Dr Francesca Holt

How to Keep Your Patient Safe in War

In 2018 I worked in Syria and have worked in other conflict zones. I was asked to write an essay on patient safety in these settings and struggled to articulate it. There are extremes and there are risks to the patient that should be considered against a backdrop of war. There is also a risk to your own safety and certainly operating with your passport, Nokia 360 and ransom money in your back pocket contextualises patient safety in a different manner to what we are used to. I met Janine di Giovanni, the War Correspondent, and I refer to her when she says, “war is the destruction, the skeleton and the bare bones of someone else’s life.” I ask that you consider this when reading this article. Within a few hours of arriving to my hospital in Syria I had intubated a 2 year-old boy with chemical poisoning and asked whether we could arrange transfer to a hospital with ventilatory support. We could not offer prolonged ventilation outside of theatre. A taxi arrived with a man holding an ambu bag. It was about 9pm and he was planning to bag the baby on a journey through multiple checkpoints, which may have lasted several hours. The boy went with the man in the taxi and I later learnt that he had died soon after arrival. It was too dangerous to assess the capabilities of other hospitals; our own hospital was de-mined and we operated in caravans due to the damage left from an assault by ISIS. Another infant had burns to his buttocks. I remember kneeling on the floor to put a line into his neck, as the bed wouldn’t raise. I remember his dad, in his military fatigues, questioning me about types of formula milk and laughing to myself, as the line of questioning seemed more suitable to Dublin than to Syria. We had alternated between referring the child to another hospital or not, as his father’s political and military allegiance was problematic for the transfer and I was reticent to transfer into the unknown. Then the boy deteriorated. His dad changed his clothes and they left. That boy died too. There was one burns unit in the country, in Damascus, where there was heavy fighting. Flying these patients, wrapped head to toe in dressings, meant orchestrating a journey assisted by the coalition and WHO, leaving our hospital in a van and travelling for many hours through checkpoints, until they arrived at an airstrip outside of a no-fly zone. My understanding was that they sat buckled in, upright. In Ireland, I am cautious of raising the head of the trolley too fast. We lived in the hospital compound, which was guarded by armed military personnel. When it was dark, I was not allowed to walk to the hospital and was driven for two minutes to the door of theatre or ICU. Was I right to send my patient and my patient’s relatives, quite literally, into the darkness, to a place whose safety I could not assess? Is it better to know the limits of what you can do, or trust the immeasurable? I did quickly learn what we could do and found comfort in the safety of what is known. I constantly deliberated whether sending a patient through these checkpoints, to a hospital whose standard and safety was unknown, was the right choice. Equally, it is important to know the limits of the system in which you find yourself. In Gaza, my mandate was to set-up a nitrous oxide sedation room. The room dedicated to this purpose was in a basement, with no ventilation and a ceiling height exhalation hose. Despite pressure to set up this service, we did not use this space. Although risk mitigation is challenging, as working in a country ravaged by war has many variables and inputs, even on a political level, (for example, one morning all of the national staff resigned, due to a hypothetical political threat), adherence to simple, evidence-based routine practice provides a strong foundation for a rapidly evolving situation (1). This is replicable in every area in anaesthesia; pre-oxygenate (even an oxygen concentrator allows this), check your own laryngoscope, have a Plan B and then, when quite literally an explosion happens, you have some security in the routine. It is estimated that almost half of all errors in the operating room are secondary to communication breakdown amongst personnel (2). Working through a translator requires some element of trust but forces you to make a clear and concise instruction, particularly during a crisis. In Syria we worked with approximately 20 translators, who were invariably young university graduates. I actually found it easier to work through a translator, than to try to professionally communicate with someone with poor English, during these times of crisis. I think this is because the translator expedited the communication process and was able to use standard phraseology in his translation, a nuance of which I may not know. Impulsive noise events adversely effect cognitive performance and the uncontrollability of noise, rather than the intensity, is the most critical variable (3). A study on noise-exposed schoolchildren found that adaption strategies such as tuning out to maintain task performance, came at the price of increased adrenaline and noradrenaline secretion (4). My own experience is primarily of gunshot noise. Within a few days I could differentiate “happy-firing” from retaliatory, which would warrant retreating away from a window or open space. We had “safe” rooms in all the hospitals and a bunker. To moderate the risk of stray fire landing in the operating room, we had Kevlar®-lined roofs, which, much like corrugated iron, amplifies noise, even rain. I was distracted when firing seemed close but this noise ends and you can refocus within a few moments. I never worked through the whistling of a barrel bomb, nor worried about my family when this sound goes quiet. I cannot write about working under aerial bombardment, as was the case in Kunduz or Al Shifa or Kafr Nabl or al-Ma’rra… etc. During a mass casualty involving children injured by a landmine, relatives started banging on the doors of the caravan and screaming. We were working inside, on children with blast injuries and the emotional distraction was hard enough. The psychologist was inside the caravan but was not needed during that acute phase. I was busy and so asked him to direct the response to the crowd so I could cognitively offload that job. He also had more time to communicate with the translators than I did at that moment. He task focussed the relatives by asking for blood donations and the inside of the caravan quietened. Another example of task simplification is in the use of whole blood. Whole blood simplifies administration and storage and reduces donor exposure (5). Indeed warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries (6). Whilst much of the literature pertains to its benefit in combat settings, my opinion is that it is safer because it is simple. We also used Combat Gauze®, an inert, non-allergenic material which hardens when packed into wounds, causing haemostasis in the field. Furthermore, I believe protocolised care is key to cohesiveness within this complex team. There is little room for individual variation when working in an emotionally and physically stressful environment, often through the use of translators and with multicultural input. Helping Babies Breathe is a good example as it is a resuscitation protocol designed specifically for resource-limited environments. Following its simple steps is shown to reduce neonatal mortality by up to 47% and fresh stillbirths by 24% (8). Operational centres outside of the field can collate outcome data and have the time and resources to prepare evidence-based protocols; another example of cognitive offload. The WHO checklist has been proven to reduce surgical-related mortality (7). On the other hand, one particular day I asked if we had a neonatal facemask before starting a caesarean section and was told yes. When the baby was born I discovered the answer was no. Adaptability (show me the facemask) and education (we taught Helping Babies Breathe) are key tools. Finally, a mission statement or charter is central to humanitarian aid. Aiming to ensure all stakeholders uphold these similar values is an important step in recruitment and retention of staff. The WHO Global Strategy for Emergency Medical Teams aims to efficiently hold medical teams to minimum standard and includes broad membership from organisations such as MSF, ICRC and UN OCHA. MSF asks that its members observe neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance. Using this as a guiding principle focuses your mind and your work, when everything around you is chaotic.

