Conflict and Catastrophe Medicine Flashcards
What are disasters?
Overall a small contributor to the global burden of injury
media attention
artificial distinction between natural and man made - all are man made
where and how people are forced to live
vulnerability of affected community
poverty
main threat to health is mass movement of people - not orthopaedic injury
What is the epidemiology of disasters?
Last quarter of century: 3 million deaths, 1 million people affected
annually 250,000 deaths
£23 billion cost
increasing by incidence
by 2100, 17 of 23 cities with .10 million inhabitants will be within at risk zones
About natural disasters
Tsunami
Pakistan earthquake
Haiti
Developing world locations
resources overwhelmed
delayed, haphazard international response
average of 2 earthquakes > richter 8 per year
33 earthquakes with > 1000 deaths since 1980
injuries, number, severity
What is the sub-saharan African shortage of workforce?
falls short of the WHO guidelines of 25 doctors per 100k population
Orthopaedic surgeons distribution
80% of all orthopaedics surgeons are in developed countries (26 of 191 nations)
only 40 in 8 east African countries - population of 200 million
problems - recruiting surgeons, medical migration
What is the need due to conflict?
160 wars and armed conflicts in 1945 mostly developing world 50 currently 22 million killed, 3x as many injured 90-100 million landmines 500 million small arms 125 million AK 47 ? duration
What is a complex emergency?
Combine any of:
- natural disaster
- conflict
- famine
- mass population movement
- social and political breakdown
Ongoing, not time limited
haiti
What is the delivery of emergency disaster assistance like?
- Chaotic aftermath of natural disaster
- Local infrastructure and resources overwhelmed
- Delayed & inaccurate assessment
- Lack of coordination between agencies / govts
- Competition between NGOs
- Inefficiency, duplication
- Lack of accountability
- Short term volunteers, no continuity of care
What is the UN (IASC) cluster system?
• 2005 UN review of global humanitarian system
- Coordination be strengthened
- Central emergency response fund
• Clusters
- Increase capacity
- Leadership (WHO for health, UNHCR for IDPs, WFP in logistics))
- Agreed objectives
- Accountability
- Field-level coordination
• Global (11) or field level ( number may vary)
• Pakistan earthquake
• Timor-Leste 2009
• Accountable to UN ERC ( Baroness Amos)
• Participation not mandatory: ICRC, MSF etc
What is DFID/UK aid?
· UK is 2nd largest bilateral humanitarian aid donor
· £528 million in 09/10
· Mostly via partners
· 11% on humanitarian emergencies
· ECHO £100m, ICRC £66m
· Small amount of “direct” aid; Ops team (CHASE OT) and UKISAR
What is the disasters and emergencies committee (DEC)?
· Created 1963 · Up to 15 charities working in disaster field (currently 14) · Joint fundraising · Response focal point · Co-operation & coordination · Accountability & effectiveness · Each member: § Income > £4m / yr § Emergency work > £10m / yr § Good governance
What did the recommendations of the 2007 crisp report include?
- links between NHS and developing world (THET)
- education and training
- improved UK medical response to disasters (database, coordination, release of staff)
About the Haiti earthquake…
· 12 January 2010 · Richter 7.0 · First “mega-urban” less developed world disaster · 200,000 dead, 300,000 injured · Within 1 month § 600 organisations § 274 in health field · “Wild market” , not coordinated help · UK major donor § DFID £7.5 million § DEC £101 million · UK Human resources § Initial assessment team(4), 64 SAR § No database § Minimal pre-training § Short duration § No coordination
What is the international emergency trauma register (IETR)?
• Following Haiti earthquake • Meeting of DFID / DoH & interested NGOs • Hosted by UK Med • Database of volunteers – Accredited / trained – Up to date – Prospective agreements with employing Trusts for timely release for reasonable duration – Funding – First used for Libya conflict 2011
What is the humanitarian emergency response review (HERR)?
· Commissioned by Sec of State · Chaired by Lord Ashdown · Reported March 2011 · 40 recommendations: § Anticipation , resilience § Leadership § Innovation § Accountability § Partnership § Delivering differently § ….. ‘Incorporate surgical teams into first phase deployments, especially after earthquakes.’
About emergency projects…
· Unpredictable level of activity · “on-the-bus..off-the-bus” · ?Duration · Funding · Security · Very few organisations able to mount field hospitals
About Foreign Medical Teams and their involvement in disasters…
· Huge increase in FMTs responding to sudden onset disasters (SODs) · WHO cluster report · Classification o Outpatient o Inpatient emergency surgical care o Inpatient referral care o Specialist teams · Minimum standards · ! Most lives are saved by early local provsion not FMTs
What is the military involvement in humanitarian assistance?
· Long history of military involvement in disaster situations § Affected country § Foreign troops · Contentious · “Oslo” guidelines · Advantages § Strategic planning § Surge deployment § Logistics / communications · Future Reserves report 2011
What is disaster risk reduction (DRR)?
· Artificial distinction between “natural” and “man made
· “At risk” areas can be identified
· Measures taken to protect vulnerable populations
Investment in infrastructure as emergency preparedness
What sit eh hypo framework for action (HFA)?
- World conference in Kobe, Japan 2005
- Building resilience of nations and communities to disasters by 2015
- 168 signatories
- 5 Priorities:
- DRR as national / local priority
- Assess risks, enhance early warning
- Innovate / educate to build resilience
- Reduce risk factors
- Strengthen disaster preparedness
About disaster/development…
- Increasingly humanitarian aid and development aid is merging
- Funding and access post disaster is opportunity for development
About typhoons…
- Mature tropical cyclone
- Develops in the western North Pacific
- Throughout year, but mostly June-November
- Factors:
o Warm sea temperature
o Atmospheric instability
o High humidity
o Coriolis force
What is the UK international emergency trauma register?
· Crisp report recommendation (2007) · Revisited in wake of Haiti earthquake · Joint initiative DFID / DoH / NGOs · Administered by UK-Med · Surgeons, anaesthetists, emergency physicians · Aims for prospective agreements with Trusts · Website www.uk-med.org/trauma · Activated by Secretary of State · Under Merlin / Save project
What is Manilla?
· Merlin coordinator attending WHO / MOH cluster meetings · “Level 1” response · Logistic support · Personal contacts · Initial tasking N Palawan · Team arrived 14 Nov · Re-tasked Northern Cebu
About HMS Daring…
· Type 45 destroyer · Complement 190 · Lynx helicopter · Tasked to assess impact on remote outlying islands · UKIETR team: o 2 x ER physicians o 2 x ER nurses o 1 x GP o 1 x plastic surgeon
About Tacloban…
· Leyte Island, Philippines · Eastern Visayas region · Population 221,000 · Highly urbanised city · Transportation hub · First landfall of Haiyan o Wind o Storm surge wave
AUSMAT staffing…
· c50 Australian staff · 1 x medical director · 4 x ED physicians · 2 x surgeons (1 ortho, 1 general surgeon) · Firemen as logisticians · Mostly from Northern Australia · Exercised together
WHO cluster meeting tacloban
· Daily 1700 WHO DoH cluster meting at EV hospital
· Coordination of medical teams
· Assessment of outlying areas
· Commissioning response, eg mental health
Extraction from Tacloban…
· By 23/24 November fewer injuries presenting
· Emphasis of healthcare assistance moving to:
- Primary healthcare
- Paeds/O&G
- Water/sanitation
- Shelter
- Reconstruction of local healthcare infrastructure
Save the children field hospital - tacloban
· tacloban team contributed to over 1000 consultations and 100 operations
· save now commissioned to provide UK civilian field hospital
· on location, treating patients within 72 hours…
What is the nature of war and conflict?
- The essence of war/conflict is the implied or actual use of force
- War/conflict is the process of organised and purposeful use of violence of one human group against another
- War implies an act by a sovereign nation state
- Conflict often undeclared and intra-state in nature
- Massacre, genocide and criminal behaviour
- The question of legality!
What is the legality of war and conflict?
- How effective is international law in legislating global conflict?
- Blunt tool for increasingly complex states of warfare
- Rule of law dissolving within a state
- Rarely universal consensus
- No enforcement within a state
- Enforcement by other countries dependent on politics?
- International laws slow to adapt to changing nature of war ie increase in intrastate conflict, technology
What are the traditional concepts of war?
- Symmetric (conventional) Warfare (Clash of equals)
- Asymmetric Warfare (Clash of unequals)
- Protracted struggle (Giap/Vietnam, IRA, Basques) – Terrorist war?
- Manoeuvrist Approach vs attrition (exploiting uncertainty)
- Technocentric Warfare (Standoff, Remote, Drones) – Wars of the future?
What is symmetrical warfare?
Similar power, resources and strategies (varying execution)
what is asymmetrical warfare?
(Mack 1975)– imbalance in forces, and/or strategies eg established army and resistance (undermanned and underequipped) – insurgency/terrorist as well as counterinsurgency/terrorism
How does the use of warfare vary?
varying use dependent on Military (use to describe varying indirect/unconventional strategies of weaker actors) vs academics seeking to explain the weak versus the strong
Warfare methods are on a continuum between attrition (wear down through continuous loss of personnel and supplies/equipment, often won by armies with greater resources) manoeuvre (killing by stragegically disrupting the enemy, often used by smaller, more cohesive, well trained armies)
What is the conflict analysis framework?
Actors
Who are the primary actors in the conflict? Who are the secondary actors? Who else has influence over events?
Root Causes
What is driving the conflict? What are the needs and fears of each group?
Issues, Scope and Stage
What are the key issues for each side? What phase is the conflict in? Who is suffering the most?
Power, Resources and Relationships
What are the resources and capacities of each side? What is the state of the relationship among the leaders? What are the existing channels of communication?
History of the Relationship
Did the parties ever co-exist peacefully? What were the previous attempts at a settlement, and why did they fail? Was there a pattern to the failures?
What is the spectrum of conflict?
- Military Assistance (early Vietnam)
- Humanitarian Operations (Early Balkans)
- Peace Support Operations (Balkans later)
- Low intensity Operations (Britain’s Colonial Wars)
- Mid Intensity Operations (Falklands war – Limited use of available weapons)
- High Intensity Operations (Iraq 2003 - Full and Integrated use of full range of weapons)
What has been the evolution of war?
• Ethnic violence
• Genocide
• Rwanda, Croatia, Bosnia, Kosovo, break-down of communism
• Civil violence
• East Timor, Sudan
• Arab Spring:Egypt, Syria
• Post-interstate war: Iraq, Afghanistan
• Interstate war
• Iraq x 2 , Afghanistan
Since WWII, reduction in interstate wars but significant rise in intrastate conflict (93 wars in 70 countries between 1990-95 = a quarter of all conflict deaths since WWII), subsequent lull until 9/11
What is the modern era of war?
- Characterised by world wide terrorism on an unprecedented scale
- Emergence of non-state actors (militias, gangs, war lords)
- Intra-state conflict rather than inter-state war
- Emergence of international terrorist groups – Al-Quaeda & ISIL
- Unheralded terrorist outrages
- The west’s response – expeditionary warfare
- Elusive enemy leading to asymmetric war
- Stand off weapons - incidental or deliberate targeting of civilians
- “Bombing the enemy back to the stone age”
- Hatred and rage
- The emergence of failed & rogue states
- The elephant in the room - Globalisation
What are the threats to the west?
- Bombs is Europe and US (and elsewhere)
- Suicide bombings
- CBRN threats
o Dirty bombs
o Chemical 7 biological attacks
o Chimeras - Cyber warfare
- Hybrid warfare (Frank Hoffman)
Global death by conflict
- How easy is it to collect data in this context?
- Who’s responsibility
- Controversy around Iraq
- Lancet surveys:
- 2004 (without Fallujah) & 2006
- Direct & indirect deaths
- Higher estimates than Iraqi Health Ministry, UN
- Divided belief; govts, epidemiologists Iraq Body Count
- Iraq body count:
- UK & US academics
- media based estimates
- Most quoted estimates – criticised by the conservative right but used over Lancet
- Criticism of cluster sampling (Spagat)
What are failed states?
- No consensus definition
- failure in state sovereignty
- loss of authority for enforcing legislature
- loss of sole legitimate use of force
- non-provision of public service
- reduced interaction with international community
- Consequences
- Corruption & criminality
- Intervention by non-state actors
- Internally displaced people and refugees
- Economic decline
What is the future of war?
- No precise science: unpredictable
- Adversaries (state/non-state) and threats (conventional and unconventional) will blur
- Range of threats to spread with proliferation of WMD, cyberspace and novel irregular threats
- Battle of narratives will be key
- The qualitative and quantitative advantage may no longer be assumed
- Climate Change
- Pandemics
- Global arena no longer the elephant in the room
Force alone is inadequate - what are alternative ways forward?
- By all means use force but should be limited, focused & not be a recruiting sergeant for terrorist groups
- Force alone will fail
- Northern Ireland as a case example
- Deal with world poverty
- Resolve civil conflicts before they inter-nationalise
- Interdicting terrorist & rogue state funding
- Focus on recruitment & radicalisation
- Pressuring totalitarian and authoritarian states
- Look at wider causes and consequences of conflict
- Achieve the UN’s Millennium Development Goals
What is conflict and what are its physical components?
· Organised fighting between human groups – at its most basic – fists, feet and clubs
· The defeat of one human group by another using the treat or actual delivery of organised and purposeful violence
· At its essence its very currency is injury and death
· War is a form of conflict, but not vice versa
· The nature of conflict continues to evolve and is related to available technology
· The modern trend appears to be towards depersonalisation with killing at a distance with stand off precision munitions
What is face to face engagement in conflict?
· Direct face to face fighting still occurs
· There is a military requirement to close with an opponent and engage him in the most direct and intimate form of fighting
· A vital component of conflict
What are unintentional consequences of warfare?
getting uninvolved civilians - collecting water, shopping
women and children
Threats to the west - new physical component
· Bombs in Europe & US (& elsewhere) · Suicide bombings · CBRN threats – Dirty bombs – Chemical & Biological attacks – Chimeras · Cyber warfare · Hybrid warfare (Frank Hoffman)
a warning from history on war..
“…….a terrible awakening in store for us when we next have to face the hideous horrors of war amidst unfavourable surroundings”
Clinton Dent BMJ 1900
(on the excellent results achieved in the Boer War 1899 – 1900)
What are definitions of a leader?
