wound probing or delayed primary closure. Similarly, surgical drain management by patients and family members without close supervision and follow-up may result in significant wound complications and is ill advised.
76.5 Allocation of Scarce Resources
The concept of triage, thought to have originated in France in 1792, was originally applied as a means of sorting wartime casualties into immediate, urgent, and non-urgent categories. In the modern era and in the civilian sector, these categories have been modified and have come to take on slightly different connotations. Regardless, the availability of certain resources will directly influence our ability to provide surgical care.
Under austere conditions, care for a patient with a traumatic brain injury, for example, may be limited to basic life support. In the absence of computed tomography, neurosurgical expertise, and intensive care resources, therapeutic intervention cannot be undertaken. Similarly, a cervical spinal cord injury may be lethal in this setting due to the lack of a mechanical ventilator or a reliable power supply. Severe burns represent another type of injury that cannot be cared for effectively in the absence of critical care resources.
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