The War Surgeon

by Chris Giannou

New Internationalist magazine, September 1997

Until his first mission to Somalia in 1990 for the International Committee of the Red Cross, Chris Giannou worked as a war surgeon in Lebanon. Dealing with the life-threatening injuries that humans inflicted upon each other was part of every working day. However, he had seen only a few cases of mine injuries. Berbera, Somalia, changed all that. There he found that 95 per cent of his patients had set off mines and he had to learn, as he puts it, 'a whole new chapter of war surgery'. He has since operated on the mine injured in Cambodia, Afghanistan, Burundi and Chechnya and has seen innocent lives changed beyond recognition by one wrong step. Working within their war-shattered medical systems he has encountered situations where basic medicines were hard to come by and anesthetics unavailable. He tells of times when bandages and gloves had to be boiled and recycled. During this interview he was careful to describe precisely the medical consequences of mine injury, but there was no mistaking the passionate indignation in his voice.

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After 17 years as a war surgeon, I know that war wounds are particularly ugly. But there is something specifically horrific and barbaric about mine injuries, so that even after everything I have seen I am still appalled by them. I don't think anybody can be hardened enough not to be affected when they see what mines do to a human being.

When someone steps on a blast mine the explosion literally tears their foot or leg off -- tissue gets vaporized, torn to shreds. The blast also picks up gravel, other debris, grass, parts of the mine casing, pieces of footwear and fragments of bone from the foot, and forces all of this up into the tissues proximal to the place where the leg has been torn off or into the other leg, the genitals, buttocks or even the arms. We call this a 'pattern one' injury, and it invariably results in a traumatic amputation. The amount of damage depends upon the explosive charge: if it is large enough it will kill the person on the spot.

The second pattern of injury is caused by shrapnel from a fragmentation mine, which is usually set off by a trip wire. For example, a Claymore-type mine shoots several hundred steel balls in an arc in one direction. If you're close it can tear the body to pieces, there will be nothing left. At a sufficient distance the wounds will be relatively superficial.

The third pattern occurs when you manipulate a mine. This could be someone laying mines, or doing mine-clearance work who has an accident. I think of Cambodia where people bending over to plant rice shoots in the paddies have hit mines with their hands. Or the very small mines that come in bright colors, fascinating little things which children go out and pick up, which don't have enough explosive charge to kill but have sufficient to injure several fingers, or amputate the entire hand and also cause injuries to the face and eyes.

By far the largest use of mines is in rural areas where at the best of times there is a problem of communication and of transport. In a semi-nomadic society like Somalia, waterholes (which are important to the survival of people and their flocks) have often been mined. So it may take up to two weeks for someone who is injured to reach a hospital which could be hundreds of kilometers away. A major problem in rural areas is that, if the injured person is accompanied, the immediate reflex of their friend is to rush and help them, thus entering a minefield. Then you are talking about two injured people and nobody to go get help. People have to overcome this natural urge to rush in. They have to fetch help, get the person removed from the minefield, staunch the bleeding, provide basic first-aid which may not always be available and transport the victim to the nearest health facility. In areas such as Angola, Mozambique and Somalia you are talking about hundreds of kilometers.

Our estimate, based on anecdotal evidence, was that for every person who reached the hospital one person died out in the fields - and that was corroborated by a number of socio-economic studies. They are not always killed on the spot. They succumb to infection and blood loss, and it may take them several hours or days to die, in atrocious circumstances.

Many patients reach a hospital late having lost a great deal of blood and usually with an established infection in the wound. Additionally mine injuries are usually very dirty and contaminated, much more so than wounds due to bullets or ordinary shrapnel. A traumatic amputation due to a mine is not like a traumatic amputation due to a heavy machine gun. The tissues have a great deal of impregnated organic matter, dirt and debris; they are the sorts of wounds most surgeons simply have not seen before. Usually local doctors cope very badly, even the military doctors of the armies of 'developed' countries. They have difficulty in understanding how much devitalized and contaminated tissue must be removed and at what level to do the amputation. The explosion will drive particulate matter up into the tissues, even between the muscles, and unless you know that and go in and look for it and try to get it out, it is very, very easy to overlook. It is difficult, time-consuming surgery. I've been in situations where I've worked for twenty hours a day for weeks on end in the theater.

Correct war surgery usually requires two operations - the first to remove all damaged tissue and the second, five days later, to suture the clean wound. With mine injuries the average is three or four operations, due to infections and the need, sometimes, to revise stumps at a later date. With children, the bone grows faster than the soft tissues, muscles and skin. So although after the immediate amputation and closure the stump may be fine, as the child grows the bone may start to stick out of the skin, whereupon you have to reamputate. Children also grow out of prostheses very quickly. If they are not changed, this will cause problems with the vertebral column and the hip joints. You can never say to a child: 'Oh come back in another few months and we'll change the artificial limb'.

Mine injuries challenge the entire health system of a country. The health system is the first victim of any war, whether in rich or poor countries, because of the disorganization caused. People injured by mines require a multitude of things from evacuation to first aid to transportation to surgical care to rehabilitation including, if need be, an artificial limb, to physiotherapy, vocational training and social reintegration. In other words, they require resources that are in short supply in war-torn societies. In purely medical terms mine victims require more antibiotics and dressings and longer hospital stays. People who have to suffer an amputation will need seven times as much blood, on average, as those wounded by gunshot. If 10 per cent of patients in a hospital have been wounded by mines, they may constitute 80 per cent of the work in the hospital and consume 80 per cent of supplies. Sometimes people are so overwhelmed by the idea of the wounded and the dying that they fail to realize that in many circumstances even more people die from other things. In Cambodia we had a large number of mine victims but more people were dying of malaria and tuberculosis. However mine injuries, because they are more dramatic, naturally exert a great deal of social pressure to devote greater resources to their treatment than to ordinary pathology.

But of course the danger is very real. Landmines are completely indiscriminate in terms of the victim - a soldier places a mine in the fields and doesn't know whether a friendly soldier, an enemy soldier, woman, child or peasant is going to step on the mine. They are also indiscriminate in terms of the time and place. In 1992 I was working in Beled Weyne in Somalia and I had to operate on a young girl. She used to go down to the riverside every day to fetch water from a place in the center of the town. One day she went to the same place and stepped on a mine. In 1977 Ethiopia and Somalia had been at war and the troops had mined the mountains along the border. Fifteen years later the rains had carried this small plastic water-resistant mine down the hillside, along the river, 40 kilometers further downstream where it came ashore and the young girl stepped on it. The military may say, 'We make maps of our minefields and we provide notification and markings', but the rains will fall and the winds will blow and snow will melt and soil will erode. And mines will be displaced ending up, years later, in places far from the minefields. Nature does not respect national boundaries.

The international community no longer accepts that you use exploding bullets against soldiers, it does not accept that you gas soldiers, it does not accept that you infect soldiers as a means of warfare. Yet, we continue to tear people's limbs off. It seems to me that that's just as terrible as infecting or gassing someone.

Dr. Chris Giannou works for the International Committee of the Red Cross

Landmine watch