· ..the function of a leader
· ..a period of being a leader
· ..leader of a group or party
..the ability to lead
What are leadership qualities and attributes?
· Have clear vision o aka objectives · Have a clear strategy · Decision maker · Risk taker · Motivator · Team builder · Self knowledge · Integrity · Life-long learner · Good communicator ‘the art of getting someone else to do something you want done because he/she wants to do it.’ It is not ‘drivership’, which depends on intimidation or fear. Because, when a greater terror than the ‘driver’ presents itself, this form of ‘leadership’ will fail. But…
Do not confused ‘drivership’ with application of a strong will, provided this is backed-up by character, knowledge and, above all, experience.
It is not ‘management’. This is primarily concerned with organising resources rather than people. Because the word management, used without being qualified, does not imply management of people.
Leadership vs management
- Give direction o Contingency planning o Response to crises - Build teams o Alien environment and alien caseload o Multi-national composition - Set an example - Provide inspiration
What is the trait theory of leadership?
Meta-analysis of current evidence suggests…
- Individuals can emerge as leader in a variety of situations and
- There is a relationship between good leadership and certain traits especially:
o Intelligence
o Extraversion
o Conscientiousness
o Learn from experience
o Belief in own ability
o Adjustment
There is nobody who cannot vastly improve his powers of leadership by a little thought and practice – Field Marshall William Slim
The will to detonate, together with the character which inspires confidence – Field Marshall Bernard Montgomery
What are some examples of leadership styles?
Charismatic
o personality driven ‘I’d follow him/her anywhere’
Participative
o hands-on
Situational
Transactional
o reward or punish
Transformational
o redirect subordinates’ needs & thinking. Tend to challenge & inspire
Authoritarian
o close control. Often have distinctive professional relationship alongside direct supervision
Democratic
o share decision-making
Free rein aka laissez faire
delegate, but provide little or no direction ,or support
What is the key thing that leadership needs to be?
Flexible
What is the RMA slant on leadership?
COMMAND: controlling an directing
ORGANISING: what’s to be done and doing it
MANAGEMENT: look after your people
What are some practical issues of leadership?
MISSION ANALYSIS: question, question and question - What ifs? - So whats? - The name of the game is CONTINGENCY Team selection – fit for task Team preparation - What ifs - So whats? - And (intellectually) REHEARSE THE CONTINGENCIES
What are the seven secrets of successful leaders?
- Sensitive to followers
- Positive and inspirational
- Treat followers with respect
- Meeting staff expectations
- Avoidance of arrogance
- Support staff
- A good listener
What is the downside of leaders?
‘Leadership trajectory’ – crash and burn. Why?
o Believe their own hype
o Fail to hide the fact they are trying to be ‘one of the boys’
Qualities of a leader
· Vision aka Objectives · Clear strategy · Decision maker · Risk taker · Motivator · Team builder · Self knowledge · Integrity · Life-long learner · Good communicator Nearly all men can withstand adversity. If you want to test a man’s character, give him power. – Abraham Lincoln
What kind of person should not be a leader?
· Listen · Learn from mistakes · Communicate · Be flexible but, ultimately – be prepared to make a judgement call, aka: a DECISION You should never be allowed to lead. A leader is a dealer in hope – Napoleon Bonaparte
What is the challenge of clinical complexity in trauma?
· Volume of trauma · Severity of trauma · Different concepts o ABC o Damage Control Resus · Different practices o Consultant-based care o Right Turn Resuscitation o Massive transfusion à Media interest
What are the three trauma population groups?
· KIA - 17-20% · Severe but, potentially survivable injuries - 10-15% · Moderate to minor injuries - 65-70%
What is the concept of damage control resuscitation?
it’s a continuum of care, with a significant paradigm shift
aim to maximise tissue oxygenation
minimise blood loss
these two will optimise outcome
What is DCR achieved by?
· BATLS o ©-ABC o Tourniquet/FFD/Topical Haemostatics · Advanced in-transit care o Induction of anaesthesia o Thoracostomy · Haemostatic Resuscitation o Administration of blood and blood products o (rVIIa) Consultant based ED care · Aggressive approach to o Hypovolaemia o Hypotension o Coagulopathy o Hypothermia o Acidosis · Near-patient diagnostics · Focussed abbreviated surgery · Intensive/Critical Care
What is the massive haemorrhage protocol in major injury (FFP:RBC:(platelets))?
Ratio 1:8 - mortality 70%
Ratio 1:2.5 - mortality 30%
Ratio 1:1.5 - mortality 18%
Platelets:RBCs 1:5
What is the difference between NHS and DMS trauma resuscitation?
NHS: emergency department (rests) and theatres (damage control surgery)
DMS: surgery is part of rests and therefore integrated
What has to happen in the first 48 hours to trauma care?
· BATLS paradigm is now: “C” ABCDE o New tourniquet o Novel haemostatics § Chitosan § QuickClot § (rVIIa) · MERT & MERT+ · Hypovolaemic resuscitation · Massive haemorrhage protocol started early 1:1:1 · Consultant delivered service · Surgery as part of the Primary survey: the ‘right turn’ approach · Time-tested principles of war surgery · Damage control surgery when indicated · Rapid return to UK (CCAST)
What are the levels of trauma treatment?
T1 - immediate treatment
T2 - delayed treatment
T3 - minimal treatment
What is T1 treatment?
· T1 Immediate treatment
o require emergency life-saving resus and/or surgery that is not time consuming & has a good chance of survival
What is T2 treatment?
· T2 Delayed treatment
o require major surgery/medical Rx but can wait after receiving sustaining Rx, e g, I V fluids, splintage, antibiotics. Examples: long bone #s; joint injury; burns.
What is T3 treatment?
· T3 Minimal treatment
o relatively minor injuries & longer delay is not life threatening. Can effectively take care of themselves or be helped by untrained people.
§ T4 Expectant treatment
o multiply injuries, need time/materiel consuming Rx. Given supportive Rx
What is the challenge of governance in leadership in trauma?
· Difficult colleagues
o There is not the space for interpersonal conflicts
§ “You are an important component, but a replaceable component”
· Patient safety incidents
o NHS culture pervasive
o Build staff trust
§ High visibility + openness
§ “I want to hear from you, not about you”
§ Be prepared to tackle difficult problems
§ Fair and decisive
· Dealing with cross-boundary frictions
o R1 inadequacies detected at R3
§ Constructive support to build R1 teams
§ Remember to reward exemplary performance
o Coalition PHEC errors/inadequacies
o R3 concerns expressed by R4
§ Clinicians will be highly sensitive to criticism
What is supply chain fragility?
Unprecedented casualty load strains blood stocks
What is the challenge of ethics in trauma management?
· Casualty regulation
o Who is prevented from entering R3?
o When are LNs moved to maintain capacity?
· Treatment withdrawal
o What factors interplay in the complex decisions to suspend/withdraw/withhold treatment?
Balancing conflicting military and medical imperatives.
· Ethical dilemmas are a daily occurrence
· The military imperative demands that local nationals are treated only within the capacity of the hospital
· DMD carries significant professional risk
o Requires experience and mental robustness
o DMD role is to make uncomfortable decisions
What is the challenge of multinationality in trauma management?
· Culture
· Language
· Scope of practice
· Guidelines
· Governance
¨ Key success factor is to avoid “ethnocentrism”
¤ Projecting one’s own frame of reference onto others
¤ The inability to see the situation through the eyes of a different national group
¤ The tendency to prefer one’s own culture over all others
This demands a knowledge and understanding of the cultures of coalition nationalities.
What is PDI?
the acceptance/expectation of distribution of power in the society
What is MASC?
the difference in men’s values (assertiveness/competitiveness) from women’s values (modest/caring)
what are the lessons we can’t take from cultural differences in trauma?
· Shorter “power distance index”
o Expect nurses and junior doctors to question senior doctors’ decisions/opinions
o Greater autonomy of nurses
· Less “masculinity”
Senior medical personnel tend to adapt within team and are non-confrontational (with exceptions!)
· Lower “uncertainty avoidance index”
o Less risk averse
o Less constrained by culture of checks and culture of blame
We need to accept there are cultural differences, prepare for working in a multi-cultural setting and be flexible enough to learn from the strengths of each other’s approaches
What is the challenge of multinational people in trauma management?
“The military machine…is basically very simple and very easy to manage. But we should bear in mind… each part is composed of individuals, every one of whom retains his potential for friction…”
CLAUSEWITZ, On War
people can cause friction
leaders key role: reducing friction
What is the challenge of infrastructure damage in trauma management?
· ED, Theatres, ITU, Admin corridor destroyed
· Hospital on fire
· Evacuate hospital, rescue & treat injured
What is the leadership role in the case of infrastructure damage?
· Contingency planning o Partial damage o Hospital destroyed · Leadership in crisis o Maintaining effect o Restoring effect
What is the challenge of staff degradation in trauma management?
· Outbreak of meningitis + severe gastroenteritis
· 60% hospital staff affected over 3 days
· Hospital quarantined
· Protect the well, treat the sick
What is the MD’s leadership role in presence of staff degradation?
Contingency planning
§ Impact on blood stocks and implication for Emergency D P
Demonstrate clinical leadership in a crisis
What is needed in R3 from deployed medical director?
- Directly managed: hierarchical
- Walking the floor
- Clinically led hospital
- Quality as excellence
What is the health management norm?
- Indirectly managed: consensus led, bureaucratic
- Flying a desk
- Management led hospital
- Quality as compliance
What are the requirements of a DMD?
¨ Deep knowledge of emerging trends and latest practices
¨ Confidence to interdict in any area of system failure
What are the activities of a DMD?
¨ Mentor Med Gp during PDT
¨ Direct leadership of crises
¨ Anticipation of clinical vulnerabilities
¨ Medical intelligence gathering
What is a ballistic injury?
Strictly: physical injury caused by a missile
It’s all about energy ‘dump’, in this case kinetic energy, into the target (tissues)
Wounding power ie missile’s available kinetic energy derived from the formula:
Musket ball - weight but not velocity counted
Modern rifle bullet - velocity is the key
Natural fragments as ballistics
Fragments formed as the weapon breaks up and also objects around it - these cause the most injuries.
Preformed fragments as ballistics
Some weapons have small fragments already in them, designed to cause as much injury as possible.
Red cross data base on ballistic injury
Causes of missile wounds (%) Shell/bomb fragments 47% Mine 21% Bullet 23% Other 9%
Injury produced by stress wave and temporary cavity
Potentially severe within solid tissues, especially those enclosed by bony or capsular integument
- Brain - Liver - Muscle
Importance of treating ballistic injuries…
- All wounds are dirty
- Always dead tissue in varying amounts
- Injury may be remote from wound track - beward covert injury eg vascular
- Missiles do not respect anatomical boundaries
- Not all need surgery
- Excise dead tissue
- Release tissue tension
- Delayed primary closure for all H E-E wounds
- Do not hunt for metal
- Antibiotics alone will do for some
- (specific-for-task bullets)
Most damage is caused by energised fragments.
Simple physics of an explosion…
Blast wave has 2 elements:
• Shock wave - travels at >330m/s, high overpressures, short duration
• Dynamic overpressure - aka blast wind, moves things
Heat from explosive products
What is a shock wave?
• Travels through air - similar to a sound wave
• Characeristics
- Very high overpressures
- Faster than speed of sound in ambient air (»330m/s)
- Effectively instantaneous rise in overpressure
- Short duration (milliseconds)
What is the dynamic overpressure/blast wind?
- Motion of explosive products
- Associated with the shock wave at time of detonation –> shock wave accelerates ahead very quickly
- Moves things due to gas flow
What is overpressure reflection?
- At a surface, sound pressure is doubled
- For shock waves: overpressure at surface may be up to 8 times incident
- Reflection and enhancement will lead to very complex loading
- Atmospheric pressure
What is the interaction of blast waves with the body?
The shock wave:
- Accelerates the body wall - Propagates through tissues as a pressure (stress) wave - Loses energy at air or gas/tissue interfaces eg lung
What is the interaction of pressure waves and interfaces?
passage of a stress (pressure) wave leads to pressure gradients between alveoli
What are the pulmonary and cardiac consequences of a blast?
- Alveolar haemorrhage with consolidation
- Acute pulmonary oedema
- Pneumothorax, haemopneumothorax
- Air embolism
- Adult respiratory distress syndrome (ARDS)
What class injury can occur to the bowel?
- Contusions to large and small bowel - occasional acute perforation - usually associated with primary lung injury
- Difficult to diagnose without laporotomy
- Risk of delayed perforation
- Caused by shock wave (small) and shear (large)
What auditory injury can results form a blast?
- Eardrum rupture - low overpressures required (~35 kPa)
- Sensorineural hearing loss - with high pitched tinnitus
- Ossicular injury with severe blast
- Not a marker for lung injuries
What is the importance of primary blast injuries?
- Generally low incidence in explosions and bombings in the open: high overpressures requires, fragments are principle threat
- Higher incidence in very confined spaces: multiple high frequenct pressure loads
- High incidence with blast weapons
What is overpressure reflection?
• At a surface, sound pressure is doubled
• For shock waves:
- Overpressure at surface may be up to 8 times incident
- Reflection and enhancement will lead to very complex loading
What is the interaction of blast waves with the body?
Dynamic overpressure (gas flow)
- Flow shears tissue eg gross soft tissue injury
- Loads the body and body wall – displacement
- Avulse fractured limbs
- Burns from products
What are the classifications of blast injuries?
PRIMARY SECONDARY TERTIARY QUARTERNARY QUINTERNARY
What are primary blast injuries?
principally air containing organs primary blast lung - 70psi bowel injury auditory - 2psi some solid viscera
What are secondary blast injuries?
wounds from fragments
penetrating - superficial to perforating
visceral injury from blunt impacts
What are tertiary blast injuries?
traumatic amputation of limbs
displacement of the body
tissue stripping by gas flow
What are quarternary blast injuries?
crush injuries
burns
psychological
what are quinternary blast injuries?
neurological - repeated TBI
immuno-ompromise
What is traumatic amputation?
- Only very close to explosive
- Very severe blast loads
- (was) a high mortality
Mechanism of amputation: limb flailing and avulsion
Blast amputations in Northern Ireland
Not through joints.
