A short while ago I was in Mogadishu, the capital of Somalia, a country immersed in a longstanding civil war. I had moved fast to get there. A double bombing had been triggered in a populated area and nearly 500 victims had been involved. At least 25% had died, most before they reached hospital. I was part of a small team whose task was clear, but the solution was not. Work out how healthcare might have acted differently, so that fewer casualties would have perished.
To lose 25% is double what might be expected. As I looked into the eyes of the first responders, those who had collected the dead and dying from the street, it was clear that, in Mogadishu, history was repeating itself. Take any war – Ukraine, Yemen, World War I, World War II, Vietnam, Falklands and more – it is a sad fact that many who die need not do so. Although nearly 90% of deaths occur before a casualty reaches a medical treatment facility, one quarter might survive if there is proper management at the point of injury. Most (90%) casualties perish from haemorrhage, so-called bleeding out. The remainder (10%) generally expire thanks to airway obstruction or a tension pneumothorax.
Next time you visit a war cemetery, to see the depressing lines of headstones, imagine that 25% of the dead may have survived and the cemetery could be considerably smaller. The Commonwealth War Graves Commission presently commemorates 1.7 million casualties from the two World Wars, in 153 countries. One quarter of 1.7 million is huge. They are young casualties, too. The mean age of death in the Great War was 27 years, although more 19-year-olds were killed than any other age.
The solution? First, be aware that avoidable death is a problem. It is global, enormous, and tragic. It is bigger than COVID-19, malaria, tuberculosis, HIV, and other conditions that make headlines more commonly. No land is spared, and it is not just conflict that is the problem. Most zones of conflict have more casualties from road traffic accidents than from missile injuries. The second step is to act, which was why I was in Mogadishu. A casualty, however injured, should expect prompt treatment.
First aid, immediate therapy, call it what you will, is a genuine lifesaver. This is not only care from a trained paramedic, but also from bystanders. In a developed urban society, the average time for a first responder to arrive at an accident is 7-10 minutes. In a rural setting this will be longer, and especially in less developed lands. Meanwhile, the time to bleed out from an injury – imagine a gunshot wound – is only 3-5 minutes. There is a natural reaction, too, that I have seen during surgery. Accidentally cut a blood vessel, and the surgeon instinctively steps forward to gain control. Meanwhile, any visitor looking on, steps backward, fearful of being contaminated by blood. In real life, speed is essential and hemophobia not an option. Telephoning for emergency services is not fast enough.
Haemorrhage control forms part of first aid teaching, although the specifics require more detailed training. Such courses do exist and are not complicated. First, apply pressure, second add dressings, one on top of another and avoid the temptation to peek. Third, if you have one, and direct pressure does not work, apply a tourniquet. Improvise if you must.
In many parts of the world where my work has taken me, and that is more than 35 countries over four decades, there is a lack of community awareness about avoidable death, and certainly there is a lack of training. Prehospital trauma systems are rudimentary. First aid is seen as someone else’s problem, when it is not. Making communities aware of their deficiencies is difficult but essential and requires a major effort by public health, governments, NGOs, and full involvement of the media.
The World Health Organization has already recommended the education of layperson first responders where feasible. A study in Chad, where motorcycle taxi drivers were instructed in scene safety, as well as airway and haemorrhage control, not only improved casualty outcome, but bettered the social status of the taxi driver. The same can be said of other lands in sub-Saharan Africa, with studies in Ghana and Uganda showing that the training of first responders can help significantly. Meanwhile, a Vietnamese study on road traffic accidents, showed that only 48.1% of the injured received first aid at the point of injury. Those with better outcomes were the ones who received first aid. Despite these findings, the British Red Cross has a depressing statistic. Only 5% of people know what to do in a first aid emergency. That is simply insufficient.
Society must stand up and take note. Anyone and everyone should know the basics of first aid, and certainly how to control haemorrhage. That includes those who are medically qualified.
About the author: Richard Villar is a retired consultant orthopaedic surgeon in the UK and is now the Head of Research and Field Advisor for WHO’s Trauma Operational & Advisory Team. He has a lifelong and global experience of working in conflict and disaster zones.
Competing Interests: None
Acknowledgements: I am more than grateful for the assistance of the Trauma Operational & Advisory Team (TOpAT) and to USAID for its invaluable funding.
Handling Editor: Neha Faruqui