Following the criminal and out-of-proportion actions that are happening in Gaza during 2024 as a response to a terrorist attack by a small group of people, and under the silence of most of the mediocre politicians and the supportive inaction of the entire world ruled by people blinded by money, horrific reports come from Gaza’s hospitals. War crimes are every day committed against the population. Murdering children is the nowadays standard in Gaza. However, not only murder is being promoted and causing trauma among the Palestinians. Many are being amputated without anesthesia, including children. Can you imagine the trauma such a procedure will cause in both the patient and the doctor? Can you imagine the screams of children who should be playing and running outside instead of losing their limbs? Can you imagine the screams of their father and mother (if they are still alive)? Can you imagine the nightmares doctors and nurses will face for the rest of their lives? This is barbaric and medieval. No one should be submitted to this in the 21st century. Crime is being broadcast on television directly into our homes, and humanity is turning its back on the victims. Local politicians and world rulers should be ashamed. Their hands are covered in blood.
"Yes, and how many times must the cannonballs fly
Before they're forever banned?
And how many years can some people exist
Before they're allowed to be free?"
in Blowin' in the Wind, by Bob Dylan
Reading articles about amputation, I found one interesting paper about painless amputation with tourniquet use. Impressive is the horror reported by James Cook writing in 1685 on amputation. I give you some of his words: “(…) one man be at the patient back holding him, and another before him, holding the upper part of the limb, and a third holding that part that must be taken off… (…) with your dismembering knife take two large slashes round the part in the form of half rounds, and let one meet the other as evenly as possible (…) with the back of your catling, remove the periostium that it may not hinder the saw, nor cause greater torment in the operation. So saw off the bone at as few stokes as possible (…) Set the teeth of your saw wide enough, so it may not stick, have two saws, lest one should break, (…) and several knives, because after one or two they lose their keenness.” The author ends this description saying, “we should stop there, before the pain of cautery and sutures”.
Interestingly, pre-anesthesia doctors did not use alcohol or opium preoperatively. The reason why this potential pain reduction method was not used is not clear. Some say that doctors believed patients should be conscious so that the decision to amputate could be made quickly and before the patient would not resist the procedure. Other authors think the idea was to induce such pain that syncope would come, and pain would disappear. Another idea is that surgeons were to do operations and did not use medications nor were they aware of that need. The only pain-killing method was performing amputation as fast as possible. However, trauma from the extreme agony was inevitable.
Why was the tourniquet not used as a pain controller? The tourniquet was applied immediately before surgery, allowing vessel ligation, and avoiding painful cautery. If the tourniquet had been applied earlier before the procedure, ischemia would induce proximal anesthesia and paralysis after 30 minutes. However, narrow cuff and high pressures would cause local pain. In conclusion, applying a broad tourniquet 30 minutes before amputation would have allowed for a pain-free amputation, some authors say.
Sam Shuster states that this idea of tourniquet anesthesia was not discovered earlier because doctors were not focused on pain-killing methods at that time. Only when anesthesia becomes a thing, does awareness of several methods to control pain become a reality. But descriptions of the numbness effect of the tourniquet on pain are present in old reports from the 17th century. Why did doctors not consider the effect of compression? Surgeons were under great stress of battle and aiming at doing a fast amputation. They had no time to think or analyze the important effects that were in front of their eyes. Surgeons were “machines” without time to think out of the box, nor even set for investigation. Crucial questions like – What causes this outcome? How can we repeat this effect? - were not globally possible in that era. Sam Shuster says, “the failure of busy surgeons to extend their use of the tourniquet to anaesthesia is an almost inevitable consequence of the constraints of practice at that time”. Clinicians need to have time to analyze outcomes. Innovation is only possible when reflection, experiment, and study come together in clinical practice. Those doctors who limit themselves to repeating countless times what is written in books with the justification that repetition makes them better, do not give humanity a fertile field for evolution and innovation.
Yes, and how many times can a man turn his head
And pretend that he just doesn't see?
Yes, and how many deaths will it take 'til he knows
That too many people have died?
in Blowin' in the Wind, by Bob Dylan
To finalize this post, I would like to highlight the fact that no human being should be submitted to war nor should be amputated without anesthesia. The criminal is the one who commits the crime, the one who supports the criminal, the one who watches in silence, and the one who does not help the victim. Having people being ripped out of their homes, having their lives shattered without reason, and having people being amputated without anesthesia, is not acceptable in the 21st century. Humanity forgets and repeats the failures from the past. The world is still ruled by greed, indifference to the weakest, and inhumanity. Will humanity need tourniquet amputation? I hope not!
Link to article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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