Mechanism:
- Shock wave enters limb and fractures bone - Dynamic overpressure avulses the limb and strips remaining soft tissue
About the united nations
· Intergovernmental organisation · Established 24 October 1945 · 193 states · Headquarters in New York · Offices in Geneva, Nairobi, Vienna
· WW1: League of Nations – extensively to prevent another conflict of that scale, but WW2 did happen.
· UN founded 24 October 1945 to prevent another conflict like WW2 occurring
· 51 nations, now 193
· Cold war
What is the structure of the UN?
· 6 principal organs: o General Assembly o Security Council o Economic and Social Council (ECOSOC) o The Secretariat o International Court of Justice (ICC) o Trusteeship Council (inactive since 1994)
What sit eh UN genera assembly?
This is the main body of the UN. · Assembly of all 193 members states · Except Palestine & the Vatican · Admits new members · Adopts budget · Elects UNSC, ICC judges, Secretary General
What is the UN security council?
· Responsible for the maintenance of international peace and security
· 15 members
· 5 of these members are permanent with veto powers: USA, China, Russia, UK, France (colonial legacies – there is controversy over who should have these veto powers)
· Peacekeeping missions
What is UN:ECOSOC?
UN Economic and Social Council
· Responsible for cooperation between states on economic & social matters
· Coordinates cooperations between the UN’s specialised agencies
· 54 members
What is the UN secretariat?
· Supports other UN bodies administratively; conferences, reports, prepares budget
· Chairperson is the UN Secretary General, 5-year mandate.
What is the international court of justice?
· Decides disputes between states which recognise its jurisdiction
· This differs from the international criminal court, which is for individuals who are criminals of war etc
· Issues legal opinions
· 15 judges, 9 year terms
What is the UN systems agencies?
· World Bank Group · World Health Organisation · World Food Programme · UNESCO · UNICEF
What is UN funding?
· Assessed and voluntary contributions from member states, based on GNI (Gross National Income)
· $5.5 billion in 2012/13 budget
· UK pays c5%
· Peace & security $7.5 billion 13/14
· This $7.5 billion supports 82,000 troops in 15 missions globally
· UNICEF, WFP funded by individual voluntary donations, not coming out of the UN budget.
What is OCHA?
· United Nations Office for the Coordination of Humanitarian Affairs
· Formed 1991, replacing DHA / UNDRC
· Inter-agency body, serving UN Agencies and NGOs
· Headed by Baroness Amos, Emergency Relief Coordinator – now taken over by Steven O’Brien
What is UNHCR?
· Office of the United Nations High Commissioner for Refugees, UN Refugee Agency
· Founded 1951
· Geneva HQ
· Provide protection for refugees and seek a solution for them
What is WFP?
· World Food Programme
· World’s largest humanitarian organisation
· Hunger and food security
· 90 million people per year
· 2011 : $3.73 billion
· Voluntary payments from Governments, corps, private donors
What is UNICEF?
· United Nations Children’s Fund
· Created 1946, NYC based
· Contributions from governments & private donors
· Budget c $3 billion (2008)
· Convention on the Rights of the Child vs child mortality
What is the WHO?
· Specialised agency of the UN
· Remit of international public health
· Founded 1948
· Geneva based
· Cost $4 billion a year
· Funding is from member states & outside donors
· In general, WHO is not an implicating agency, it is a commissioning agency
· Leadership on health matters
· Shaping research agenda
· Setting norms & standards
· Articulating policy
· Monitoring health situation & trends
· Sustainable development goals especially from MDGs (millennial development goals), infectious disease, maternal health, HIV / Aids, Malaria
What is the red cross and red crescent movement?
· IFRC (International Federation of the Red Cross), National Societies, ICRC
· International humanitarian movement
· 100 million volunteers
· Founded 1863 Geneva, Henry Dunant
What is IFRC?
· International Federation of the Red Cross
· Coordinates & directs international assistance following natural & man-made disasters in non-conflict
· Work with national Red Cross / Crescent societies
· Coordinates with civil relief eg floods etc
What is ICRC?
· Mandate under international law to carry out humanitarian actions in situations of armed conflict
· Prison visits
· Monitoring adherence to international conventions
· Relief operations
· Missing persons
· Family reunification
· War surgery & rehabilitation
About the NHS…
· NHS England budget of £95.6 billion for delivery.
· £65.6 billion to local commissioning groups
· £25.6 billion to commission specialist services
What is DFID?
· UK Government Department with a cabinet minister in charge · Separated from the FCO (Foreign Commonwealth Office) 1997 · “promote sustainable development and eliminate world poverty” · Budget c £10 billion · UK Govt commitment to 0.7% GNI · Aims (Sustainable Development Goals): o Halve numbers in poverty o Children primary education o Reduce child death rates o Improve maternal health o HIV, Malaria, TB o Environmental protection o Global partnership
What is CHASE OT?
· Conflict, Humanitarian and Security Operations Team
· Crown Agent…contracted to DFID – independent body contracted out, the people who work for CHASE OT are not direct workers of DFID
· 70 full time staff, working at DFID offices in Whitehall
· Database of experts
· 24/7 capability to respond to crises
What is the secretary of state for international development?
Priti Patel: 14th July 2016
Full cabinet minister position, invest fully in the position.
What are the functions of NGOs?
- Humanitarian functions
- Bring citizens concerns to governments
- Monitory policy and programme implementation
- Encourage participation of civil society stakeholders at the community level.
- Privde analysis and expertise
- Serve as earyl warning mechanisms
- Help ontot and implement international agreements
- Some are organised around specific issues, such as human rights, the environment etc
What is the function of the ICRC?
- The ICRC has a hybrid nature
- Private association formed under the Swiss Civil code
- Existence is not in itself mandated by governments
- Functions and activities are mandated by the ICRC has a hybrid nature
- Private association formed under the swiss civil code
- Existence is not in itself mandated by governments
- Functions and activities are mandated by the international community of states and are founded on international law, specifically the Geneva conventions
- Enjoys working facilities comparable to those of the united nations
- Eg exemption form taxes and custom duties
What are some examples of NGOs?
- MFS
- MDM
- MERLIN
- EMERGENCY
- Save the Children
- Oxfam
- Medical Aid for Palestinians
What is MSF?
- 1968 Nigerian civil war
- humanitarian workers are also expected to stand up for the victims
- 1971-1975 initial stages of MSF’s establishment
- 1971 MSF formed by a group of doctors. Active solely in Nicaragua and Honduras.
What are the two types of medical relief activities?
emergency relief
long term relief
What is emergency relief?
elief to refugees of wars and victims of natural disasters
- serving in the front line, healthcare, nutrition, medicine distribution, vaccination, water and sanitation facilities to control spread of disease
- psychological therapies
- rescue missions known for their reliable speed and great efficiency
- tried to avoid people just going and volunteering, only to become a burden on the local infrastructure themselves
What is long term relief?
- countries that either lack medical facilities of health care
- works closely with local health authorities in rebuilding hospitals and epidemic prevention stations
- promoting projects in health and nutrition and training local medical staff
- working on resilience
- much focus on the importance of human rights to the use of medical care and resource aids
- stands by the principles of ‘impartiality’ and ‘neutrality’ in order to protect its humanitarian volunteers.
No weapons etc, so the only thing that keeps you safe is the perception of neutrality, you don’t have any interest except for helping humanity. You will treat whoever comes to your doors, no political or economic agenda etc.
Where are the 5 NGO operational centres?
Amsterdam Brussels Geneva Barcelona Paris
What is an NGO?
A NGO is a not for profit, voluntary citizens group, which is organised on a local, national or international level to address issues in support of the public good.
Task oriented and made up of people with common interests.
What does NGO not imply?
- independence
- humanitarian
- not for profit
- noble motives
Jean Henri Dunant (1828-1910)
Nobel prize 1901 (ICRC 1917, 1944, 1963)
First recipient of the Nobel Prize for Peace.
First Geneva Convention 1864:
- Establishment of the red cross symbol
- Recognition of the special status of health workers in war and guarantee for their protection
Died in seclusion and buried without ceremony.
Under what authority do NGOs operate in these contexts?
- Usually, by arrangement with the ‘governing authority’
- Often, in the case of conflict, also by local negotiation (eg Afghanistan, DRC)
What is International Humanitarian Law (IHL)?
ody of rules which, in wartime, protects people who are not or are no longer participating in the hostilities
· Central purpose to limit and prevent human suffering in times of armed conflict rules to be observed not only by governments and their armed forces, but also by armed opposition groups and any other parties to a conflict
· Principal instruments are 4 Geneva Conventions of 1949 and 2 Additional Protocols of 1977
· Protection of non-combatants
· Protection of the wounded and sick
· Prohibition of inhumane or extreme acts
· Prohibition of torture, exploitation or collective punishment
· Special protection of children
à applies to international and internal conflicts
What bad effects can aid have?
- In precarious markets the supply of free food can destroy local production
- Sometimes it may unwittingly sustain militias, encourage exploitation underpinned by distribution
- Sexual exploitation identified in camps in West Africa
- Vulnerable people
- Goma
Niger aside.
But sometimes people are caught in a trap which development aid cannot reach.
à Nig
What is ‘donor driven’ healthcare?
the ‘market’ often ignores those to whom the care is given
- Centred on donor societies
- Overall plan may be set by international economic agendas
- Can be media driven
o Prey to individual enthusiasms
o Emotional response: ‘something must be done’
o Eg SE Asian tsunami vs NW Asian Earthquake
- Need for ‘success’
o Donors
o Expatriate workers
- Failure may mean withdrawal rather than redesign
- Little need to
o Build sustainability
o Engage with existing structure
- Recipients frequently blamed for failure
o ‘ungrateful’
o ‘corrupt’
- Cultural insensitivity
- Other agendas determine priority
- Very dependent on security
à collapse of the former Soviet Union
What happens in ‘collapsed systems’ in terms of NGOs/IHL?
· Expectation may be very much greater than what can be provided
· Distortion of provision by desire for expensive services from both patients and doctors
· Diaspora of providers
· Early re-provision of high-tech services
What is the duty of medical care?
· Do best for individual patient · Do best for population · Communicate experience · Conflicts amongst all of these Communication - Report what we see - May lead to expulsion - May put patients at risk à is high tech medicine inappropriate for marginalised people?
What can make a difference to maternal survival?
- Transport
- Blood transfusion
- Safe obstetric intervention
- Safe anaesthesia
The same things can be said about HIV, malaria, TB. It is not good enough to just think we are making a difference.
Every nation, in every region, now has a decision to make. Either you are with us, or you are with the terrorists. – GWB September 20, 2001
How does the military integrate in humanitarian operations?
• Insecurity affects health
• Military support for health services of indigenous security forces
• Wider military support for international community to develop indigenous civilian health sector
- Water desalination
- Chinook Pakistan – operational/tactical lift
- Engineers and JCB
- Operational and strategic influence
What can the military bring to humanitarian operations?
- Corporate knowledge
- Strategic capability / lift
- Engineering / environmental health expertise
- C2 expertise and communications
- Multinational networking
- Security sector reform (SSR)
Policy, politics and involvement of military with humanitarian work…
• Requirement for clear objective and end state
• Ideally: To establish a situation where indigenous civilian health sector takes over
– Short-term until civilian services can take over
• Nature of mission:
– Humanitarian mission: civil-military relationship
vs
– Military mission with ltd involvement according to the Geneva Convention
o Ultimately, culturally and morally acceptable standard of sustainable healthcare o Mobile healthcare clinics shown to be effective only in the short term SUSTAINABILITY IS KEY
About Op Safe Haven/Provide Comfort…
- April 1991 Kurdistan
- Mission: military and humanitarian; once security had been established
- Exodus from Iraq to Turkey and Iran border heavily mined post Iran / Iraq War
- Dirty water – Typhoid outbreak
- Importance of Triage
Kurds fear massacre
5 April, United Nations Resolution 688, calling on Iraq to end repression of its population.
6 April, Operation Provide Comfort began to bring humanitarian relief to the Kurds.
No-Fly Zone was established by the U.S., the UK, and France north of the 36th parallel
Main task: Enter Northern Iraq, clear the designated area of the Iraqi threat and establish a safe environment for the Kurd refugees to return to their homes
Mission: military and humanitarian; once security had been established
The ground mission within Iraq: 58 days to complete.
Operation Provide Comfort/Safe Haven officially ended shortly after and the enforcement of the ‘No Fly Zone’ continued to ensure security in the region.
24 July 1991 Provide Comfort I ends and Provide Comfort II ends.
About Operation Gabriel - RWANDA
UNAMIR 1994 Rwanda
UK: NW Rwanda – to reduce flow of Rwandan refugees to Goma, Zaire
French: SW Rwanda Op Turquoise June 1994
Humanitarian Protection Zone (HPZ)
Rwandan government suspicious of French (colonial history)
Instability in HPZ as ? Individuals implicated in massacres present & innocent individuals concerned about being caught in repercussions
Concern these would flee to Zaire rpting the crisis without the means to manage them
UK replaced French in SW:
Reassurence
Prevent insurgency / violence
Prevent large scale refugee movement
UK static and mobile health posts
Outcomes:
Humanitarian provision
Reassurence and security
State security on support on emergence from the Conflict Phase
Op GRITROCK
- Ebola
- Culminated in a lot of help and assistance, training programmes, in order to develop an effective response
- Integrated assistance between the military, department of health, department of international development and ministry of defence
Direct request for assistance form WHO and government of Sierra Leone to contain the Ebola outbreak. 62 bed facility Kerrytown.
Op WEALD
- Op WEALD 2 May – 3rd July 2015
- UK General Election 7th May 2015
- 7 rescues
- 1100 people embarked
Significant portion of the world is unstable, and will continue to be so. Therefore there will continue to be a requirement for response, with interaction between the military and civilian NGOs.
What is the commonly held view of PMSCs?
Private military enterprises are Mercenaries. Unregulated, poorly disciplined and violent.
Actually, most are contractors, well disciplined due to military background and operate with clear rules of engagement.
These slides show the breadth of legitimate corporate military activity:
Body-guarding esp mention that of elected officials and embassy / consulate staff.
