The number of casualties in the latest fighting between the government and rebels in eastern Chad has been so high that the International Committee of the Red Cross (ICRC) surgical team in the country was unable to cope, and a second team had to be sent out from Geneva.

“As soon as I arrived [on 2 December] I was presented with plenty of wounded,” the head surgeon of the back-up team, Amilcar Contreras, told IRIN while on a break from performing surgery at La Liberté Hospital in N’Djamena. “Some had been there for almost a week waiting to be operated on while others had just come in.”

Contreras said he quickly set up a “triage” system to prioritise the most urgent cases.

“I had to deal with some pretty terrible things, like one guy who had a piece of shrapnel lodged in his eye,” Contreras said. “The only solution was to remove the eye completely and I had to do it fast otherwise [infection would spread and] he could have lost the sight in his other eye.”

But Contreras first had to get the patient’s consent to remove the eye, and that was not easy. “He said he wanted to seek traditional treatment instead. I had to convince him that no one could possibly save the eye and if I didn’t remove it the dirt inside would remain trapped there and his condition would worsen.”

Contreras said most of the wounds from the battle front were caused by bullets and shrapnel. “It’s actually hard sometimes to tell the difference, particularly when a bullet goes in and out of one body, then enters another,” he said. “It has passed through so much bone and tissue that it often completely deforms and may look like shrapnel.”

War surgeons do not need to be experts in different types of ammunition to do their job, he added. “Whether a bullet is a ‘full jacket’ bullet or `part jacket’ [hollow point] really doesn’t concern me. All I care about is the damage that the metal has caused the body,” he said.

War movies

If a piece of metal ends up lodged in a part of the body that is not life-threatening, war surgeons just leave it there. “In war movies you see surgeons always focused on extracting the bullet but that’s simply wrong,” he said. “A bullet makes a small hole and to extract it you have to make a bigger hole so you can end up doing more damage than the bullet did.”

War movies also often have scenes of a surgeon sowing up wounded soldiers on the battlefield, he said. “The thing about battlefields is that they’re dirty, so most of the time that’s a big mistake to close up a wound as the dirt is kept inside and you can’t treat the infection that ensues.”

He said medical staff who have not been properly trained in war surgery often make that mistake.

In fact people wounded in war often receive two operations, the war surgeon said. The first is to cut out damaged tissue and clean the wound; the second, which usually takes place a few days later, is to close up the wound.

Reserving capacity to treat civilians

As hospitals in N’djamena filled up with injured combatants in the days following the start of the fighting in late November, the ICRC also had to ensure that the normal case load of civilian surgery continued. “We always make sure we have a reserve capacity for treating civilians,” Contreras said. “It is a principle of the ICRC that when people are injured in a car accident or whatever, they are not deprived of treatment.”

The ICRC must balance that principle with international humanitarian law on war causalities, the head of the ICRC delegation in N'Djamena, Thomas Merkelbach, said. “Wounded persons no longer participating in combat are entitled to prompt medical treatment,” he said.

Three basic objectives

In fact ICRC doctors only undertake surgery on wounded combatants with three basic objectives: The first is to save the combatant’s life; the second is to save his limbs, and the third is to save the functionality of limbs and organs. “That’s all we should ever do,” he said.

But sometimes those three simple objectives come into conflict with each other. “People always say they want us to save their limbs even after we tell them their lives are at risk,” Contreras said. “It doesn’t matter when we tell them that they will never be able to use the limb again anyway.”

Making the decision to amputate is difficult, he added. “I had a young man this week who was just 26 years old with a leg so mangled that I had no choice but to remove it.”

“It was really sad but what can you do?” he said. “That’s war for you.”

That does not mean that war surgeons are insensitive to the suffering of the war wounded, he said. But it is also no good to get overly involved, “otherwise you burn out”, he said. “The trick is to strike the right balance,” he said.

One of the better moments in Contreras’s 10 days in the surgical theatre occurred when he attended to a combatant with a bullet hole in the chest. “The bullet passed right through him and he had an exit wound in his back. Yet it only broke five ribs,” he said. “None of his vital organs were damaged which meant we didn’t even have to operate,” he said.