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hospitals war cover april20039.6.200513:47Page 1ICRCHOSPITALSFORWAR-WOUNDEDHOSPITALS FOR WAR-WOUNDEDA practical guide0714/002 05/2005 1000This book is intended for anyone who is facedwith the task of setting up or running a hospitalwhich admits war-wounded. It is a practical guidebased on the experience of four nurses whohave managed independent hospitals set up bythe International Committee of the Red Cross.It addresses specific problems associated withsetting up a hospital in a difficult and potentiallydangerous environment. It provides a frameworkfor the administration of such a hospital. It alsodescribes a system for managing the patients fromadmission to discharge and includes guidelines onhow to manage an influx of wounded. Theseguidelines represent a realistic and achievablestandard of care whatever the circumstances.A practical guide for setting upand running a surgical hospitalin an area of armed conflict
HOSPITALSFORWAR-WOUNDEDInternational Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT 41 22 734 6001F 41 22 733 2057E-mail: icrc.gva@icrc.orgwww.icrc.org# ICRC, April 2005, revised and updated edition
This book is dedicated to the memory ofJón Karlsson(died in Afghanistan, 22 April 1992)Fernanda CaladoHans ElkerboutIngebjørg FossNancy MalloyGunnhild MyklebustSheryl Thayer(died in Chechnya, 17 December 1996)
HOSPITALSFORWAR-WOUNDEDA practical guidefor setting up and runninga surgical hospitalin an area of armed conflictJenny Hayward-KarlssonSue JefferyAnn KerrHolger SchmidtINTERNATIONAL COMMITTEE OF THE RED CROSS
ISBN 2-88145-094-6# International Committee of the Red Cross, Geneva, 1998WEB address: http://www.icrc.org
viiCONTENTSCONTENTSFOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiPREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiiiACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvABOUT THE AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviiINTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xixChapter 1. SETTING UP THE HOSPITAL . . . . . . . . . . . . . . .1.1 PRIORITIES . . . . . . . . . . . . . . . . . . . . . . .Negotiation and information . . . . . . . . . . . .Finance . . . . . . . . . . . . . . . . . . . . . . . . . . .Protecting the hospital, patients and staff . . . .Physical protection and security of the hospitalCommunications . . . . . . . . . . . . . . . . . . . . .Logistics and transport . . . . . . . . . . . . . . . .1.445681011.1212131415.161617181.4 HOSPITAL EQUIPMENT AND SUPPLIESStandard lists . . . . . . . . . . . . . . . . . . . . . . .Hospital equipment . . . . . . . . . . . . . . . . . . .Hospital supplies . . . . . . . . . . . . . . . . . . . . .Sources of supply . . . . . . . . . . . . . . . . . . . .Warehousing and storage . . . . . . . . . . . . . . .191919202223.25.25252626261.2 HOSPITAL INFRASTRUCTUREThe buildings . . . . . . . . . . . . . . .Tents . . . . . . . . . . . . . . . . . . . .Water and power . . . . . . . . . . . .Waste disposal . . . . . . . . . . . . . .1.3 PERSONNELKey people . . .Additional staffRecruitment . .Chapter 2. RUNNING THE HOSPITAL2.1 ADMINISTRATION . . .Finance and book-keepingOffices and secretariat . . .Purchasing . . . . . . . . . . .Inventory . . . . . . . . . . . .