Demining and the provision of training packages with legitimate humanitarian benefit
This is why the industry has arisen. Risk map generated by the Insurance Company Control Risks.
Increasingly unstable world with states at risk / in danger of collapse and core functions of government such as the judiciary and national security failing to function.
Non-government and translational state actors
What is the new situation with PMSCs?
new trend:
– No longer small bands of men fighting for profit
– A more organised, professionally run, almost ‘corporate’ approach to soldiering
• The humanitarian’s concerns:
– PMSCs are undertaking tasks that it is believe should be performed by the armed forces of a state
– the nature of that enterprise which provokes strong response.
Is it so bad?:
Private concerns in failed states employ considerable numbers of the local population in a vast spectrum of tasks, making a contribution to nation building and civilian empowerment. Does this confer a tangible humanitarian benefit?
Conflicts now engaged in are different. They often require bespoke packages that PMCs can deploy at a moment’s notice, free of the time constraints of official military beaurocracy, together with having a significant ‘hearts and minds’ component which may be best served by employing local nationals as part of the implementation process.
What is the historical background of PMSCs?
• Modern standing armies - contemporary practice
– until the 19th century military commanders preferred to use professional mercenary soldiers.
• Full time military forces expensive.
• Conventional view of mercenaries:
– ‘Dogs of War’ African mercenary figure in central Africa circa 1960s and ‘70s.
• New view: a more recent brand of corporate military soldiering in the 1990s
– one in Africa
– one in the Former Republic of Yugoslavia.
The creation of modern standing armies is a contemporary practice and up until the 19th century military commanders preferred to use professional mercenary soldiers.
Standing military forces are also very expensive.
Conventional view of mercenaries:
- ‘Dogs of War’ mercenary figure operating illicitly in central Africa in the 1960s and ‘70s.
New view: a more recent brand of corporate military soldiering in the 1990s
- one in Africa
- one in the Former Republic of Yugoslavia.
What are executive outcomes of PMSCs?
Direct involvement of EO operatives in support of combat operations, together with the alleged intricate connection between the military side of the business and wider corporate interests in the energy and mineral extraction industries.
Did not serve as a proxy for government aims abroad and had been shown to be an effective provider, if not sustainer, of security.
ANGOLA
SIERRA LEONE
Historical definition: mercenary
• Definition: a mercenary is an individual who satisfies all of the following criteria:
– recruited locally or abroad to fight in & takes direct part in the hostilities;
– is motivated by the desire for private gain and seeks material compensation
– is neither a member of armed forces or a resident of territory controlled by a party to the conflict;
– has not been sent by a state
• The UN definition of a mercenary.
Article 47 of the Geneva Convention
A mercenary is defined under Article 47 of the Geneva Convention as one who satisfies all of the following criteria:
is specifically recruited locally or abroad to fight in an armed conflict;
does, in fact, take direct part in the hostilities;
is motivated to take part in the hostilities essentially by the desire for private gain and, in fact, is promised, by or on behalf of a party to the conflict, material compensation in excess of that promised or paid to the combatants of similar ranks and functions in the armed forces of that party;
is neither a national of the party to the conflict nor a resident of territory controlled by a party to the conflict;
is not a member of the armed forces of a party to the conflict; and
has not been sent by a state which is not a party to the conflict on official duty as a member of the armed forces.
Article 47 of the 1977 First Additional Protocol to the Geneva Conventions of 12th August 1949. This at present represents the UN definition of a mercenary.
Organisation for African Unity Definition
The Organisation for African Unity (OAU) in its Convention for the Elimination of Mercenarism in Africa attempts to define a mercenary ‘as anyone who is not a national of the state against which his actions are directed, is employed, enrols or links himself willingly to a person, group or organisation whose aim is:
• to overthrow by force of arms or by any other means, the government of that Member State of the OAU;
• to undermine the independence, territorial integrity or normal working institutions of the said State; or
• to block by any means the activities of any liberation movement recognised by the OAU’.
What are the types of activity in the PMSC spectrum of activity?
– specialist security provision and close protection capabilities
– provision of advice and training packages,
– training of local police forces,
– logistical support,
specialist advice with de-mining and monitoring roles in peace keeping
1989 international convention against the recruitment, use, financing and trainmen of mercenaries…
– does not ban mercenaries, only their activities that undermine the state.
– real confusion about the status of the new PMC contractors and the point at which international law takes over from domestic legislation to assert the rule of law upon them
– customary international law pertains to the individual and not to a company.
Note that this legislation has become currently very interesting due to the interest in prosecuting jihadists travelling to Syria. Draws in legislation from the Foreign Enlistment Act
What are Private Military Companies (PMCs)?
Corporate entities providing offensive services designed to have a military impact in a given situation that are generally contracted by government
What are Private Security Companies (PSCs)?
Corporate entities providing defensive services to protect individuals and property, frequently used by multinational companies in the extractive sector, humanitarian agencies and individuals in situations of conflict or instability
What are the other actors in the humanitarian sphere?
Medical services have been provided by companies often employing experienced ex-military medical staff, such as Medical Support Solutions, Frontier Medical or Prometheus Medical, the last of which typically employs medical staff with experience of supporting special forces personnel.
Trained dog handlers (Chilport)
De-mining companies (EOD Technology, Ronco Consulting Corporation) similarly provide a substantial humanitarian effect in post conflict situations.
Companies with the ability to mount counter piracy operations, such as Background Asia Solutions are becoming widely employed in the Horn of Africa.
Iraq 2003-2009
In 2004, the second largest foreign contingent in Iraq not from British forces but from that provided by 20,000 PSC and PMC personnel operating in a variety of roles
Examples:
guarding civilian buildings and telecommunications workers throughout Iraq,
guarding supply convoys
performing routine base functions such as maintenance, laundry services and electrical maintenance
Blackwater was given the contract to guard provincial outposts of the Iraqi Coalition Provisional Authority and its leader, Paul Bremner.
Dyncorp had a contract worth tens of millions of dollars to train an Iraqi police force.
British private security industry was estimated to be making in excess of $1 billion in post-war Iraq.
Estimated that of the $18.6 billion (£10 billion) earmarked by the United States Congress for regeneration of Iraq, 15% was being spent on contracts for private military firms.
What was the work of PMSCs in Iraq 2003-2009?
• In 2004, the second largest foreign contingent in Iraq not from British forces but from that provided by 20,000 PSC and PMC personnel operating in a variety of roles
• Examples:
– guarding civilian buildings and telecommunications workers throughout Iraq,
– guarding supply convoys
– performing routine base functions such as maintenance, laundry services and electrical maintenance
– Blackwater was given the contract to guard provincial outposts of the Iraqi Coalition Provisional Authority and its leader, Paul Bremner.
– Dyncorp had a contract worth tens of millions of dollars to train an Iraqi police force.
– British private security industry was estimated to be making in excess of $1 billion in post-war Iraq.
– Estimated that of the $18.6 billion (£10 billion) earmarked by the United States Congress for regeneration of Iraq, 15% was being spent on contracts for private military firms.
David Claridge, managing director of British firm Janusian, quoted in ‘The Baghdad boom’, The Economist, 27th March, 2004. It has been suggested that prior to the campaign in Iraq, the British PMC / PSC industry made $200 million but after the end of the war the industry was making more than $1 billion, making it Britain’s leading export to post-war Iraq.
Examples:
guarding civilian buildings and telecommunications workers throughout Iraq,
guarding supply convoys
performing routine base functions such as maintenance, laundry services and electrical maintenance
Blackwater was given the contract to guard provincial outposts of the Iraqi Coalition Provisional Authority and its leader, Paul Bremner.
Dyncorp had a contract worth tens of millions of dollars to train an Iraqi police force.
British private security industry was estimated to be making in excess of $1 billion in post-war Iraq.
Estimated that of the $18.6 billion (£10 billion) earmarked by the United States Congress for regeneration of Iraq, 15% was being spent on contracts for private military firms.
Why has private military provision flourished and what are the drivers for it?
• Financial concerns:
• perception that it is cheaper / more effective to enlist contractors as the need arises.
• Reluctance of politicians and their voting public to see rising troop casualty numbers.
• Deaths of private contractors:
– No headline news
– Troop casualty levels have been lower than they would have been had contractors not been used so widely in the campaigns in Iraq and Afghanistan
What are compelling reasons to outsource some military functions?
• “Employment of Iraqis not only saves money but it also strengthens the Iraqi economy and helps eliminate the root causes of the insurgency – poverty and lack of economic opportunity”.
General Ray Odierno , Commanding General, Op Enduring Freedom.
(Memorandum ‘Increased Employment of Iraqi Civilians Through Command Contracts’ Multi-National Force
Iraq, 31st January, 2009).
• “Hire Afghans first, buy Afghan products and build Afghan capacity”.
Commander ISAF Afghanistan General Patreus, March 2011.
Regulation of PMSCs
• No over-arching international agreement in place.
• 2008 Montreux Document (commissioned by the Swiss government and the ICRC)
– Summarise all legislation in place at a national and international level and advocate best practice for the industry.
– Legislation is an amalgam of national legislation and customary international law often ill-defined to fit the new PMC industry Montreux.
– No new new legislation but clarifies existing domestic and international law for all parties involved with PMCs.
No over-arching international agreement in place.
The closest legislation has come to regulating the industry comes in the form of the 2008 Montreux Document (commissioned by the Swiss government and the ICRC)
Attempts to summarise all legislation in place at a national and international level and advocate best practice for the industry.
Legislation is an amalgam of national legislation and customary international law often ill-defined to fit the new PMC industry Montreux.
It does not provide new legislation but clarifies existing domestic and international law for all parties involved with PMCs.
The Montreux Document
recalls the pertinent international legal obligations of States, PMSCs and their personnel in situations of armed conflict;
• contains a compilation of good practices designed to help States take national measures to implement their obligations;
• highlights the responsibilities of three types of States: Contracting States (countries that hire PMSCs), Territorial States (countries on whose territory PMSCs operate) and Home States (countries in which PMSCs are based);
• makes it clear that States have an obligation to ensure respect for international humanitarian law and to uphold human rights law; as a result, they have a duty to take measures designed to prevent misconduct by PMSCs and ensure accountability for criminal behaviour;
• recalls that PMSCs and their personnel are bound by international humanitarian law and must respect its provisions at all times during armed conflict, regardless of their status;
• recalls that misconduct on the part of PMSCs and their personnel can trigger responsibility on two levels: first, the criminal responsibility of the perpetrators and their superiors, and second, the responsibility of the State that gave instructions for, directed or controlled the misconduct;
• provides a toolkit for governments to establish effective oversight and control over PMSCs, for example through contracts or licensing/authorization systems.
- Most comprehensive attempt to synergise all existing legislation pertaining to PMSCs.
- Product of legislation from a number of countries including the UK, US and South Africa.
- The essential difficulty concerning any sound evaluation of PMSCs is the failure to grapple with the evolution of the mercenary concept.
UK regulation of PMSCs
• Sandline
• 1999: House of Common Foreign Affairs Committee Inquiry into the Sandline Affair
• 2002: Government Green Paper titled Private Military Companies: Options for Regulation
• April 2010: FCO published “PMSCs: Summary of Public Consultation Working Group”.
– Focus of discussions to review a draft BAPSC Code of Conduct and attempt to harmonise it with the recommendations of the international Montreux Document.
What is the future of PMSCs?
• Control of non-state violence becomes more and more tenuous, activities of PMSCs can become a matter of great concern.
• A situation could arise where corporations could command forces that threaten states.
– East India Company
• Use of the term mercenary promotes moral indignation and is not helpful.
Appropriate scrutiny should be is focused on PMSC activities.
Contracts:
- scrutinised appropriately
- Seen to obviate the concerns of human rights groups
Regulation:
- opacity in the dealings of a company
- no governmental policy objections are taken as the ‘gold-standard’ for sound business practice overseas
Ability to force generate in time of dwindling armed forces and increased need for intervention.
• Anyone deployed on a humanitarian mission in these areas needs to understand who these companies are and what they do.
• The amalgamation of existing legislation under one umbrella in the form of the ICRC’s Montreux Document represents a helpful aid to understanding these companies.
• What constitutes a legitimate company?
• Who decides what represents a legitimate host country to work for?
• Are the means available to adequately police the industry?
• From the foreword to the Montreux Document:
• “…PMSCs are viewed in some quarters now as an indispensible ingredient of military undertakings.”
Why ATLS?
· James styner 1976 · Systematic, concise approach to early care of trauma patient · Golden hour · International standard · Evidence based…
What is the initial assessment?
Primary survey and resuscitation of vital functions are done simultaneously using a team approach. At each stage when you find something wrong you do something about it and don’t move on to the next stage until it’s dealt with.
If you’re alone you do vertical resuscitation, if in a team then do vertical and horizontal resuscitation.
What are the concepts of initial assessment?
Use certain adjuncts to ABCDE e.g. airway. We resuscitate according to the findings from the primary survey. If the patient is becoming more unwell, we re-evaluate where we are and re-intervene. Primary survey looking at vital functions, secondary is in more detail, head to toe, looking at any injuries we might have missed. When we think we have control, we then think about definitive care (eg should you transfer elsewhere?). You evaluate a patient in the context of the environment you are in.
What is the primary survey?
To assess someone in 10 seconds: ask a question (what happened, whats your name, who am I) – tells you about brain/head (conscious), heart (perfusing brain sufficiently to reply) and breathing (able to speak). - Identify yourself - Ask his/her name - Ask what happened Airway with c-spine protection Breathing with adequate oxygenation Circulation with haemorrhage control Disability – assessing level of consciousness, looking at pupils, to see how the injury has affected the patient. Checking for a bleed, which could compress 3rd nerve and dilate pupil. Exposure/Environment The priorities are the same for all patients. You must go through the systematic ABCDE assessment.
What are special considerations for ATLS?
- Trauma in the elderly
- Paediatric trauma
- Trauma in pregnancy
They are more vulnerable in general. The elderly have very little cardiovascular reserve, will often be taking a myriad of medications, affecting how they respond to trauma, their lungs may have a lot more dead space, less respiratory reserve. Children can be very badly injured, but only drop off right at the end, giving little warning. Pregnancy changes people massively, cardiovascular changes, blood pressure it hugely changed, and there is an extra physiological burden on the mother, and some things may need an emergency C section in cardiac arrest if after 24 weeks.
