War Surgeon

Dr Jorma Salmeda

It was necessity rather than choice that Dr Salmeda became a war surgeon. When he started his medical training in the late 1960s, Finland was still struggling to cope with some 200,000 war wounded personnel from the Second World War. The government’s response was a requirement that all Finnish surgeons undergoing medical training also study the principles and practices of war surgery. Throughout his medical training, Dr Salmeda’s primary interest was always trauma, so it naturally followed that the field of war surgery was particularly inviting.

Dr Salmeda started work with the Finnish Red Cross in 1974. In 1982 he accepted his first overseas assignment, with the ICRC in the frontier town of Peshawar on the Pak-Afghan border. Pakistan could not cope with the influx of weapon-wounded casualties from the conflict in neighbouring Afghanistan. It appealed to the ICRC for assistance in running a specialist surgical unit dealing with those fleeing the war there. At that time, the Russians were not permitting any NGOs to operate from inside Afghanistan, so Peshawar was the closest ICRC could get to dealing with casualties from the war.

The number of wounded civilians coming out of Afghanistan was so high that within three more months they had extended the unit from an initial 40-bed facility to 150 beds. Dr Salmeda remembers there were reports of some 6 million afghan refugees in Pakistan during the early 1980s.

In 1988 the ICRC finally gained permission to open their first delegation in Kabul. On 16^th April 1992, infighting between warlords resulted in a brutal civil war in Afghanistan. Dr Salmeda recalls that the resulting fighting did more damage to Kabul than the Russians ever managed. It was during this time that Dr Salmeda says he experienced the worst moment in his medical career. In July 1992, Dr Salmeda was in charge of triage at the ICRC hospital when a rocket attack on a nearby market and bus station resulted in the more than 200 civilians killed, and more than 700 critically injured. The hospital admitted more than 400 patients in the first two  hours following the attack.

Each corner of the hospital was filled with injured patients, he says. They filled the corridors, kitchens, storerooms, reception areas, everywhere. It took two days and a night just to get patients through triage. Salmeda was fortunate to have five surgical teams to deal with the injured. He says the experience was a good exercise in dealing with weapon-wounded patients for all the surgeons that day.

It was also during this time he says the Taliban made the first of three attempts on his life. The first was in April 1982. He had been ‘on call’ at the hospital, and had just returned home and was preparing to get some rest. He went to the bathroom when a sniper opened fire on the house, destroying the bedroom where he would have been . The second attempt came later the same day. The sniper attack was a prelude to fierce house-to-house fighting between different tribes seeking control of the city. Sprayed gunfire confined him to lying face down on the floor while gun battles raged throughout the neighbourhood. When he finally got off the floor of his bullet-ridden room and stood up, a mujahid approached and put a rifle to his forehead.

He recalls how he watched the fighter’s finger tighten around the trigger. Just as the militant was about to pull the trigger, Salmeda’s cook entered the room and pleaded to spare his life, explaining he was a doctor. Dr Salmeda says what happened in the coming minutes was a flood of 10 mujahideen coming into the house seeking medical treatment. While some hours earlier they were intent on clearing the house and killing anyone inside, the doctor was now the mujahideen’s new best friend.

The third attempt came when he was assisting a fellow surgeon during an operation at the field hospital. He says a disturbed relative of one of the patients entered the theatre and opened fire. Dr Salmeda says he felt a bullet pass by his hair.

After so much violence, he relocated to the Cambodian-Thai border with the Finnish Red Cross in 1983 for a three-month assignment to assist with treatment of those fleeing the genocide in Cambodia. Two years later, he returned to Peshawar for a three-month posting. He returned again in 1986-87 to Pakistan as medical coordinator for the Finnish Red Cross.

Dr Salmeda next posting took him to the remote border town of Lokichokio in Northwest Kenya in 1988. ICRC had established a delegation dealing with civilians wounded from the conflict in neighbouring Sudan. Unfortunately during this time, he fell ill and was repatriated back to Finland. This was the only time he has been unable to see out an assignment, he says. Towards the end of 1988, he had recovered enough to returned to Kabul as medical coordinator for a one-year assignment.

In 1996-97 he returned to Lokichokio for 14 months as Senior Surgeon where he says there were two more attempts on his life.

In between postings Dr Salmeda always returned to Finland where he practised as a general surgeon in his hometown of Kuopio. In 2000-2001, and again in 2004-2005, he returned to ICRC missions in Kenya.

Oct. 8th 2005, a 7.6 earthquake rocked Kashmir, killing at least 79,000 people.. He was given the urgent responsibility of establishing an Emergency Medical Response Unit hospital. Jointly funded by the Finnish and Norwegian Red Cross, Dr Salmeda led the survey team that established the location for the field hospital in the immediate hours after the quake.

The rough tented surgical hospital he helped establish lasted for three months. He says treating patients from a natural disaster is completely different from treating weapon-wounded people. The treatment of war wounded can be dependent on the weather conditions, so that will decide the number of patients that are admitted to a hospital at any given time. e.g. patients from certain areas of Afghanistan may not be able to reach the hospitals for days or sometimes weeks because of snows or landslides. But with a natural disaster, a surge of patients arrives in a single wave. In an earthquake, most of the victims suffer fractures. Within two days of the earthquake, all the nearby Pakistanis hospitals were filled with patients with fractures, he said. Conflict wounds, by contrast, vary immensely.

In 2007-08, Dr Salmeda returned to Africa teaching young doctors in general surgery in Eritrea. In the west, he says, most doctors take six to eight years to qualify as surgeons. This is not practical in certain parts of the world. So, he says his task was to teach the local doctors proficiency in just 10 general medical procedures. “Eritrea does not have specialist war surgeons,” he says. ; “Everyone’s a generalist.”

He had always considered himself a freelancer, he says, and had turned down several opportunities to be head of “medical this or that” or a desk job at HQ. He likes to be hands on with surgery. He took his most recent job on condition that security was assured.

When asked what it takes to become a war surgeon, he says that there are special principles involved in the practice of war surgery, and a young surgeon needs to fully commit to such principles before embarking on that path. War surgery is different from trauma surgery, he says. “Its not just trauma caused by weapons of war.” Take the example of a bullet wound. A bullet’s entry and exit wound cannot be replicated by any other trauma; the breakdown and collapse of bodily mass caused by the energy of a bullet is unique. Thus the treatment of such trauma is unique.

The treatment of wounds caused by weapons brings added complications such as bacteria—not only from the weapon but also through clothing, environment etc. If a patient is treated within six to eight hours, they have a better chance of recovery. I saw this problem when I visited the ICRC facility in Peshawar. A patient arrived for treatment on a wound that was three weeks old and bacteria were now the main threat to his life. Some patients travel great distances to reach the WWAP in Peshawar from Northern areas of Pakistan, Afghanistan or FATA regions. Patients were turning up with wounds that were sometimes weeks old and heavily infected.

He is beginning to slow down however. He “no longer feels compelled to take the globe on my lap and heal everyone” when he hears of a war or natural disaster. If ICRC needs him they call him, he says, and he assesses the situation. Rushing off to cover every conflict and natural disaster is best left for those with energy and youth on their side.

When asked what drives him to keep going away on postings instead of a life of fishing and slippers in Finland, he replies, “The principles of the Red Cross align with his principles of surgery and humanity.” Despite being 69 years old, he considers himself a ‘lost case’ when it comes to retirement. He’s easily convinced of the need to continue to help the Red Cross and pass on some of his wisdom, experience and knowledge.

“Why shouldn’t I make myself available if I am still physically able?” He says. “I love teaching surgery.”

End.