A surgeon in troubled times



WASHINGTON – The political violence that plagued Northern Ireland for nearly 40 years has subsided, and the memories of those dark days in Belfast have begun to fade. But for Roy A. J. Spence, OBE, J.D., M.D., LL.D., FRCS, those years of treating trauma patients in the emergency room of the Royal Victoria Hospital in that city served as an important opportunity for learning and service.

Dr. Spence worked with a team of surgeons and other staff to treat thousands of victims of bombings, shootings, torture, kneecapping, and assault that happened in the context of clashes between two sides of a sectarian conflict and the British Army. Dr. Spence, who delivered the I.S. Ravdin Lecture in the Basic and Surgical Sciences during the annual clinical congress of the American College of Surgeons, discussed his experiences and lessons learned.

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During the worst period of The Troubles, as the conflict is called, emergency room surgeons were treating what were essentially combat injuries in an urban hospital setting. The great majority of the injuries in Belfast occurred within 1 mile of the Royal Victoria Hospital and the Belfast City Hospital, "some at the door of the hospital, some within the hospital, and we even had one patient shot in a bed in the hospital," he said. One victim was killed in the presence of Dr. Spence in the ER.

Dr. Spence, now professor and head of the department of surgery, imaging, and perioperative medicine at Queen’s University of Belfast, stated that despite the at times overwhelming numbers of injured that flooded into the ER, 90% of patients were delivered to the ER within 30 minutes and 50% within 15 minutes. The staff developed systems to speed patients through the ER to treatment and surgery if needed. In 1972 alone, 20,000 individuals were injured in various ways, and most of these injuries occurred in Belfast.

In addition to a streamlined admission process, the surgeons developed their protocol based on lessons learned over the years.

"We had disaster plans, but, in truth, we almost never had a rehearsal. The rehearsals were for real. The rehearsals were occurring day by day."

It became clear in the early years of the conflict that, in most cases, patients were best served if the doctors stayed at the hospital to receive patients instead of rushing to the scene of a bombing or shooting. "We were almost a nuisance if we went to the scene, because there was often continuing gunfire, there were secondary explosions, and sometimes the bodies themselves were booby-trapped."

In addition, the system of handling large numbers of injured patients worked best if there was a senior surgeon and senior nurse at the door to triage patients. Those with minor injuries were taken to a separate room for treatment.

It was also important that one senior surgeon took charge of the situation and led the team. Surgeons discovered that in these crisis situations, x-raying patients could turn into a bottleneck in the treatment process, leading to dangerous delays, so at times surgery proceeded without imaging to save a patient’s life.

Dr. Spence said that the Royal Victoria distinguished itself in treating patients in the midst of a civil war by upholding the highest standards of care, documenting cases thoroughly, and treating all patients with the same level of care. Although the duty surgeons lived in the community, knew many of the victims, were aware of which group had carried out an attack, and even had family members killed in the conflict, Dr. Spence asserted that they maintained their professional standards and did not allow politics to deter them from their duties as physicians.

In the peak years of violence, the early 1970s to the early 1980s, two types of injuries – gunshot wounds to the head and kneecapping trauma – led to innovative treatment plans. The hospital established the standard of care for gunshot wounds to the head in that era, and also pioneered the use of vascular shunts to treat blast-injured limbs. The vascular shunt in particular was considered invaluable by Dr. Spence. This procedure reduced the number of amputations in cases of limb trauma from one-third to less than 10% and "allowed a very unhurried fracture reduction and external fixation."

Dr. Spence noted that general surgeons were valued in the ER because of their capacity to deal with a wide variety of injuries and because of the potentially fatal delays caused by waiting for a specialist. Although specialists were definitely needed and utilized in complex cases, most patients were treated by general surgeons. "I come from a generation that could do chest and abdominal surgery and amputations," said Dr. Spence.

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