What are the pitfalls of airway in ATLS?
o occult airway injury – situations such as if someone has tried to hang themselves and has fractured their larynx.
o progressive loss of airway – eg bleeding causing an haematoma which could squeeze and compromise airway
o equipment failure
o Inability to intubate – not ideal conditions, not been starved, may vomit, may have blood/teeth/etc sitting over vocal cords if damaged in accident.
What are the pitfalls of breathing in ATLS?
- Airway versus ventilation problem? May be giving lots of oxygen but might not be exchanging the gas at alveolar level, so don’t assume its fine just because giving the oxygen. Lung could have collapsed, air around the lung, can’t transfer efficiently.
- Iatrogenic pneumothorax or tension pneumothorax?
Breathing management in ATLS
Assess and ensure adequate oxygenation and ventilation.
- Respiratory rate – normal: 12-20
- Chest movement
- Air entry
- Oxygen saturation – normal: 98
Circulatory management in ATLS
- Level of consciousness
- Skin colour and temperature
- Pulse rate and character (60-80 normal)
Capillary refill time usually 2 seconds.
- Control haemorrhage – pressure, elevate
- Restore volume – if possible give blood rather than fluid
- Reassess patient at each stage
What are the pitfalls of circulatory management in ATLS?
o Elderly – little cardiac reserve
o Children – fine, fine, fine then drop off cliff
o Athletes – might have resting heart rate of 50, physiological response to injury is blunted, can react similarly to children
o Medications – eg beta blockers, poisons, drugs – effects cardiovascular response
Disability in ATLS
Baseline neurologic evaluation
- Glasgow coma scale score
- AVPU system (Alert, Voice, Pain, Unresponsive)
- Pupillary response – morphine/drugs can cause pinpoint pupils, bear in mind, would also compromise level of consciousness and ability to protect airway.
Caution
Observe for neurologic deterioration – do checks over and over again – always reassess.
It is essential to identify neurologic injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctible lesions rapidly, and provide a baseline GCS score to identify trends and changes.
Exposure/environment in ATLS
Completely undress the patient to adequately assess the entire patient.
Log roll to look at back.
Caution: prevent hypothermia – lethal triad: hypothermia, coagulopathy and acidosis. When people are cold they don’t form clots properly.
Pitfalls: missed injuries
What is a quick was to assess a patient in 10 seconds?
· Identify yourself
· Ask the patient his or her name
· Ask the patient what happened
A. Patent airway
B. Sufficient air reserve to permit speech
C. Sufficient perfusion to permit cerebration
D. Clear sensorium
There is a need for sufficient cardiac output to ensure clear sensorium.
The patient who fails this simple test needs immediate attention.
Resuscitation
· Protect and secure airway
· Ventilate and oxygenate
· Stop the bleeding! – dressings, elevation, pressure
· Vigorous shock therapy
· Protect from hypothermia
Treatment is administered at the time the life-threatening problem is identified and that assessment and treatment during the primary survey and resuscitation phases of the initial assessment process often are done simultaneously.
What are adjuncts to primary care?
Adjuncts are done selectively, depending on the patient’s spectrum of injuries and physiologic responses.
What are diagnostic tools in ATLS?
• The primary purpose of these adjuncts during the primary survey is to determine where occult bleeding may be occurring that is not obvious on clinical exam.
• Emphasize the need to determine the source of shock.
• Portable chest and pelvic x-rays in the emergency department are the ONLY x-rays obtained during the primary survey. Previous editions of the course included lateral cervical spine x-rays, but this film is now obtained selectively and at the appropriate time, based on the doctor’s judgment.
à FAST – ultrasound on abdomen
à DPL – blunt injury to abdomen with bleeding somewhere, put in small needle to flush out any blood
à CT – if see bleeding inside, need surgery
DPL and FAST may also be used during the primary survey to detect intraabdominal blood.
Early transfer in ATLS
Consider early transfer
· Use time before transfer for resuscitation
· Do not delay transfer for diagnostic tests
• The time to initiate the transfer process is when the need is recognized. Therefore, the need to transfer must be considered early. The sooner the need is recognized and communicated, the more efficiently it occurs.
• In addition, transfer should not be delayed to perform the secondary survey or to perform diagnostic tests such as CT scans. The time spent waiting for transportation to arrive should be spent stabilizing the patient.
What is the secondary survey?
The COMPLETE history and physical examination
When do you start the secondary survey?
AFTER:
- Primary survey is completed
- ABCDEs are reassessed
- Vital functions are returning to normal
What are the components of the secondary survey?
- History
- Physical exam: head to toe
- Complete neurologic exam
- Special diagnostic tests
- Reevaluation
Secondary survey: HISTORY
Allergies Medications Past illnesses Last meal Events/Environment/Mechanism
Mechanisms of injury: head
- External exam
- Scalp palpation
- Comprehensive eye and ear exam
(Including visual acuity)
Pitfalls:
- Unconsciousness – look at these things anyway
- Periorbital oedema
- Occluded auditory canal
Mechanisms of injury: maxillofacial
- Bony crepitus
- Deformity
- Malocclusion
Pitfalls
- Potential airway obstruction
- Cribiform plate fracture
- Frequently missed
Check mid-face stability, dental occlusion, and contraindications for nasogastric tubes.
Mechanisms of injury: chest
- Inspect
- Palpate
- Percuss
- Auscultate
- X-rays
• The photograph shows an unrestrained passenger who was thrown into the dashboard.
• Ecchymosis of chest wall from blunt trauma.
• Review how the chest is evaluated during secondary survey, including appropriate imaging studies.
Mechanisms of injury: abdomen
- Inspect/auscultate
- Palpate/percuss
- Reevaluate
- Special studies
Pitfalls:
- Hollow viscous injury
- Retroperitoneal injury
Review how the abdomen is evaluated during secondary survey, including appropriate imaging studies.
• The lap portion of the belt appears to have been applied incorrectly.
• You may wish to emphasise the use of x-ray for pelvic assessment
• Remind the students that the back also is a part of the torso and requires examination.
• Appropriate spine precautions and protection must be taken whenever the patient is suspected of having a spinal cord or vertebral injury.
Mechanisms of injury: perineum
contusions, hematomas, lacerations, urethral blood
Mechanisms of injury: rectum
sphincter tone, high-riding prostate pelvic fracture, rectal wall integrity, blood
Mechanisms of injury: vagina
Blood, lacerations Pitfalls - Urethral injury - Pregnancy · Inspect for injury · If injury is present, emphasize the need for vaginal and rectal exam looking for pelvic fracture · Prior to Foley catheter placement, evidence for injury necessitates a digital prostate exam.
Mechanisms of injury: pelvis
· Pain on palpation · Leg length unequal · Instability · X-rays as needed Pitfalls - Excessive pelvic manipulation - Underestimating pelvic blood loss
Mechanisms of injury: musculoskeletal
Pitfalls
- Potential blood loss eg femurs bleed a lot (1.5L per leg)
- Missed fractures
- Soft tissue or ligamentous injury
- Compartment syndrome (especially with altered sensorium/hypotension)
There is great potential for hidden haemorrhage, compartment syndrome, missed fractures and soft tissue injury.
Mechanisms of injury: extremities
- Contusions, deformity
- Pain
- Perfusion
- Peripheral neurovascular status
- X-rays as needed
Neurologic - spinal assessment (ATLS)
· While spine · Tenderness and swelling · Complete motor and sensory exams · Reflexes · Imaging studies Pitfalls: - Altered sensorium - Inability to cooperate with clinical exam
Neurologic - brain (ATLS)
· GCS · Pupil size and reaction · Lateralising signs · Frequent reevaluation · Prevent secondary brain injury à early neurosurgical consult
Neurologic - spine and cord (ATLS)
Conduct an in depth evaluation of the patient’s spine and spinal cord.
Early neurosurgical/orthopaedic consult
Important to evaluate the patients entire back and take precautionary/protective measures when logrolling the patient.
Pitfalls of neurologic injury (ATLS)
Incomplete immobilisation
neurologic deterioration
Special diagnostic tests as indicated pitfalls (ATLS)
Pitfalls: - Patient deterioration - Delay of transfer - Deterioration during transfer - Poor communication These include specialised radiographic studies. Adjuncts should NOT delay appropriate transfer to definitive care.
How do i minimise missed injuries?
· High index of suspicion · Frequent reevaluation and monitoring Meticulous attention to detail, integrated with clues from the mechanism of injury and physical findings, and continued reassessment, are the best methods to avoid missed injuries. Some institutions conduct a ‘tertiary’ survey within 24 hours of admission to assess for missed injuries. · Relief of pain/anxiety as appropriate · Administer intravenously · Careful monitoring is essential à Need of judicious relief of pain associated with careful patient monitoring.
Which patients do I transfer to a higher level of care?
Those whose injuries exceed institutional capabilities:
- Multisystem or complex injuries
- Patient with comorbidity or age extremes
When should the transfer occur? (ATLS)
As soon as possible after stabilising measures are completed:
- Airway and ventilatory control
- Haemorrhage control (operation)
à need to avoid delay and unnecessary tests
Major trauma in austerity
- Multiple injuries
- Multiple systems
- Multiple victims
- Lack of experience
à multi-disciplinary but you may be on your own
What is the problem with multiple injuries?
· Critical decision making · Priorities · Communication · ‘between two stools’ · environment
What special considerations should be taken with trauma in the elderly?
- 5th leading cause of death
- Reduced capacity to compensate
- Co-morbidities
- Medication
- Need early & vigorous management
- Big problem in war and disaster
Preparation for trauma in austerity
- Transfer guidelines
- Communication & direction may be a problem
- Closest, appropriate hospital may be hundreds of miles away
- Transfer may not be possible
Standard precautions for ATLS in austerity
- Head cover
- Gown/scrubs
- Gloves
- Mask
- Shoe cover
- Eye cover
- Face shield
- Joking of course!
Initial assessment components
- Rapid primary survey – the same
- Concurrent resuscitation – ideally the same
- Adjuncts – likely to be none
- Detailed Secondary survey - not in the field
- Adjuncts – likely to be none
- Definitive care rarely possible
Initial assessment
Primary survey resuscitation of vital functions are done simultaneously – the ideal is a team approach (horizontal management) but you may be on your own (vertical management).
ATLS - ABCDE
A Airway & c-spine control B Breathing C Circulation & haemorrhage control D Dysfunction of the CNS E Exposure, environment, evacuation
What are the possible pitfalls of primary survey?
Establish Patent Airway - C spine injury must be considered Pitfalls - Equipment failure - Inability to intubate - Occult airway injury - Progressive loss of airway Suspect C-spine injury - Spinal protection as best as possible - C-spine x-ray rarely available
Breathing ATLS in AUSTERITY
· Assess · Oxygenate if you have some · Ventilate by hand using bag Pitfalls - Airway v ventilation problem - Iatrogenic pneumothorax - Tension pneumothorax
Circulation ad organ perfusion assessment - pitfalls
· Altered conscious level – subtle · Skin colour and temperature · Pulse rate and character Pitfalls - Elderly - The very fit - Children - Medication
Circulatory management in austerity
· Control of haemorrhage
· Restore volume if you have IVs
· Reassess
Disability management in austerity
· Baseline neurological evaluation · GCS scoring · Pupillary response Caution Observe for neurological deterioration not that you would be able to do much!
ATLS exposure/environment in austerity
Completely undressing the patient may not be possible.
à Prevent hypothermia
Resuscitation in austerity
· Protect and secure airway · Ventilate and oxygenate · Stop the bleeding! – pressure/elevate/tourniquet · Shock therapy – may be by drinking! · Protect from hypothermia
Limb injury and primary survey in war and conflict
Often life threatening injury
- Femoral shaft
- Pelvic
- Other with vascular injury
- Multiple
- Sepsis
- Gross soft tissue injury
Secondary survey in austerity
IF POSSIBLE!
Key components
- History
- Physical examination: head-to-toe
- “tubes and fingers in every orifice’
- complete neuro exam
- special diagnostic tests
- re-evaluation
Pitfalls of musculoskeletal injury in austerity
- potential blood loss
- missed fractures
- soft tissue and ligamentous injury
- occult
- compartment syndrome
Re-evaluation during ATLS in austere environments
Minimising missed injuries
- high index of suspicion
- frequent re-evaluations and monitoring
How do you know that an airway is adequate?
· Patient is alert and oriented
· Patient is talking normally
· There is no evidence of injury to the head or neck
· You have assessed and reassessed for deterioration
There is a great need for a rapid and accurate airway assessment.
What are the signs and symptoms of airway compromise?
· High index of suspicion · Change in voice/sore throat · Noisy breathing (snoring and stridor) · Dyspnea and agitation · Tachypnea · Abnormal breathing pattern · Low oxygen saturation (late sign) There is a need for a high index of suspicion for airway problems with trauma, burns, high energy mechanisms and coma. These signs are often apparent on approaching the patient. Abnormal breathing pattern includes rocking respiration, use of accessory muscles, Cheyne-Stokes, etc. Airway problems should be addressed before oxygen saturation is allowed to drop.
When to intervene when the airway is patent?
· Inability to protect the airway · Impending airway compromise · Need for ventilation You must intervene to secure the airway and facilitate breathing. Common reasons for intervention include the inability to protect the airway, coma, impending airway compromise, burns, retropharyngeal bleeding, need for ventilation, hypoxia and shock.
Impending airway obstruction
These photographs show the same patient 2 hours apart. The preintubation image is meant to identify carbon on the tongue, nasal hair singeing and blistering. The postintubation photo shows oedema, which would have compromised airway management. Need to get the intubation done befroe the injuries set in – if had waited wouldn’t be able to get it in with the condition in the right hand image.
How do you manage the airway of a trauma patient?
· Supplemental oxygen · Basic techniques · Basic adjuncts · Definitive airway - Cuffed tube in the trachea · Difficult airway adjuncts - Unexpected difficult airway - Predicted difficult airway Protect the cervical spine during airway management. o Inline immobilisation o Assume unstable spine
Basic airway techniques
chin lift – need to be careful in case of c-spine injuries.
à jaw-thrust – this is painful, so if it is being tolerated there is something wrong.