viiiHOSPITALS FOR WAR-WOUNDED2.2 FIRE SAFETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .282829302.4 MAINTAINING THE HOSPITAL INFRASTRUCTURE . . .312.5 THE HOSPITAL KITCHEN . . . . . . . . . . . . . . . . . . . . . . .322.6 THE LAUNDRY AND TAILOR . . . . . . . . . . . . . . . . . . . .The laundry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The tailor workshop . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3434352.3 PERSONNEL MANAGEMENTTerms of employment . . . . . . . .Salaries . . . . . . . . . . . . . . . . . .Staff evaluation . . . . . . . . . . . . .403.2 ADMITTING THE PATIENT . . . . . . . . . . .The admission room . . . . . . . . . . . . . . . . . .Equipment and supplies for admitting patientsAdmitting the individual patient . . . . . . . . . .Patients’ records and documentation . . . . . . .Patient flow . . . . . . . . . . . . . . . . . . . . . . . .4243434650513.3 MANAGING THE WARDS . .The nurse in charge of the wardOrganizing the workload . . . . .Keeping patients’ files . . . . . . .3.1 THE HEAD NURSE: A KEY POSITION . . . . . . . . . . . . . .39.3.4 NURSING THE PATIENTWard and patient hygiene . .Nutrition . . . . . . . . . . . . .Wound management . . . . .Post-operative nursing . . . .The intensive nursing ward .Limb injuries . . . . . . . . . .Amputations . . . . . . . . . .Abdominal wounds . . . . . .Chest wounds . . . . . . . . . .Head injuries . . . . . . . . . .Skin grafts . . . . . . . . . . . .Burns management . . . . . .Drugs and antibiotic policy .36363637Chapter 3. MANAGING THE PATIENTS.2.7 ORGANIZING THE HOSPITAL STORESOrdering supplies . . . . . . . . . . . . . . . . . . .Distributing supplies . . . . . . . . . . . . . . . . .The hospital pharmacy store . . . . . . . . . . . .27.53535356.5757596265656671727374767783
ixCONTENTSPatients’ relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Discharging the patient . . . . . . . . . . . . . . . . . . . . . . . . . . .Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .868687.8888889191949596100102.103103106107.1094.1 PERSONNEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1124.2 EQUIPMENT AND SURGICAL SUPPLIES . . . . . . . . . . .Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Surgical supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1131131134.3 THE STERILIZATION DEPARTMENT . . . . . . . . . . . . . .Autoclaves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Compresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1171181194.4 SURGICAL INSTRUMENTS . . . . . . . . . . . . . . . . . . . . . .Care of surgical instruments . . . . . . . . . . . . . . . . . . . . . . . .1221233.5 AN INFLUX OF WOUNDED AND TRIAGEPreparing for an influx of wounded . . . . . . . .Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . .Triage categories . . . . . . . . . . . . . . . . . . . . .The triage area . . . . . . . . . . . . . . . . . . . . . .Managing the triage process . . . . . . . . . . . . .Admitting patients in a triage situation . . . . . .Documentation . . . . . . . . . . . . . . . . . . . . . .Patient flow during triage . . . . . . . . . . . . . . .Evaluation . . . . . . . . . . . . . . . . . . . . . . . . .3.6 SUPPORT SERVICESPhysiotherapy . . . . . . .Laboratory/blood bankX-ray . . . . . . . . . . . .Chapter 4. THE OPERATING THEATRE.124124124125127.129Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Teaching basic surgical nursing . . . . . . . . . . . . . . . . . . . . . .1291305.1 PLANNING TRAINING PROGRAMME . . . . . . . . . . . . . .First steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Setting aims and objectives . . . . . . . . . . . . . . . . . . . . . . . . .1311311324.5 ORGANIZING THE OPERATING THEATREThe routine operating list . . . . . . . . . . . . . . . .Emergencies . . . . . . . . . . . . . . . . . . . . . . . . .Keeping records . . . . . . . . . . . . . . . . . . . . . .Cleaning and maintenance . . . . . . . . . . . . . . .Chapter 5. TEACHING UNTRAINED PERSONNEL.
xHOSPITALS FOR WAR-WOUNDED5.2 ORGANIZING TEACHING . .What to teach? . . . . . . . . . . . .The next steps . . . . . . . . . . . . .How to teach? . . . . . . . . . . . . .Making the best use of resourcesEvaluating the programme . . . .APPENDICES.133133137137139140.1431. LIST OF CONSUMABLE MEDICAL SUPPLIES NEEDEDFOR 100 HOSPITAL ADMISSIONS OF WAR-WOUNDED1452. SURGICAL INSTRUMENT SETS . . . . . . . . . . . . . . . . . . .1533. BASIC ANAESTHETIC EQUIPMENT . . . . . . . . . . . . . . .1574. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158FURTHER READING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159INDEX161.
