Interview with Dr. Mauro Dalla Torre

Medical Advisor of the Weapon Contamination Unit, International Committee of the Red Cross

International Committee of the Red Cross (ICRC)

The International Committee of the Red Cross (ICRC) is an independent, neutral organization ensuring humanitarian protection and assistance for victims of war and armed violence. It takes action in response to emergencies and promotes respect for international humanitarian law and its implementation in national law.

The weapon contamination unit (WeC)

The weapon contamination unit provides the ICRC with operational expertise on landmines, explosive remnants of war, stockpiles, and small arms. The unit is responsible for activities to reduce the impact of weapon contamination on people. These may include field assessments on weapon use, risk education, clearance, and information gathering. The unit directly implements activities in the field, advises and provides technical support to other units within the ICRC, and plays a lead role within the International Red Cross and Red Crescent Movement.

Can you tell us a bit about your background?

I am a general surgery and anesthesia specialist. Before joining ICRC, I worked as a surgeon at the liver transplant unit at Padua University in Italy. After my first experience as a war surgeon in Afghanistan with an Italian NGO, ‘Emergency,’ I joined the ICRC in 2004. Since then, I have been involved in major conflict areas around the world. In 2015 I became the medical advisor of the Weapon Contamination Unit in Geneva. It was a new position back then, and the WeC unit needed someone with experience related to the consequences of explosions, and who can also deal with CBRN incidents. Currently, I am in charge of giving medical support to the patients affected by the conventional effect of explosion and nonconventional CBRN incidents.

What kind of activities does the Weapon Contamination Unit do to reduce the impact of CBRNe weapon contamination on people?

The reality that the ICRC face is quite unique. We operate within the areas of conflict, where there is a mix of situations. For example, patients who are contaminated by chemicals can, at the same time, be injured from an explosion. When dealing with a patient in such a critical condition, we need to decide which effect will kill the patient first. It could either be the wound from shelling, bullet, or the nerve agent. The ICRC has extensive experience, especially in war surgery. Nowadays, the relevant context in the CBRN incidents has ensured a challenging approach for the ICRC. One of the WeC approaches to mitigate the consequences of a CBRN threat is by raising public awareness regarding risks related to being in contact with a dangerous chemical substance. When the Iraqi government launched a decisive military campaign to retake the city from ISIS control, the ICRC-WeC unit was involved in a special mission. The unit prepared the hospitals to be ready to deal with contaminated victims from a possible chemical attack. We trained the hospital staff in being familiar with such a challenging situation.

What is your current role as Medical Advisor and Expert in Explosive Weapons at the Weapon Contamination Unit?

The main role of the WeC Medical Advisor is to provide a significant contribution towards all the aspects related to conventional and nonconventional (CBRN) incidents. The advisor is in charge of coordinating the medical team consisting of trauma anesthesiologists. He/she works closely with the worldwide medical association to be sure that information on CBRN is up to date for the field practice.

Personally, I am in charge of the ICRC training courses conducted around the world that are related to the explosion effect and CBRN medical component The WeC Medical staff are involved with the ICRC-CBRN experts, in a training session run in collaboration with the Irish army, to implement our skill in CBRN victims management. Furthermore, I am an instructor of the Advanced Hazmat Life Support (AHLS).

Lastly, I produced a specific medical standard operational procedure suitable for our CBRN risk assessment process.

About the explosion effect, a dedicated course, named Blast Trauma Care (BTC) is addressed to the specialist dealing with anti-personnel mines or bomb squad members in order to give them the specific knowledge about the medical treatment of a blast victim.

What kind of CBRNe incidents have you dealt with in the war zones?

As I mentioned above, the ICRC was involved in the training of hospitals located close to Mosul during the last attack in November 2017. Furthermore, we worked in war zones struck by the Ebola virus. In the Kivu Region, Democratic Republic of Congo, we trained the ICRC surgical team in treating victims affected by Ebola infection in need of war surgery. It was a challenging condition for the surgical team since the full PPE was extremely uncomfortable in such a hot environment, but at the same time, the only option to operate safely. People tend to think that during a conflict, CBRN incidents are caused by missiles or grenades struck into chemical pipelines or factories. However, the gap created in the manufacturing procedure presents a real challenge. Sometimes the person in charge of the production line is not present or is too tired due to the ongoing conflict. This affects the safety at the production line. Lack of proper continuity in production can have massive consequences. An example, although not related to a war zone, was the Bhopal, India, incident, where Methyl isocyanate exploded because proper attention was not given to the production line by the low-ranking personnel.

What is the most challenging forms of CBRNe weapon contamination?