Basic airway adjuncts
Oropharyngeal airway
Patients who can tolerate an oral airway will usually need intubation. Tolerating it shows that they are already in an altered state of consciousness – would usually make people gag/vomit. (GCS – 8)
Nasopharyngeal airway
Often well tolerated. Contraindication in basal skull fractures.
A talking patient is unlikely to require emergent airway intervention and will not tolerate an oropharyngeal airway. Patients who will not tolerate or permit the passage of an oropharyngeal airway may accept a nasopharyngeal airway.
How do you predict a potentially difficult airway?
· Maxillofacial trauma and deformity · Mouth opening · Anatomy - Beard - Short, thick neck - Receding jaw - Protruding upper teeth
Definitive airway - easy
Oral intubation (medication assisted) - Cricoid pressure, suction, back-up - Maintain c-spine immobilisation Plan for failure: - Gum elastic bougie - LMA.LTA - Needle cricothyroidotomy - Surgical airway · Preoxygenate · Cricoid pressure · Sedate (midazolam) · Paralytic (succinylcholine) · Intubate · Confirm (auscultate, CO2) · Release cricoid pressure and ventilate à characteristics that would indicate a difficult airway à management of a difficult airway eg ‘tricks of the trade’ such as gum elastic bougies
Definitive airway - difficult
· Get help
· Be prepared
· Consider rapid sequence intubation (RSI) vs. awake intubation
o Maintain c-spine immobilization
· Consider use of:
o Gum elastic bougie (bendable piece of plastics which can be passed down into airway if difficult and can then pass tube over it as a guide)
o LMA / LTA – sit above the larynx rather than going past it
o Surgical airway
o Other advanced airway techniques, eg, fiberoptic intubation
· Surgical airway
o Cricothyroidectomy
How do you know the airway tube is in the right place?
· Visualise it going through the cords · Watch the chest · Auscultation · Pulse oximeter · CO2 detector · Radiology
What is shock?
The body’s reaction to inadequate tissue perfusing and oxygenation
Types of shock
- Hypovolaemic – loss of blood
- Cardiogenic – heart failure/heart attack/problem with heart
- Neurogenic – loss of vasomotor tone (ability of vessels to constrict to maintain and regulate blood pressure) from spinal cord injury and sympathetic chain input is lost
- Anaphylactic – hypersensitivity reaction to a stimulus e.g. peanuts/bee sting
- Septic – infection, inflammatory response, toxins released affecting permeability of capillaries, plasma leaks out of peripheries and blood pressure drops
Early pathology of shock
· Decreased venous return · Reduction in cardiac output · Hypotension · Hypoperfusion, if uncorrected……... · (Tissue hypoxia) – no longer to respire aerobically, get lactic acid from anaerobic respiration, can start denaturing proteins, can lead to clotting problems, multi-organ dysfunction and failure à death
What are the corrective mechanisms of shock?
· Fluid moves from tissues into blood vessels
· Increase in heart rate
o Tachycardia - sympathetic response
· Vasoconstriction
o Cold & pale - sympathetic response
· Reduced urinary output
Late pathology of shock
· Anaerobic metabolism · Production of lactic acid · Metabolic acidosis · Cellular oedema · Tissue oedema · Loss of organ function · Cell death à DEATH
What is hypovolaemic shock?
· Most common cause of shock in war · Due to FLUID LOSS o (haemorrhage / burns etc) · Most amenable to prompt management · Must be recognised early Where is the blood..? “Blood on the floor and 4 more” 1. Chest 2. Abdomen 3. Pelvis and retroperitoneum 4. Thighs – long bones
Loss of circulating volume
Injured tissue –> blood loss AND oedema
not just blood loss!
Examination in bleeding
· Primary survey à Identifies presence of bleeding + or - site
· Secondary survey à Identifies site of bleeding
· If the site is non compressible
o You identify presence of bleeding
o Surgeons identify what is bleeding
Immediate assessment of shock
· Mental state - AVPU · Respiratory rate · Colour (pale & cyanosed) & temperature · Capillary refill · Pulse - rate & volume · Blood pressure.
Quick guide to BP
BP 90 = Palpable radial pulse
BP 80 = Palpable femoral pulse
BP 70 = Palpable carotid pulse
Assessment and management of shock and haemorrhage
lassical signs obvious o But are late in onset & equate to 1500ml or more blood loss · Early signs are: o Vasoconstriction (cold) o Tachycardia o Narrow pulse pressure · Assume shock if cold and has rapid pulse o ‘Rapid’ in a fit soldier may be < 100
Resuscitation in shock and haemorrhage
ABCD · Establish, maintain, secure, protect airway · Oxygen if available · Ensure adequate ventilation · Now assess and treat circulation o Stop the bleeding o Establish iv access o Restore lost volume
Management principles in haemorrhage
save life
prevent deterioration
promote recovery
resuscitation in haemorrhage/shock
· Compressible haemorrhage o Limb fracture o External wounds o Pelvic fracture (to a degree) · Management o Direct pressure o Indirect pressure o Correct use of tourniquet o Splintage Stop Bleeding · Non compressible haemorrhage o Chest o Abdomen o Pelvis o Retroperitoneum · Management o Urgent surgery
Vascular access - haemorrhage
· Percutaneous access upper limbs · Intravenous cutdown o Medial malleolus - long saphenous vein o Antecubital fossa · Femoral vein cannulation o Seldinger technique
Replacement of lost volume following haemorrhage
- Crystalloids – all roles (more physiological salt based solutions, distribute across all the different fluid compartments)
- Colloids – all roles (have large protein molecules/strings, they are too large to pass through gaps in vessels so they stay in blood vessels – good for increasing blood pressure, but not replacing fluid in other compartments)
- Blood – roles 2+3
But to do no harm – make sure its warm! à lethal triad
Crystalloid use in haemorrhage
· Immediate replacement of lost volume
· 3:1 rule
· Short duration
· Safe
· Initial challenge of two litres & reassess
· Challenge in a child - 20 ml/kg body weight
· Challenge may be repeated
Use of colloids in haemorrhage
· Immediate replacement of lost volume · 1:1 rule · Long duration · Safe · Initial challenge of one litre & reassess · 10 ml/kg body weight in a child · Forms a jelly when cold
Management principles of haemorrhage
· Early recognition
· Early restoration of tissue perfusion:
o Stop the bleeding
§ Compressible haemorrhage - YOU
§ Non compressible haemorrhage - SURGEON
o Then Restore volume
· Resuscitation end point - systolic BP 90
§ Dilemma!
§ Closed HI, ideal systolic BP 120+
· IV fluid resuscitation protocol
· With non compressible haemorrhage
“Better a live casualty who has stopped bleeding & stabilised with a low BP without iv fluids, than one given iv fluids causing a transient rise in BP with re-bleeding that consumes what clotting factors remain. He then bleeds to death!
· A live clot or a dead bleeder?
You can’t stop the re-bleed - only a surgeon can!
IV fluid resuscitation protocol
· If bleeding is non compressible and surgery not readily available, a low BP is better than no BP!
· If the radial pulse is present, curtail the fluid challenge or, don’t challenge at all
but…monitor!…monitor!…monitor!
Supportive measures for haemorrhage and shock
· Treat hypothermia § Clotting mechanism is temperature sensitive · Analgesia § Pain = agitation - worsens shock · Fracture immobilisation § Controls blood loss & pain · Tubes in orifices § Gastric dilatation
Monitoring shock and haemorrhage
A. Adequate airway with O2 B. Respiratory function and rate C. Capillary refill (pulse (rate and pressure) + BP) D. AVPU · Pulse oximetry · ABGs (arterial blood gas) · ECG & non-invasive monitoring · End tidal CO2 (intubated casualties) Urinary output
Problems during management of haemorrhage
· Continuing haemorrhage à From where?
· Fluid overload à Pulmonary oedema, NB, beware blast lung
· Acid/base imbalance à Occurs, but should be furthest from your mind in the early stages of management!
Causes of cariogenic shock
Causes · Cardiac tamponade · Myocardial contusion · Myocardial infarction · Tension pneumothorax · Pulmonary embolism · Air embolism
Causes of anaphylactic shock
· Medications · Allergens o Bronchospasm o Urticaria o Peripheral vasodilation 1 mg adrenaline IM 1:1000 or iv 1:10000 (10ml) slowly
Causes of neurogenic shock
· Brain stem injury
· Cervical or high thoracic spine injury
Signs of neurogenic shock
· Hypotension & bradycardia
· Warm periphery
· Rule out mixed aetiology before atropine
Causes of septic shock
· Delayed evacuation
· Penetrating abdominal injuries
· Vasodilation due to endotoxaemia
Signs of septic shock
· Bounding pulse (wide pulse pressure)
· Rule out mixed aetiology
General management principles of haemorrhage and shock
· IV fluid resuscitation protocol
· Compressible - not shocked - no fluids
· Compressible - shocked - IV fluids
· Non compressible - urgent evacuation available- no fluids
· Non compressible - urgent evacuation not available - IV fluids
· This is a guide not a maxim! Why?
Management principles - 6 IV fluid resuscitation protocol
· Why give fluids to a shocked casualty with compressible haemorrhage?
§ Re-bleeding should not occur from the compressed site when the BP rises (although it can from other sites!)
§ Restoring circulating volume (crystalloid/colloid) even without restoring haemoglobin levels (blood), will increase tissue oxygenation-perfusion and reduce the risk of cellular anaerobic metabolism cascading on to cell death
Examples of disasters responded to by faith based organisations - e.g. samaritans purse
Haiti cholera epidemic
philippines typhoon Haiyan
european refugee crisis
ebola epidemic - liver July 2014
Why is is important to consider disability in emergencies?
- Those with an injured that are at risk of developing into an impairment (for example, injuries such as bone fractures not properly treated or followed up after discharge)
- Peoples who injuries result in permanent impairment (for example spinal cord injuries, amputations etc)
- People who are already disabled prior to the emergency or disaster
People with chronic diseases eg HIV, epilepsy, diabetes which can all deteriorate without medication.
What is the bad thing about improved response to emergencies?
Improved response is likely to result in less mortality, but more disability.
Rehabilitation services have had to be reimagined as worse and worse injuries are now surviving.
What are the implications of increased/better response to emergencies?
- Improvements in global health are seeing a reduction in global deaths
- And a rise in disability
WHILE - Persons with disabilities are more likely to have health needs
- But are less likely to access health services and have these needs met
à rehabilitation staff – poor staffing, variable training with limited access to up to date research, lacking autonomy. Not focused on trauma care.
à medical/surgical/nursing staff - not able to prioritise long term care, resources stretched, low awareness of rehabilitation
à equipment - lack of equipment or inappropriate, patients lack the info or money to resource themselves
Not just about managing the initial disaster, but how you’re going to manage the consequences longer term.
This is all supported by international guidelines – WHO essential trauma guidelines, Sphere humanitarian standards, WHO EMT minimum standards, EMT minimum standards for rehab
About the Nepal earthquake 25th April 2015
- Over 8000 killed
- Over 20,000 seriously injured
- 500,000 homes destroyed
- 456 health facilities destroyed
What is the work of the UK and EMTCC?
- Referral mechanism and hotline established
- Mapping and needs assessment conducted
- Locally led coordination group for prosthetics and SCI established
- Step down facilities established
- Long term strategic response plan developed with MoHP
What are the WHO essential trauma guideline (2004)?
- Much of the disability form extremity injuries in developing countries should be eminently preventable through inexpensive improvements in orthopaedic care and rehabilitation
- The consequences to the individual of injuries that result in physical impairment are minimised by appropriate rehabilitative services
- Basic physiotherapy/occupational therapy for those recovering form extremity injuries (especially fractures and burns) is deemed essential at all hospital levels
What are the Sphere humanitarian standards?
- Surgery provided without any immediate rehabilitation can result in a complete failure in restoring functional capacities of the patient
- Early rehabilitation can greatly increase survival and enhance the quality of life for injured survivors
- Patients requiring assistive devices (such as prosthesis and mobility devices) will also need physical rehabilitation
What are the WHO EMT minimum standards?
- Rehabilitation is one of the core functions of trauma care systems in regular healthcare and as such, FMTs should have specific plans for the provision of rehabilitation services to their patients post SOD
- Rehabilitation is included as a core component (either integral or via referral) of any inpatient surgical team
- In the case of amputations, rehabilitation services and psychosocial support ideally should be involved prior to or at the same time as the surgery
- Rehabilitation specialise support embedded within the team can offer triage and peri-operative advice as well as rehabilitation post-surgery, and have been shown to reduce length of stay
- FMTs should be aware that cross cutting issues of disability and vulnerable population care is an important part of ethical SOD response, and teams should plan to specifically assist or refer those with disability that present for treatment
What are the EMT minimum standards for rehab?
- 1 rehab professional per 20 beds
- Essential rehabilitation equipment list for first 2 weeks
- Hospital accessible
- Requirements for discharge planning and documentation
- Minimum reporting standards including amputation, SCI and fracture requiting fixation
About the UK emergency medical team?
- A register of health professionals who respond to disasters on behalf of the UK government
- Emphasis on professionalising the response: register members must access clinical and humanitarian training
- Clinical rehabilitation training developed by handicap international and professional networks including BACPAR, ACPIN, ADAPT, PPA and BAHT
- Backfill funding provided by the government to employers
What is the history of disability approaches?
Traditionally provided through specialist institutions:
§ Segregation and social isolation
§ Small proportion of disabled people actually benefited from such services (e.g. depends on location, access, affordability etc)
§ Disabled people were seen as passive recipients of charity/welfare - medical/charity models
1970s-present (social model):
§ Community-based rehabilitation (CBR)
§ Increased social contract between disabled people, their families, local communities, wider civil society institutions – and increasingly, governments
§ Rise of disability movement – social model
1990s onwards (bio-psychosocial model/human rights model):
§ Increasing emphasis on “mainstreaming” disability service provision within public services to facilitate facilitates social inclusion
Increasing shift to bio-psychosocial model/ human rights model
How is addressing disability about attitude change?
§ Changing mindsets of policy-makers, service providers, communities, families, friends and neighbours
§ Dismantle deeply entrenched physical, attitudinal and institutional barriers to effective social inclusion
§ Increase levels of social capital and relational bonds for persons with disabilities
§ Ensure adequate governance infrastructure for effective implementation of services
§ Support rule of law and effective implementation of human rights principles
§ Improve knowledge about what works – including improved data
What is the primary prevention approach to disability?
