Page 119 - JSOM Fall 2025

BOX 1 List of Nations in Conflict FIGURE 2 Small surgical team (four members) setting up an
Afghanistan Mauritania operating table in an irregular warfare environment.
Algeria Mexico
Bangladesh Morocco
Benin Mozambique
Burkina Faso Myanmar
Cameroon Niger
Central Africa Repuablic Nigeria
Chad Pakistan
China Palestine
Colombia Philippines
Democratic Republic of the Congo Russia
Ecuador Somalia
Ethiopia South Sudan
Ghana Sudan
Haiti Syria
India Tanzania
Iraq Togo
Israel Tunisia
Ivory Coast Uganda
Libya Ukraine
Mali Yemen
Source: World Population Review, Accessed Feb 12, 2025.

landscape. Healthcare providers are viewed as force multipli-
ers through their ability to help heal the opposition’s forces
and/or boost morale. Historical protections under the Geneva
Convention for health care providers is non-existent.

The patients are subject to care in an austere environment—
care that is often delayed or limited, and therefore, must be
able to “fail well”. The delays may lead to increased risk for
medical complications. Power will be unreliable, communica-
tions frequently disrupted, and language barriers insurmount-
able, among other setbacks. Cautery, lighting, instrumentation,
and staff education will all be uncertain. Follow-up rarely ex-
ists. Diagnostic modalities are limited. Treatment algorithms team need to be experts in their own field with overlapping
are shortened, and complications are harder to manage. Out- knowledge and skills for other team members’ roles. Team
comes are likely to be inferior to a modern Western medical members need to exhibit leadership in their content area and
facility (Figure 2). submission to the leadership of their fellow teammates’ exper-
tise. Integrity and trust among team members is essential.
Risk to the provider and risk to the patient will lead to risk to
the organization. Any time patients are perceived as receiving The provider must understand and have a mindset that accepts
or actually receive sub-standard care, commands and politi- that the trappings of war will become more visible. Guns, gre-
cians become vulnerable. Thus, DFC as a primary plan will nades, and armed soldiers presenting within clinics and oper-
require discussion before acceptance, as the cost to the patient, ating rooms are the norm. There is no clearing one’s weapon
provider and organization is substantial. Nonetheless, as his- on the way to the dining or medical facility—neutrality is not
tory demonstrates, DFC does occur. appreciated. While the surgical element is not itself engaged
in combat, it is clear they are force multipliers for the group
The adage, “a plan poorly executed is better than no plan,” they support, and providers entering this environment must
summarizes the risk associated with DFC. This risk needs to understand this context.
empower governments, politicians, and commanders alike to
strive to develop casualty plans beyond a proposed evacuation Providers must understand that evidence-based medicine is vir-
system that many know will fail. tually non-existent in these environments. Best practice is rarely
established for isolated, austere, resource restricted locations.
Mindset When antiseptic soaps are missing, clean water is rationed,
patients arrive hours after wounding with gross contamina-
Only after understanding the operational considerations and tion, postoperative patients sleep on the floor and insects roam
risk tolerance, can the mindset of DFC be fully appreciated. freely across operative fields, the provider will never replicate
Each individual and parent organization must obtain and Western outcomes. A provider must be comfortable in this con-
maintain the right mindset and soft skills to function effec- text and not carry an unnecessary weight of concern. The risk
tively in small surgical teams. of “morale injury” must be countered with the “permission” to
do one’s best under such extreme conditions. A greater latitude
There are many soft skills required to work effectively in an for the surgical element’s judgement must be granted. High lev-
IWE. These teams historically are composed of 1–5 individu- els of grit, resilience and perseverance in such environments are
als. A small footprint decreases visibility, allows for improved crucial. Monday morning quarterbacking from a Western view
mobility, and reduces resource requirements. Individuals on a will never be appreciated or helpful.

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