The biggest challenge is not the chemical itself. The real challenge comes from not being prepared. For example, the ICRC doesn’t distribute PPE if recipients are not trained for proper use. The people in charge should be trained, and they need to be fully committed to the training.

The war strategy has changed very fast. Terrorist groups nowadays try to create chaos in the system. Although not conflict-related, the COVID-19 pandemic is an example of a destabilizing reaction in society. The main impact of CBRNe weapon is the fear that you instill in the system. A peculiar example was the Tokyo subway Sarin attack, which only killed 12 people, but more than 5000 people were affected, roads were blocked, and hospitals were paralyzed.

One death is still one too many, but the impact of systemic failure can be bigger than a few numbers of deaths. In war zones, people, of course, die from shelling. However, many more died from not being able to reach hospitals because of the crossfire. The same can be said about the CBRN incidents; many people die not from the CBRN agents but from ensuing systematic failures.

What kind of medical support is the unit ready to provide to victims of CBRNe incidents?

In a normal context, CBRN impacts need to be managed by huge technical, logistical, and military support or by a special unit in the country. ICRC WeC is not a large unit in terms of budget and staff. We, therefore, try to provide sustainable guidelines and support through training. Our goal is to create a system that is sustainable and easy to replicate so that our partners can perform like a specialized military team.

What is the role of medical staff in the process of CBRNe decontamination?

In the context of war zones, it’s very difficult to have enough medical staff. We need to maximize the quality of medical service with the few people left in the hospital. In the decontamination line, we assign nurses, not doctors, and we train them to provide basic aid like opening the airway, injecting antidotes, and cleaning patients. What are some of the challenges that medical workers face with regard to CBRNe incidents?

The major challenge is not the medical treatment itself. The treatment is usually supportive. When we have antidotes, it’s not too difficult to treat people affected by chemical agents. The real challenge for medical staff comes from the fact that they need to wear PPE all the time when they are executing surgeries. In Iraq, when wearing PPE, the temperature inside the PPE can be upwards of 40 degrees. It’s like being in a sauna. Wearing PPE can be very physically and psychologically challenging. Some doctors don’t feel safe wearing PPE and therefore begin to panic. When medical staff is not in the right condition to provide medical services, the medical team leader should be able to overlook their condition and remove them operation room if necessary. I used to have a monitoring device to check not only the status of patients but also medical staff. The device kept track of the heart rate and the posture of our staff. When the heart rate goes up dramatically or when the person is on the ground, I could check on them through the radio, without having to go inside the contaminated area. In a CBRN context, the person in charge needs to have a good communication method. If there is no sophisticated device, the leader should at least have a megaphone and be ready to replace doctors. Here, once again, training is an essential component of successful medical support.

Any final comments to our readers?

We have seen some significant escalation of CBRN accidents. War strategy has been changing. Nowadays, homemade Sarin with a recipe downloaded from the internet can cause a bigger systematic problem than conventional threats. Many industrialized countries are not as prepared as they think they are for such threats. We have to expect that the types of threats will continue to change rapidly. We need to find a way to mitigate the risks accordingly and efficiently and ensure preparedness. As we have seen during the COVID pandemic, there is nothing we can do after such an incident happens. Prevention is key. We need to convince national governments and officials, including people further down the chain of command from firefighters and police to hospital staff, to continually be prepared. Governments around the world should realize that now is the time to prepare.

Doctor Mauro Dalla Torre graduated in Medicine and Surgery at University of Padua (Italy) in 1991. He completed his General Surgery residency at the University of Padua in 1996 followed in 2006 by a residency in Anaesthesia and Resuscitation at the same university. Author of more than 40 papers. He is ATLS (Advanced Trauma Life Support) instructor since 2010. From 1992 to 1998, he has been working as liver transplant surgeon in the Liver Transplant Unit in Padua. During that period, he spent a year in the main liver transplant centres in US (Pittsburgh, New York, Miami) as visiting surgeon. In 2005, he joined the ICRC as general surgeon, working in conflict areas (Afghanistan, Darfur, South Sudan, Kenya, Libya, Iraq, Gaza Strip, Somalia, Congo, Eritrea, Caucasian region Mali, CAR, Uganda, Libya, Chad and Kyrgyzstan).From 2011 to 2015 he was Regional Surgeon for Africa in charge of the ICRC surgical programs in the continent. Currently, he is the Medical Advisor for the Weapon Contamination Unit (WeC) at the HQ in Geneva. He is Advanced Hazmat Life Support (AHLS) instructor. He is in charge to develop the health strategy for Hazmat threat (conventional and CBRN components) for the WeC Unit.