Primary prevention – actions to avoid or remove the cause of a health problem in an individual or a population before it arises. It includes health promotion and specific protection (for example, HIV education/polio vaccination efforts)
What is the secondary prevention approach to disability?
Secondary prevention – actions to detect a health problem at an early stage in an individual or a population, facilitating cure, or reducing or preventing spread, or reducing or preventing its long-term effects (for example, supporting women with intellectual disability to access breast cancer screening; glaucoma surgery for older adults)
What is the tertiary prevention approach to disability?
Tertiary prevention – actions to reduce the impact of an already established disease by restoring function and reducing disease-related complications (for example, rehabilitation for children with musculoskeletal impairment)
Why is disability a human rights issue?
- Inequalities
- violations of dignity
- denied autonomy§ People with disabilities experience inequalities – for example, when they are denied equal access to health care, employment, education, or political participation because of their disability.
§ People with disabilities are subject to violations of dignity – for example, when they are subjected to violence, abuse, prejudice, or disrespect because of their disability.
§ Some people with disability are denied autonomy – for example, when they are subjected to involuntary sterilization, or when they are confined in institutions against their will, or when they are regarded as legally incompetent because of their disability.
(Source – World Report on Disability 2011: 9)
What is the international disability policy environment?
International Instruments:
§ UN Convention of the Rights of Persons with Disabilities (2008)
§ Culmination of 30 year involvement of UN involvement in disability issues:
§ UN International Year of the Disabled (1981)
§ UN Decade of Disabled Persons (1983-1992)
§ UN Standard Rules on the Equalisation of Opportunities of Persons with Disabilities (1993)
§ Links to other international human rights instruments, as well as International Humanitarian Law
There are approximately 650 million persons with disabilities in the world, 80% of whom live in developing countries
§ Many impairments could be prevented with timely and appropriate health interventions (public health and basic rehabilitation services)
Disability and poverty are a cause and consequence of each other
§ It is estimated that around 20% of the world’s poorest are persons with disabilities
Persons with disabilities constitute one of the most marginalised and socially excluded groups within any society
§ Lack of access to mainstream public services, including health, education and employment
What are the challenges with disability data?
What are the challenges? à availability à accuracy Why? à definitions à stigma à priorities Without this data, what do we know about the health and well being of these individuals? - Inclusion in/access to general health care - Inclusion in public health/global health outreach efforts - Disability specific issues à need for better health statistics
What did the world report on disability 2011 say?
§ To provide governments and civil society with a comprehensive description of the importance of disability and an analysis of the responses provided, based on the best available scientific information;
§ To make recommendations for action at national and international levels.
What are the washington group short set questions (disability assessment)?
- Do you have difficulty seeing, even if wearing glasses?
- Do you have difficulty hearing, even if using a hearing aid?
- Do you have difficulty walking or climbing steps?
- Do you have difficulty remembering or concentrating?
- Do you have difficulty (with self-care such as) washing all over or dressing?
- Using your usual (customary) language, do you have difficulty communicating, for example understanding or being understood?
What is the gender dimension?
§ Women with disabilities may encounter double “discrimination”
§ Social anthropological studies in South India demonstrate that disabled men are more likely to benefit from and receive health services than disabled women (Erb & Harriss-White, 2000).
§ Also, the level of impairment has a greater for disabled women for them to be exempted from undertaking household chores then disabled men
§ Disabled Women are often subjected to sexual violence and abuse
§ Increased risk of HIV/AIDs
§ ‘Virgin myth’: belief that sex with a virgin can cure HIV/AIDs
§ Women invariably are the principal and often sole care givers for children with disabilities
So how does this translate into emergency situations?
What is UNCRPD?
Article 11 - Situations of risk and humanitarian emergencies:
“States parties shall take, in accordance with their obligations under international law, including international humanitarian law and international human rights law, all necessary measures to ensure the protection and safety of persons with disabilities in situations of risk, including situations of armed conflict, humanitarian emergencies and the occurrence of natural disasters.”
“In general, the needs of persons with disabilities are often overlooked by disaster planners and they have little or no input into disaster risk reduction planning.” (Kett and Twigg 2007) [this exclusion mainly the result of] “inappropriate policies or simple neglect” (IASC Operational Guidelines on Human Rights and Natural Disasters)
What does article 11 (disability) mean in practice?
- Children and adults with disabilities must be considered as a key target group across all intervention processes from identification, assessment and planning, delivery of support programs, monitoring and evaluation
- DPOs, parents, and NGOs working in the field of disability should be involved and consulted by humanitarian agencies to ensure the needs of persons with disabilities are recognised
- humanitarian aid agencies must pro-actively seek-out persons with disabilities to ensure they are registered and supported in humanitarian situations as they are often hidden away and/or not easy to identify
- Donor agencies should include, in their funding guidelines, information about systematic universal design for all reconstruction projects including temporary shelters and camps
- Sectoral agencies must include the needs of persons with disabilities, including access, in their operations (including shelter, water and sanitation, food distribution, health activities, education)
- Funding for post-conflict and post-disaster interventions needs to include persons with disabilities in a more tailored way, both to support persons with disabilities as beneficiaries of assistance and also as a means to enable persons with disabilities to be included as part of the community response to the disaster or the emergency
What situations necessitate humanitarian intervention?
- Geophysical hazards (earthquakes, flooding…)
- Large scale accidents (i.e. industrial)
- Population displacement (including situations of violent conflict)
- Failure of states to protect citizens (including situations of violent conflict)
- Resource scarcity/famine
- Insecurity (including food insecurity)
- Epidemics
What are some of the social impacts of violence and conflict?
- Social structures/networks destroyed
- Poverty and social exclusion
- Loss of infrastructure i.e. homes, health care facilities, schools
- Loss of essential skills/personnel
- Lack of security (physical and psychological)
- Increased civilian injuries and deaths
- Small arms circulation
- ‘Normalisation’ of violence
What are the features of humanitarian crisis?
- can be sudden or slow onset (eg earthquake or famine)
- rarely swift to resolve – and can be protracted (eg Somalia, Sudan…)
- Affected by geopolitical considerations, poverty and donor attention
What is disability inclusion?
“Disability is the result of the interaction between an impairment limiting or altering a person’s capacities and that person’s environment”
(Preamble, UNCRP)
In Emergencies there are structural changes that can affect this :
àPhysical environment
àSocial support network
àPoverty
àKnowledge
àPoliticalAbout disability and humanitarian emergencies…
- An estimated 6.7 million persons with disabilities are forcibly displaced worldwide as a result of persecution, conflict, generalized violence and human rights violations (WRC 2014)
- Armed conflict will be 8th most common cause of disability worldwide by 2020 (WHO)
- Around 10% of an affected population will develop serious psychological trauma (UN)
What is the impact of disability on a household?
• Increased risk of poverty and social exclusion
• Lack of access to food/jobs/healthcare/other essential services
• Lack of security (physical and psychological)
• Increased risk of displacement/separation
• Exclusion/discrimination
• Effects on children and families
→ Compounded by disasters and conflict
What are the impacts of conflict or disasters on persons with disability?
- Poor environments and poor people are disproportionately affected by disasters and emergencies
- Persons with disabilities are very often the least visible in emergencies, and sustain disproportionately higher rates of morbidity and mortality
- Persons with disabilities often unable to access emergency aid
- Increased vulnerability (to violence and abuse; loss of support structures; issues of accessibility and exclusion etc.)
- Increased susceptibility (to secondary disabilities through conditions, including lack of medical care, loss of infrastructure, lack of rehab facilities etc.)
How can we ensure inclusion for the disabled?
- Standards and guidelines (e.g. SPHERE (and INEE companion standards; IASC Guidelines; NGO-specific and/or context specific Guidelines/Toolkits
- Training
- Advocacy and awareness raising
- Legislation
What are the achievements in disability inclusion following disaster etc?
- UNCRPD
- Earlier and better mainstreaming of disability as a cross-cutting issue (UN system, donors – including DFID)
- Standards/Guidelines/Toolkits
- Advocacy and awareness Training
- Rights-based language and approach
- Promotion of more integrated assessments
What are the ongoing challenges of disability in disaster?
• Definitions/data
• Lack of coordination
• Little internationally comparable data
• Costs?
→ post crisis potential for inequalities to grow
What are some opportunities in disability and disasters?
- Timing of interventions
- Increased visibility (including CRPD)
- Funding – Costs?
- ‘Build back better’
What still needs to be done with disability and disasters?
• Stronger linkages between DPOs and other advocacy organisations
• Increased participation in national and international clusters/forums/coordination meetings
• Participatory assessment processes
• Mechanisms to measure impact of interventions
• Disaggregated data collection and use
• Capacity building of all actors
• Mechanisms to turn policies into practice
• Stronger commitments from donors and UN to inclusion in humanitarian and disaster relief funding and programmes
• More research to improve understanding, for example around protection needs…
→ Acknowledge diversity – one size does not fit all…
What can/should public health professionals do for disability inclusion in disasters?
- If you are not seeing disabled people in your work, ask yourself why not
- Ensure that any and all programmes you work on have a disability-inclusive component (e.g. HIV/AIDS programmes, women’s health outreach efforts etc)
- Ensure that all efforts are made to ensure health care facilities are accessible – (ramps, sign language interpreters, transportation, ability to provide information to individuals who are intellectually disabled etc)
- Support the inclusion of students with disabilities in training as health professions
- Learn about and establish alliances with disabled people and their organisations (“Nothing about us without us”)
- Remember at its core, this is a human rights issue…
What is the health assessment in conflict and catastrophe?
Health needs assessment is the systematic approach to ensuring that the health service uses its resources to improve the health of the population in the most efficient way
What is the framework for health assessment in conflict and catastrophe?
- Planning
- allocation (services to be delivered)
- production (organisation of services)
- distribution (beneficiaries of services)
- financing
- Intervention selection
- impact
- effectiveness
- scaleability
- equity
- sustainability
What considerations need to be taken in health assessment in conflict and catastrophe?
- Timescale
- Purpose
- Ability to respond
- Stove-pipes and sectors
- Politics
- Cost
- Quant vs qual
What role does the health sector play in health assessment in conflict and catastrophe?
- Health provision
- ‘stabilisation’
- Development
What are the precedents of health assessment in conflict and catastrophe?
- Health can have a significant independent effect in nation-building efforts.
- Successful health system reconstruction includes effective planning, coordination, and leadership.
- Health reform is linked to other sectors, such as power, transportation, and governance.
- Health-sector reform needs to be sustainable, with responsibility passed to the country’s health care providers and leaders.
- Security is essential for all reconstruction, including health.
What is the Sphere Project?
The Sphere Project was launched in 1997 to develop a set of minimum standards in core areas of humanitarian assistance. The aim of the project is to improve the quality of assistance provided to people affected by disasters, and to enhance the accountability of the humanitarian system in disaster response. One of the major results of the project has been the publication of the handbook, Humanitarian Charter and Minimum Standards in Disaster Response.
About the sphere project…
- Initiated in 1967
- NGOs and IRC7RC
- To improve quality of humanitarian response
- To emphasise accountability
- Established core beliefs
- Produced a humanitarian charter
- Identified minimum standards
- Produced a handbook
- Regularly updated
What is the humanitarian charter?
The humanitarian charter expresses a shared conviction as humanitarian agencies that all people affected by disaster or conflict have a right to receive protection and assistance to ensure the basic conditions for life with dignity.
What are the protection principles in the Sphere Project?
Protection principles, which underpin all humanitarian action and encompass the basic elements of protection in the context of humanitarian response. They are accompanied by guidance notes, which further elaborate the role of humanitarian agencies in protection. A reference section includes other standards and materials relating to more specialised areas of protection.
What are the six core standards in the Sphere Project?
- People centres humanitarian response
- Coordination and collaboration
- Assessment
- Design and response
- Performance, transparency and learning
- Aid worker performance
What are the minimum standards in the Sphere project?
- Water supply, sanitation and hygiene promotion (WASH)
- Hygiene promotion
- Water supply
- Excreta disposal
- Vector control
- Solid waste management
- Drainage
- Food security and nutrition assessment
- Infant and young child feeding
- Management of acute malnutrition and micronutrient deficiencies
- Food security
- Shelter and settlement
- Non-food items: clothing, bedding and household items
- Health systems
- Essential health services
What are other activities of the Sphere project?
- Health assessments
- Serveillance
- Calculating health indicators - CMR, U5MR, incidence rates, CFR
About war and conflict in the modern era?
- We are living in the most destructive period in human history
- 250 wars between 1990 and 2000
- 110 million dead
- 6 times as many deaths in 20th century wars compared with the 19th century
What are the origins of the functioning state?
- Westphalian system of sovereign states - 1648 (end of the 30 years war)
- Post 1945
- Concepts of sovereignity, legal equality and international co-operation
- UN, Bretton Wood, EC
What are the origins/emergency of the failed state?
- End of the cold war
- End of superpower interventions
- Emergence and breakdown of new entities
- Post modern market state
What is the background to the dramatic change in the concept of statehood?
- New types
- Derivates from old power blocs
- New hierarchies
- Long term conflict (never ending)
- Crises - fragility - collapse
- Emergence of failed or failing states
What are the features of failed states?
- Emergence of violent non-state actors
- Intra-state conflict
- Ideal environment for nurturing terrorism
- Forced migration and ethnic cleansing
- Dangerous place for carers
- Chaos
- Breakdown of state apparatus
- Unable to control violence
- Failure in judicial system
- Rise in crime
- Failure to fulfil international obligations
What is the definition of failed state?
A failed state is a state whose central government is so weak that it has little practical contorl over much or all of its territory - US fund for peace
What is a succeeding or successful state?
“a state could be said to succeed if it maintains a monopoly on the legitimate use of force within its borders” - max webber
About new entities - failure to agree on definition…
- Failed and failing states
- Rogue states
- Crisis states
- Fragile states
- Collapsed states
- Ochlocracy - mob rule!
What are the historical, political and economic culprits of failed states?
