Emergency war surgery

Care of Enemy
Prisoners of War/Internees


Healthcare personnel of the Armed Forces of the United States have a responsibility to protect and treat, in the context of a professional treatment relationship and universal principles of medical ethics, all detainees in the custody of the Armed Forces. This includes enemy prisoners of war, retained personnel, civilian internees, and other detainees. For the purposes of this chapter, all such personnel are referred to as internees.

It is the policy of the Department of Defense that healthcare personnel of the Armed Forces and the Department of Defense should make every effort to comply with “Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment,” adopted by United Nations General Assembly Resolution 37/194 of 18 December 1982 (and provided as Appendix 1 to this book). This is in addition to compliance with all applicable DoD issuances.

The Geneva Conventions

  • Define medical personnel as those individuals “exclusively engaged in the search for, or the collection, transport, or treatment of the wounded or sick, or in the prevention of disease; and staff exclusively engaged in the administration of medical units and establishments” (Geneva Convention for the Amelioration of the Wounded and Sick in Armed Forces in the Field [GWS]).

Medical personnel of enemy forces are not considered internees, but are classified as “retained” in order to treat other EPWs. Internees are also entitled to the protections afforded under the provisions of the Geneva Convention Relative to the Treatment of Prisoners of War (GPW). Detained persons who are not protected under GWS and GPW, may be protected under the provisions of the Geneva Convention Relative to the Protection of Civilian Persons in Time of War (GC). EPW/Retained/Detained Medical Care (Internees)

The GWS states that belligerents must care for the sick and wounded without any adverse distinction founded on sex, race, nationality, religion, political opinions, or any other similar criteria. Only medical urgency can justify priority in the order of treatment.

EPW/Retained/Detained Medical Care (Internees)


The number of internees and retained/detained personnel requiring medical in-processing and/or medical care can be staggering. The US captured approximately 425,000 prisoners in WW II and 105,000 in the Korean conflict. Coalition forces captured over 62,000 internees during Operation Desert Storm. During the 1-week ground war, 308 internees were treated by US military medical treatment facilities (MTFs). From the end of the ground war (28 February 1991) until the end of March 1991, 8,979 internees were treated.

Fragment wounds accounted for 44% of the surgical admissions during the ground war.

23% of surgical admissions required treatment for fractures.

Surgical intervention was required in 28% of Iraqi casualties admitted.

Most common operative procedures included

 Wound debridement.

 Open reduction and internal fixation of fractures.

 Exploratory laparotomies.

 Incision and drainage of abscesses.

  • The most common internee medical condition reported during Operation Desert Storm was dental disease (24%) such as periodontal infections, fractures, and extensive caries. Other common medical illnesses were unexplained fever, nephrolithiasis, peptic ulcer disease, and malaria.

Wounds in internees may be different than those seen in friendly forces due to differences in personal protective gear, preexisting diseases, malnutrition, and neglect.

Medical Care of Internees

  • What healthcare providers shoulddo.

 No matter the setting, healthcare providers have a responsibility to report information, the consequences of which constitute a clear and imminent threat to the lives and welfare of others. Information gained from patients who are internees should be treated no differently.

 As given below, healthcare providers have specific responsibilities for the care and treatment of internees. The overarching principle of this guideline, however, is that internees of any status should whenever possible receive medical care equal to that of our own troops.

 As one would expect for our own troops, physicians should report any suspected abuse or maltreatment of a detainee or prisoner.

 Just as one would write a profile or duty limitation for one of his own service members, physicians have a responsibility to inform the detention facility chain of command of internees’ activity limitations. This includes “clearing the prisoner for interrogation,” with the expectation that interrogation will conform to the standards of AR 190-8. Medical recommendations concerning internee activities are exactly that— recommendations. Decisions concerning internee activities are made by the chain of command.

 Healthcare providers should be trained in the tenets of the Geneva Conventions of 1949 and other documents and principles of internee care. They should also be trained to recognize the symptoms and signs of internee maltreatment or abuse.

What healthcare providers should not do.

 Healthcare professionals charged with any form of assistance with the interrogation process, to include interpretation of medical records and information, should not be involved in any aspect of internee healthcare.

 Healthcare providers charged with the care of internees should not engage in any activities that jeopardize their protected status under the Geneva Conventions.

 Healthcare providers charged with the care of internees should not be actively involved in interrogation, advise interrogators how to conduct interrogations, or interpret individual medical records/medical data for the purposes of interrogation or intelligence gathering.

Recusal. Healthcare providers who are asked to perform duties they feel are unethical should ask to be recused. Requests for recusal should first go to the healthcare provider’s commander and chain of command. If the chain of command is unable to resolve the situation, providers should engage the technical chain by contacting the Command Surgeon. If these avenues are unfruitful, healthcare providers may contact their specialty consultants or the Inspector General.

Specific medical requirements. Medical requirements for internee care are provided in AR 190-8/OPNAVINST 3461.6/AFJI 31-40/MCO 3461.1. Internees are entitled to medical treatment. Each must have an examination on arrival at the detention facility, as well as a chest radiograph (tuberculin skin test for children up to age 14 years). Sick call must be available daily, and each internee must be weighed at least once a month. Sanitation and hygiene must be maintained at all times (AR 190-8, para 3-4 i.).