xiFOREWORDFOREWORDThe absence of adequate care and treatment for warwounded prompted the founding of the InternationalCommittee of the Red Cross (ICRC) and the adoption ofthe first Geneva Convention in 1864. Today, the ICRCpromotes respect for the 1949 Geneva Conventions and their1977 Additional Protocols, which afford protection for allvictims of war: the wounded, the shipwrecked, prisoners andcivilians. Furthermore, they protect the medical and nursingstaff who care for the sick and the wounded.Over the last 15 years, the provision of surgical care forvictims of war, whether civilians or combatants, has occupiedan important place in the ICRC’s activities. Hundreds ofexisting hospitals in many of the world’s conflict zones havereceived protection and supplies via the ICRC. Large,independent ICRC hospitals have admitted more than50,000 wounded in the conflicts in Cambodia, Afghanistan,Somalia, Sudan and Chechnya. The experience of setting upand managing these hospitals for war-wounded is presentedin this book. The authors are nurses who have held keypositions; their accumulated experience is enormous andimpressive and their opinions well-founded.This book is much more than a practical guide. It is a uniqueproduct of commitment, clarity of thought and sheer hardwork; it has been written at a time when treatment of thewounded is no longer the exclusive domain of militarymedical services. It should not only be read with attention butalso be kept close at hand as a reference work.Dr Pierre PerrinChief Medical OfficerInternational Committeeof the Red Cross
xiiiPREFACEPREFACEWe decided to put this book together when we realized howmuch experience we had gained over the past decade workingin independent hospitals set up by the InternationalCommittee of the Red Cross (ICRC). We noticed that inICRC hospitals as in other hospitals, the same lessons we hadlearned were having to be learned by others new to treatingwar-wounded and to running a hospital under the difficultcircumstances that inevitably arise in conflict. Our primarymotivation was to help those others avoid the mistakes wemade and make sure that they do not have to start from apoint of ignorance and confusion as we did. In 1994, webegan to record some thoughts; paragraphs became pagesand pages became chapters. We hope the result will be of helpto anyone who is faced with the task of setting up or runninga surgical hospital for war-wounded.Independent ICRC hospitals have no onward referral; thepatients stay until their surgical treatment is complete. Thereare no specialist surgeons; general surgeons work inaccordance with basic surgical principles and, as a matterof policy, with a low level of technology. The patients arenursed by people who have little previous experience ofworking in a hospital. Defining the ‘‘standard’’ of carerequired for treating war-wounded is difficult. However, weare sure that the standard attained in ICRC hospitals, thepoint of reference for everything written here, provides aminimum of acceptable care whatever the circumstances.Hence the concept of ‘‘standard lists’’ of equiment andmedicines and ‘‘standard procedures’’. A team approach topatient management is an absolute necessity for achievingthose standards.The authors
xvACKNOWLEDGEMENTSACKNOWLEDGEMENTSThe authors would like to thank the Health Division of theInternational Committee of the Red Cross for making thepublication of this book possible. A great many people, both inthe ICRC Health Division in Geneva and in the field, have givenus their support, encouragement and expert advice. Special thanksare due to Alain Mourey, André Musy, Anne-Marie Cavin, RudiConinx, Riccardo Conti, Hans Samnegaard, Åsa Molde, BartholdBierens de Haan and Philippa Parker, to Jean-Philippe Lavoyerfor his assistance with the section on the protection of hospitalsunder international humanitarian law, and to the British, Germanand New Zealand Red Cross Societies for supporting this project.Above all, we would like to acknowledge the invaluablecontribution of the local staff of the independent ICRC surgicalhospitals of Khao-I-Dang, Peshawar, Quetta, Berbera, Kabul,Lokichokio and Novye Atagi without whom this work would nothave been possible.