Colonial legacy
- Post colonial states - Failure to integrate - Social, ethnic and religious frictions - Migration 0 forced and voluntary
End of the cold war - upheaval
Globalisation and disintegration
Humanitarian aid - a blessing or a curse?
- Inappropriate?
- Disincentive?
- Bypassing local enterprise?
- Disconnection - reward or punishment?
- Imposed
- Ethnic and religious tension
What is the future of humanitarian aid in failed states?
- Private military companies
- Operating outside freedom of information legislation
- Now bidding for peacekeeping, humanitarian operations - ‘aid for profit’
What are the social indicators in the 12 criteria used to score vulnerability?
- Mounting demographic pressure
- Refugees and IDPs on the move
- Vengeance seeking groups
- Chronic and sustained human flight
What are the economic indicators in the 12 criteria used to score vulnerability?
- Uneven economic development along group lines
* Sharp and/or severe economic decline
What are the political indicators in the 12 criteria used dos core vulnerability?
- Criminalisation and/or delegitamisation of the state
- Progressive deterioration of public services
- Widespread violation of human rights
- Security apparatus as a ‘state within a state’
- Rise of factionalised elites
- Intervention of other states or external factors
What are the top 10 failed states?
- sudan
- draw
- somalia
- zimbabwe
- chad
- ivory coast
- D. R congo
- Afghanistan
- Guinea
- Central African Republic
What are complex humanitarian emergencies?
The UN Defines these as: “ …a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of a single agency and/or the ongoing UN programme”
In other words a Failed State
There may be elements of both natural and man-made disasters working in concert
How big is the current problem of war and conflict?
- Globally 310 000 deaths directly related to conflict in 2000
- Over 84 countries across the world are affected by ERW, including landmines and cluster bombs, most in failed states
- Conflict-related injuries and disabilities account for some 4.8 million DALY worldwide
- Of the 600 million disabled people worldwide, 80% live in developing counties & failed states
What is the CHE environment’s impact on health?
- Economic failure - Poverty & Disillusionment
- Mismanagement & corruption
- Destruction of infrastructure, including medical
- Aid can exacerbate
- Widespread systems failure
- Reporting
- Surveillance
- Access to health care
- Unreliable data
What are some of the social impacts of complex emergencies?
- Social structures/networks destroyed
- Poverty and social exclusion
- Loss of infrastructure i.e. homes, health care facilities, schools
- Loss of essential skills/personnel
- Lack of security (physical and psychological)
- Increased civilian injuries and deaths (9:1)
- Small arms circulation
- ‘Normalisation’ of violence
What are the special needs of vulnerable groups in complex emergencies?
- Forced migrants – Refugees & IDPs
- Women (carers)
- Children
- The elderly
- The ill (HIV & AIDS)
- The disabled
What are the problems with aid programmes in complex emergencies?
- Climate of danger for uniformed health professionals
- Climate of danger for NGOs & IGOs
- Too many players – rivalries
- Competing priorities
- Novel problems – politics - contractors
About Syria as a complex emergency…
- Loss of government legitimacy
- Civil war
- Emergence of ISIL and affiliated groups
- Poverty and hunger
- No solution in sight
About Libya as a complex emergency…
- Intervention by the West unleashes violent intra state clashes by rival factions
- Loss of government legitimacy
- Economic failure
- Instability, danger and arrival of ISIL and affiliates
- No end in sight
Complex emergency - Afghanistan 2002-2014
Problems: • Dangerous • MSF pull out (But now back) • Deliberate targeting of aid workers • Access to the those in need • No front lines • Logistics • Corruption & Narcotics
Complex emergency - Sri Lanka tsunami
Background
- Earthquake 26th December 2004
- Indian/South East Asia tectonic plate intersection 800km SW of Indonesia
- Richter 9.3
- Sri Lanka deaths 30.000-50,000
- 9000 child deaths
Problems in sri lanka
- Not medical- but there are health issues
- Natural disaster compounding a man made conflict
- Disinformation
- Social & political issues (land – displacement - Access)
- Allegations of corruption
- Security – LTTE (Now quiescent)
- Risk of further disasters
What is the golden triad of moral philosophy?
- virtue ethics
- consequentialism
- deontology
What is virtue ethics?
think the two below have got it wrong because they are asking the wrong question. Virtue ethics asks ‘what is the right person to be’ not ‘what is the right thing to do’. They look at character, not actions. They answer their own question by saying ‘you ought to act in such a way that a virtuous person would characteristically act’. Many consequentialists and deontologists though that virtue ethicists would collapse into one of the other two types, and that it is not an independent way of thinking
What is consequentialism?
look forward at the consequences of your actions, what is the impact of your decision? Think that rules, duties etc are nothing more than rules of thumb, they may be useful in the consequences they get you to, but have no value in themselves – the only think that matters are the consequences. Must only act if the consequences are better than if no action was taken. (Opposite of deontology)
What is deontology?
based on the concept of duty, duties and rights belong here. Rules and principles. Reasoning and reasons. They’re looking backwards and upwards, applying rules and principles to a particular problem. (Opposite of consequentialism)
How do consequentialists choose the right outcome?
The currency question in consequentialism – what are you trying to maximise? Eg happiness, pleasure and minimise pain and unhappiness. Need to be able to reason why they chose a particular ‘currency’ (outcome priorities) without having to use rules, otherwise they become deontologists
What is pluralism?
Pluralism – choosing different types at different times/situations. To think that the right way of thinking is that it is a combination of the three. The challenge with pluralism is giving consistent answers, as you are vulnerable to how you are feeling on a certain day.
What is the ethical dilemma of a military doctor?
Military physicians are bound by professional ethical guidelines AND by their oaths as members of the Armed Forces. There may be a tension between: · The doctor qua and doctor qua soldier. A doctor’s aim is to prevent suffering and improve lives, yet the military isn’t necessarily about this, sometimes the complete opposite. à International humanitarian law – read
What do the geneva conventions say about military doctors?
· The Geneva convention designates military physicians as having ‘non-combatant’ status/ if captured, they are not to be considered prisoners but rather as ‘detained persons’.
· The Geneva convention also requires physician-soldiers to be non-discriminatory in their treatment of the ill and wounded, including enemy soldiers, even if doing so would further enhance the enemy’s overall military potential.
What is the professional guidance on military doctors?
There is very little guidance on military medicine – perhaps because they think that none is needed – first and foremost you are a healthcare professional no more is said.
There is some BMA guidance available, which is worth reading!!
~33% of military doctors would not consider medial need as the sole determinant for treatment in a triage situation.
What are two challenges on the field of battle for military doctors?
- choosing between patients
- treating the enemy
What does just war theory day about military medicine?
Aims to distinguish between ethical and unethical war and aims to determine what is morally acceptable and unacceptable during warfare.
2 traditional (and one modern*) principles:
- Jus ad bellum (right to do to war)
- Jus in bello (right conduct in war)
- Jus post bellum (right conduct after war)
Moral dilemmas in military medicine often require urgent solutions and this limited the amount of moral reasoning that can be done at the time of decision making.
But these dilemmas are also predictable and so reasoning can happen before deployment occurs.
What is international humanitarian law?
· Major part of public international law
· Rules which, at times of armed conflict:
- Protect people who are no longer taking part in hostilities
- Restrict the methods and means of warfare employed
· “Law of Geneva”
- Safeguards civilians & military personnel no longer involved I the conflict (PoWs & injured)
· “Law of the Hague”
- Rights & obligations of beligerents and restricts means of harming the enemy
What is the history of IHL?
- 24th June 1859
- Henry Dunant
- visited battlefield
- suffering of wounded soldiers
- Henri Dufour
founded the red cross movement
What did the geneva conventions say about IHL?
1864
- Geneva convention for the amelioration of wounded soldiers
1868
- Declaration of St Petersburg (prohibiting use of certain projectiles)
Reviews 1906 and 1907.
World War One - IHL
1925 à prohibition of asphyxiating poisonous gases and bacteriological methods of warfare.
1929 à review and development of 1906 convention, Geneva convention relating to prisoners of war.
World War Two - IHL
1949 – Four new Geneva conventions
· I Treatment of wounded & sick armed forces in the field
· II Wounded, sick & shipwrecked armed forces at sea
· III Treatment of Prisoners of War
· IV Protection of civilians in War
What IHL developments were made in 1954?
Cultural property
What IHL developments were made in 1972?
Prohibition and stockpiling biological and toxic weapons
What IHL developments were made in 1977?
additional protocols to the 1949 conventions protecting victims of international (Protocol I) and non-international (II) armed conflict
What happened in the 1980s with IHL?
(1980) Convention on prohibition or restrictions on certain weaponry:
- non-detectable fragments
- mines and booby traps
- incendiary weapons
What happened in the 1990s with IHL?
1993 à chemical weapons
1995 à blinding laser weapons (was decided that society wouldn’t accept a huge number of blind young men – compared with amputation injuries etc in the past – despite that no one would be dying.)
1996 à revised protocol on mines
1997 à prohibition of anti-personnel landmines
What has happened with IHL since 1998?
1998
- Rome statute of the International Criminal Court (ICC)
1999
- Protocol to 1954 (cultural property)
2000
- Rights of the Child
2001
Amendment to Article I of CCW (non-international armed conflict)
About the red cross emblem…
· Use of the RC emblem is specified in IHL
· Armed forces’ medical services
· ICRC/IFRC
· Civilian hospitals
· Strict protocol – must treat anyone who walks through the door, in priority of severity.
· Other agencies with authorisation
· Penalties for misuse (for example used in pharmacy windows or if you have a field hospital with the sign, there can not be fighting troops stationed within it – it must purely be a medical area.)
What are war crimes + examples…
Serious violations of IHL committed during international and non-international conflicts:
- Wilful killing of a protected person (eg civilian, prisoner of war, injured enemy soldier)
- Torture or inhuman treatment
- Wilful injury or suffering (within a military goal there should not be unnecessarily suffering or injury, only the minimum necessary to reach the goal)
- Deliberate attacks on civilians
- Use of prohibited weapons (eg gas, chemical weapons, deforming bullets, etc)
- Misuse of emblem
- Pillage of private property
Tailoring international law to the situation surrounding it at the time. It has been adapted overtime, so that it fits where a complex system prevails, much more technology etc.
What are some examples of war crime cases?
fire bombing of Dresden HMS Torbay 'Coup de grace' IRA in gibraltar Halabja Journalists in Iraq United States and the International Criminal Court (ICC) Guantanamo Bay Detention Centre Blackwater in Iraq Sgt Blackman MSF Hospital in Kunduz Barrel Bombs in Syria Mohammed Enwazi British Armed Forces are the European convention on human rights
What are the options for a WASH response?
- Water supply
- Sanitation
- Hygiene promotion
Links to the health sector
What is the epidemiological burden of WASH?
- 16,000 children die each day
- 50% linked to malnutrition, lack of water and sanitation
- 10% cause by diarrheal diseases
which means ~1 child each minute dies from a diarrhoeal infection
Why WASH?
- hand washing with soap reduced diarrhoea morbidity by 48%
- water treatment also reduces diarrhoea morbidity by 17%
- moving from open defecation to any type of sanitation technology results in 36% reduction in diarrhoea morbidity
About emergency water supply activities…
· Focuses on identification and set-up of water supply and distribution for affected population and households
· Installation of institutional water supply at health care facilities, schools, feeding centres
· Monitor needs, accessibility, equity and gaps
· Planning for contingencies (weather events, population movements, disease outbreaks)
What is the immediate WASH response?
- Set up storage bladders/tanks, treatment unit, distribution network
- Water trucking
- Household water treatment and storage
- Jerry can distribution
What is the medium to longer-term WASH response?
- Rehabilitation of existing water points (equipping, cleaning)
- Development of new water points (drilling, jetting, spring protection)
What are the key considerations for emergency water supply?
- Phased approach best approach (limit water trucking)
- Importance of quantity over quality i.e. good access (< 1km) is more important than perfect quality
- Choose sites near water but beware of flooding
- Assessment of water sources
- Operation and maintenance
- Community participation and training
- Importance of complimentary activities i.e. hygiene promotion
- Continuous monitoring to adjust initial response
SOCIAL, CULTURAL AND OWNERSHIP WATER QUANTITY WATER QUALITY TECHNICAL ASPECTS ECONOMIC ASPECTS ENVIRONMENTAL ASPECTS
What are the social, cultural and ownership considerations in a WASH response?
Ensure equitable access for women, children, disabled and elderly people
What are the water quantity considerations in a WASH response?
the yield must be sufficient to meet the demand for water
What are the water quality considerations in a WASH response?
all water is susceptible to contamination and may require treatment that must be acceptable to users and feasible to carry out
What are the technical aspect considerations in a WASH response?
must be feasible and operation and maintenance requirements for the extraction of the source must be appropriate, with skills and human resources
What are the economic aspect considerations for a WASH response?
ensure that funds are available to support the construction, operation and maintenance of the system
What are the environmental impacts that must be considered in a WASH response?
The hydric balance
What are the key physical parameters of water quality?
- turbidity (BTU): less than 5 NTU can be measured using a turbidity tube
- pH: between 6.2 and 8.2 can be measured using a comparator
What are the key microbiological parameters of water quality?
Faecal coliform caused by E.coli (human and/or animal faeces) should be 0 per 100ml sampled, can be measured using Oxfam GB Del Agua/Wagtech Kit
What are the key chemical parameters of water quality?
conductivity/TDS: 1000mg/l, 1400 uS/cm, can be measured using a conductivity meter
What are the methods of bulk treatment of water?
1 - sedimentation
2 - coagulation and flocculation
3 - aluminium sulphate
4 - chlorine
What is the sedimentation treatment of water?
setting out of physical impurities. If a NTU of less than 5 is not achieved then do coagulation and flocculation
What is coagulation and flocculation of water?
coagulation: chemical process that forms clots/flocs of impurities in the water
flocculation: gentle stirring or agitation to encourage the particles thus formed to agglomerate into masses large enough to settle or be filtered – flocculants assist in the removal of suspension solids, but do not disinfect water
What is the treatment with chlorine of water?
destroys all pathogens in water in short time, residual chlorine should be 0.2-0.5 ml/l after contact time of 30 minutes for water with pH < 8 (or 1.0mg/l in a situation with water related disease outbreak), most commonly use dis calcium hypochlorite (HTH)