1. Venticinque SG, Grathwohl KW. Critical care in the austere environment: providing exceptional care in unusual places. Crit Care Med. 2008;36(7 Suppl). doi:10.1097/ccm.0b013e31817da8ec 2. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614-621. doi:10.1067/msy.2003.169 3. Berglund B, Lindvall T, Schwela D. Guidelines for community noise. 1999. https://apps.who.int/iris/bitstream/handle/10665/66217/a68672.pdf. Accessed October 2, 2020. 4. The Munich airport noise study : Cognitive effects on children from before to after the change over of airports | Semantic Scholar. https://www.semanticscholar.org/paper/The-Munich-airport-noise-study-%3A-Cognitive-effects-Hygge-Evans/60b56ad64c53bf77b85257df964a48a549faefa1. Accessed October 2, 2020. 5. Cotton BA, Podbielski J, Camp E, et al. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. In: Annals of Surgery. Vol 258. ; 2013:527-532. doi:10.1097/SLA.0b013e3182a4ffa0 6. Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma - Inj Infect Crit Care. 2009;66(SUPPL. 4). doi:10.1097/TA.0b013e31819d85fb 7. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population A bs tr ac t. N Engl J Med. 2009;360:491-500. doi:10.1056/NEJMsa0810119 8. Helping Babies Breathe. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/helping-babies-survive/Pages/Helping-Babies-Breathe.aspx. Accessed October 3, 2020.