xviiABOUT THE AUTHORSABOUT THE AUTHORSJenny Hayward-Karlsson, SRN (United Kingdom)International experience:Thai-Cambodian border, Angola, Afghanistan,Kenya, Somalia, former YugoslaviaPositions held:Operating Theatre Nurse, Teaching Nurse, HeadNurse, Health DelegateSue Jeffery, RGON (New Zealand)International experience:Thai-Cambodian border, Pakistan, Afghanistan,former YugoslaviaPositions held:Surgical Ward Nurse, Head Nurse, Deputy MedicalCoordinator, Medical AdministratorAnn Kerr, OBE, SRN, CMB (United Kingdom)International experience:Somalia, Cameroon, Thai-Cambodian border,Pakistan, Afghanistan, Cambodia, Kenya,Rwanda, ChechnyaPositions held:Operating Theatre Nurse, Operating Theatre NurseCoordinatorHolger Schmidt, SRN, AI (Germany)International experience:Thai-Cambodian border, Somalia, Yemen,Afghanistan, Pakistan, southern Caucasus, KenyaPositions held:Anaesthetic Nurse, Hospital Administrator,Medical Administrator, Medical Coordinator
xixINTRODUCTIONINTRODUCTIONWhen war breaks out, any existing health care system is rapidly disrupted andoverwhelmed. Resources may be in short supply. Qualified medical and nursingstaff may have left or be simply insufficient in numbers. The hospitalinfrastructure may be damaged. The water supply may be cut off. The powersupply may be unreliable. Fuel may be difficult to obtain.Surgical units are particularly susceptible to disruption because they depend ona basic minimum of infrastructure (secure buildings, water and electricity)expertise in surgery, anaesthesia, nursing and technical matters, an organizedsystem of patient management and the regular provision of supplies. Theadditional burden of casualties, both military and civilian, arrives just when thehospitals are most likely to be in difficulty; the necessary minimum ofinfrastructure and expertise is rarely available. Assistance for such hospitalsmust be considered in terms of both materials and expertise. Both can besupplied by aid agencies. In the absence of any functioning hospital, a newsurgical facility has to be set up; this an expensive commitment. The needs arelong-term and do not disappear with the end of the fighting.An independent hospital run by and aid agency employ - and dismiss - itsown staff. It has control over the distribution and use of supplies, and can thusensure accountability. It can also provide free treatment; this reaffirms the roleof the hospital as an independent, neutral place where the wounded may betreated in safety whatever their allegiance.The organizational structure and system of patient management described inthis book is that adopted in independent ICRC hospitals. It may seem to be an‘‘ideal recipe’’. However, it not only provides for a realistic and achievablestandard of care but also constitutes a tried and tested system that works.Details of management structure may differ, but the principle of a standardized,team approach to patient management under clear leadership can be applied toany hospital which admits large numbers of war-wounded. Flexibility ofapproach is important but, whatever the circumstances, the wounded patientsmust be managed according to properly applied basic surgical principles. Thisbook is about providing the means for such management.Medical and nursing staff working in hospitals for war-wounded tend to comefrom different countries, with variable training and experience. Aid agency staffare also likely to have short contracts; this leads to a rapid turnover ofexperienced staff. Locally employed staff rarely have nursing experience. Thisbook offers practical advice to the key people (see Chapter 1.3) involved insetting up or running a hospital for war-wounded: the field director of a medicalaid agency, the director of an existing hospital, the head nurse, the hospital
xxHOSPITALS FOR WAR-WOUNDEDadministrator, the operating theatre nurse, the surgical ward nurses and thenurse responsible for staff training.Chapter 1 outlines how to set up a hospital in a difficult and potentiallydangerous environment and gives checklists of essential points. Chapter 2focuses on the administrative details involved in the daily running of thehospital. It covers all aspects of hospital organization, including personnelmanagement, organizing supplies, and running the kitchen, laundry and othersupport services. Chapter 3 addresses patient management from admission todischarge, nursing care and organizational aspects of triage. Chapter 4 explainshow to set up and run the operating theatre. Chapter 5 proposes a frameworkfor a training programme for unqualified staff. The appendices comprise lists ofstandard materials and drugs.Although the nursing guidelines focus specifically on the management of warwounded patients, the general guidelines on hospital infrastructure andorganization may be applied to any hospital set up in an emergency or disastersituation.
1SETTING UP THE HOSPITALChapter 1SETTING UPTHE HOSPITALSurgical care for war-wounded requires a combination of a well-organizedhospital infrastructure and adequate expertise. Both are necessary. A hospitalcannot function with only one of these two elements. This applies whether a newhospital is being set up or an existing hospital is being adapted for the new role oftreating the wounded.The wounded need access to a safe place supplied with water andpower where they can receive competent surgical treatment backedup by good nursing care within a well-organized system whichreceives adequate supplies.These conditions apply equally to a hospital set up under canvas in an emergency,an existing hospital adapted for war-wounded or a new surgical hospitalestablished for the specific purpose of treating war-wounded.
2HOSPITALS FOR WAR-WOUNDEDConsiderTime:Finance:How urgent are the needs?Where are the funds coming from, in the setting-up phase, in thelonger term?Security:Where is a safe place for the hospital?Take into account the nature of the conflict (aerial bombarding,shelling, confrontation lines, the presence of anti-personnelmines).Obtain guarantees of security from all parties to the conflict.Access:Is the hospital easily accessible for patients, staff and supplies?This may depend on security.Infrastructure: Buildings - do they exist? Can they be adapted? Are tents needed?Water supply - consider quantity, quality and storage. Is there arisk of interruption or contamination? Back-up needed.Power supply - does it exist? Is it adequate? Independentback-up needed.Fuel - are sources reliable? Alternatives and back-up needed.Communications systems - do they exist? Are they reliable?Is an independent system needed?Expertise:Are trained personnel available locally? Does expertise need tobe imported?Supplies:Are supplies available locally? Will they need to be imported?Are lines of supply secure?To bring all these essential elements together requires coordination and carefultime management. A plan of action (see Fig. 1) provides a strategy for actionwithin a specified time-frame.
PHASENEGOTIATEKEY PERSONNELMedical coordinator/hospital directorADDITIONAL /communicationAGREEMENT REACHED1LOCATE HOSPITAL2PLUS:Head nurseHospital administratorWater and sanitation/construction engineerEQUIPMENT & SUPPLIESORDER:Initial medical suppliesSpecial technical material(X-ray, lab., etc.)PLUS:DriversTASKSContact/written agreements with:Ministry of HealthMilitary authoritiesASSESS SITE OR BUILDING HOSPITAL SITE AND/OR BUILDINGS ting theatre head nurseTeaching nurseLab technicianX-ray technicianPhysiotherapist3RECRUIT:Administrative staffSecurity staffConstruction/sanitation staffSpecial technical staff (X-ray, physio)Lab ation materialHospital furnitureNon-medical equipment and furnitureOperating theatre andsterilization materialFoodCONSTRUCT OR ADAPT BUILDINGS:Power supplyWater supplySanitation systemStores/shelvesINFRASTRUCTURE IN PLACEORGANIZETHE SYSTEMPLUS:Experienced ward nurses (6)RECRUIT:Local medical/nursing staffTEACHING NURSE:gives initial first aid/hygiene coursesOPERATING THEATRE NURSE:trains sterilization staffPHYSIOTHERAPIST:trains physio staffWARD NURSES:establish nursing policies/proceduresset up wardsSUPPORT STAFF:PortersKitchenLaundrySterilization4OPEN THE HOSPITALBEDS AND EQUIPMENT IN PLACE - SUPPLIES IN PLACEPLUS:SurgeonAnaesthetistORDER:Follow-up medical suppliesOpen 1st ward (20-25 beds)Start 1st training programmefor ward staff5EXPAND HOSPITALCAPACITYPLUS:Experienced ward nursesOpen 2nd wardStart 2nd training programmefor ward staff6MONITOR SITUATION CONSTANTLY - BE PREPARED TO EXPAND HOSPITAL CAPACITYFig.1 Exampleof a planactionofforsettingforupsettinga 50 bedupsurgicalhospital.Fig.1Exampleof aofplanactiona 50-bedsurgical hospital.
4HOSPITALS FOR WAR-WOUNDED1.1 PRIORITIESNEGOTIATION AND INFORMATIONPlans to set up a new hospital must be discussed with everyone concerned. Mostimportant are the Ministry of Health, Ministry of Defence and local militarycommanders. Existing clinics, first-aid posts and hospitals must be taken intoaccount as they will have an influence on how and which patients reach yourhospital. If possible, the proposed hospital should become part of the existinghealth system; a separate surgical hospital set up specifically to care for the warwounded may help other health structures concentrate on their routine workwithout having to divert scarce resources to treat war-wounded.Early contact with all the parties to the conflict helps ensure the safety of thehospital and makes negotiation easier in the future. Military factors areimportant. Will all the wounded have access to the hospital? Is the hospital in astrategically important area? Can the hospital staff get to work? Curfews or otherrestrictions on movement may be in operation.The local inhabitants should be informed by whatever means possible where thehospital is and why it is being set up, and told that everyone has access to itwhatever his or her allegiances in the conflict.The location of the hospital may be also be determined by other factors such asaccess to water and logistic supply lines.ConsiderDraw up written agreements with the central, local and military authorities toensure:.permission to set up the hospitalclarity on all sides about the role and functioning of the hospitalsecurity guarantees for the hospital, patients and staff, including anunderstanding by all parties of the independence, neutrality and impartiality ofthe hospital and its staffaccess to the hospital for patients, staff and suppliespermission to employ local stafflogistic supply linespermission to operate communications systemspermission for expatriate medical personnel to practise
SETTING UP THE HOSPITAL5FINANCEExpenditure is high in the setting-up phase. It is difficult to estimate the real costof running the hospital in the initial phases until you know the number andpattern of admissions. Make sure there are funds available for what you want todo. Inform your financial donors.SETTING UP A HOSPITAL IS EXPENSIVEConsiderPlanning phase: Cost of survey/assessment of needsCost of consultations/meetingsDonor appeals, press releasesRecruitment of expertisePurchase of hospital materialTransport/logistic set-upAdministration of planning phaseSetting-up phase: Travel and transportCommunications systemsPreparation of hospital infrastructureVehicle fleetRecruitment of local expertise/staffPreparation of logistic supply linesPurchase of locally available suppliesInstallation of material and equipmentTraining of personnelInitial running expensesAdministration of setting-up phaseRunning phase: Travel, transport/vehicle fleetCommunications systemsStaff salariesRent and insurance for hospital compound and/or ctionWater/sanitationFoodOngoing purchase/ordering of suppliesOngoing donor appeals/press releasesAdministration of running phase
6HOSPITALS FOR WAR-WOUNDEDPROTECTING THE HOSPITAL, PATIENTS AND STAFFThe hospital premises must always be respected by the combatants. Withoutsecurity and protection for the buildings and staff, the hospital will not function.THE SECURITY OF THE HOSPITALIS THE PRIMARY CONSIDERATIONThere are two main factors involved in the protection of a hospital in time of war:.the protection given to medical structures and personnel under internationalhumanitarian lawpractical measures taken to physically protect the buildings, patients and stafffrom explosions or fighting close to the hospitalProtection under International Humanitarian LawIn situations of armed conflict, international humanitarian law limits the use ofviolence and protects those who are not or no longer taking part in in thehostilities (civilians, wounded and sick combatants, prisoners of war). The FourGeneva Conventions of 1949 and their two Additional Protocols of 1977 containrules applicable in international and internal armed conflicts. Almost all Statesare bound by the Geneva Conventions.The main aim of humanitarian law is to protect the civilian population from theeffects of war. Civilians therefore enjoy a far-reaching immunity. In particular,they must not be attacked and are entitled to receive assistance if they lackessential goods indispensable to their survival, such as foodstuffs and medicalsupplies.The International Committee of the Red Cross (ICRC), as a neutral andindependent institution, has the task of monitoring the implementation ofhumanitarian law. In addition, the ICRC brings protection and assistance,without adverse discrimination to the victims of armed conflict and disturbances.Humanitarian law specifically protects medical transports and civilian andmilitary medical units, in particular hospitals: they must be respected andprotected at all times and must not be the object of attack.All the wounded and sick and the medical personnel caring for them must also berespected and protected.Medical units enjoy neutral status as long as they are not used to commit actsharmful to the enemy such as sheltering able-bodied combatants, storing arms andammunition or being used as military observation posts; otherwise theirprotection ceases and they become legitimate military targets. This is why strictcontrols must be established in order to safeguard the protected status of medicalunits and transports.
SETTING UP THE HOSPITALTo enhance the protection of medical units and medical transports, they should beclearly marked by the red cross or red crescent emblem, of the largest possible size.The emblem is the visible sign of the protection conferred by the GenevaConventions and their Additional Protocols.During armed conflicts, only the following may use the red cross or red crescentemblem as a means of protection:. the medical units of the armed forces. hospitals, other medical units and medical transports that have received specialpermission to use the emblem. the medical personnel, medical transports and material that a National RedCross or Red Crescent Society has put at the disposal of the medical service ofthe armed forcesIn order to ensure effective protection in wartime, use of the emblem must bestrictly controlled in peacetime.In peacetime the emblem may only be used by:. the medical services of the armed forces. National Red Cross or Red Crescent Societies, in order to indicate that personsor goods have a connection with the Society in question (here the emblem mustbe of small dimensions). exceptionally, ambulances and aid stations exclusively assigned to the purposeof giving free treatment to the wounded and sick, with the authorization of aNational SocietyThe ICRC an
WAR-WOUNDED HOSPITALS FOR WAR-WOUNDED A practical guide ICRC This book is intended for anyone who is faced with the task of setting up or running a hospital which admits war-wounded. It is a practical guide based on the experience of four nurses who have managed independent hospital