Medical records.

 Internee medical records, like the medical records of all Service members, retirees, and their dependents are property of the US Government. Internees are entitled to copies of their medical records upon their release. The original records; however, remain the property of the United States. Entries should be made into internee medical records as they would for any other patients.

 The Health Insurance Portability and Accountability Act does not apply to the medical records of internees (DoD 6025 C5.1, C7.10, C7.11). However, the handling, disposition, and release of all types of medical records is governed by regulation. Commanders and other officials who have an official need to know can access information contained in internee medical records by following the procedures given in AR 40-66, Chapter 2 using DA Form 4254. Patient consent is not required. Receiving MTFs file and maintain all DA Form 4254s. The MTF commander or commander’s designee, usually the patient administrator, determines what information is appropriate for release. Only that specific medical information or medical record required to satisfy the terms of a legitimate request will be authorized for disclosure. Healthcare providers should expect that released medical information will be used by the chain of command, to include interrogators, in accordance with Medical Information, which follows.

  • Medical information.

 Because the chain of command is ultimately responsible for the care and treatment of internees, the detention facility chain of command requires some medical information. For example, patients suspected of having infectious diseases such as tuberculosis should be separated from other internees. Guards and other personnel who come into contact with such patients should be informed about their health risks and how to mitigate those risks.

 Releasable medical information on internees includes that which is necessary to supervise the general state of health, nutrition, and cleanliness of internees, and to detect contagious diseases. Such information should be used to provide healthcare; to ensure health and safety of internees, soldiers, employees, or others at the facility; to ensure law enforcement on the premises; and ensure the administration and maintenance of the safety, security, and good order of the facility. Under these provisions, healthcare providers can confirm that an internee is healthy enough to work or perform camp duties.


 The chain of command is the first and foremost channel for information and reporting. Healthcare providers should report routine medical information, clear and imminent threats, suspicions of abuse or maltreatment, and any other relevant information to their commanders or their commanders’ designees. If the healthcare provider is not assigned to the detention facility, mechanisms must be in place to also inform the detention facility chain of command.

 Alternative means of reporting exist for healthcare providers who are unable to resolve issues through the chain of command. The technical chain is the first alternative, and begins with the Command Surgeon responsible for medical oversight of the provider ’s activities. Other alternatives include the provider ’s specialty consultant, the Inspector General, and Criminal Investigations.


Develop plans for prisoners on a hunger strike or who refuse treatment.

Prisoners from separate armies should be housed apart—this is the responsibility of the internment camp commander.

Care should be exercised in the selection of medical personnel to serve in internee facilities.

Enemy forces may do little or no medical screening prior to conscription. Chronic medical problems will be more likely in these forces. Enemy forces may have preexisting diseases that are not present in the AO or US forces. Planning for appropriate medications may be required.

Maintain medical records for internees in the same manner as for friendly forces.

Ensure that any internee/retained/detained person evacuated to the MTF for treatment is escorted by an armed guard as designated by the nonmedical (echelon) commander. The guard must remain with the patient while in the medical evacuation and treatment chain. To the greatest extent possible, keep all internees segregated from friendly forces’ patients; but treat all enemy patients with the same level of care as provided to friendly forces’ patients.

  • An internee identification number must be secured for any internee evacuated through medical channels. This is accomplished by reporting the patient to the theater Prisoner of War Information System (PWIS). Medical personnel do notsearch, guard, or interrogate internees while in medical channels; this is the responsibility of the echelon commander.
  • Internees are housed in internment facilities that are established, maintained, and guarded by forces designated by the echelon commander. Medical personnel are not involved in the daily operations of these facilities. However, these facilities normally have a medical staff embedded in the organization to accomplish medical examinations and to conduct routine sick call and preventive medicine activities. Control procedures (guards, physical layout, and precautionary procedures) are regulated by the facility commander. If a patient must be transferred to an established MTF for specialized care, transfer procedures and guards are governed by the facility commander.
  • In a mature theater (such as during WW II and the Gulf War of 1991 [Desert Storm]), there are often sufficient internee patients to warrant the designation of a specific hospital for their exclusive care. In this case, coordination between the senior command and control headquarters, and the senior medical command and control headquarters is required to provide security, establish prisoner-control procedures, and regulate other nonmedical matters involved in establishing and administering a medical facility specifically for internees. The standard of care for this facility is required to be the same standard of care as practiced in other deployed hospitals.

It is critical that medical personnel not enter the general EPW holding area, but have patients brought out to them for sick call and any medical treatment.

Interpreters—Always a Shortage

Internees may not know any other language but their own.

NATO STANAG 2131, Multinational Phrase Book for Use by the NATO Medical Services - AMedP-5(B) provides basic medical questions in a number of NATO languages, published as DA Pam 40-3/NAVMED P-5104/AFP 160-28.

Use other retained persons/internees (especially medical personnel) as translators.

Simulation of mental illness by EPWs is a potential technique for evading interrogation, especially if combined with a captured interpreter.


Ensure internees are screened for hidden weapons and other potentially dangerous materials. This is not a medical function; it should be accomplished by the guards. Medical personnel, however, must remain vigilant of these threats and mentally prepared should a threat or attack occur.

Each prisoner who comes into the facility must receive a complete physical examination including a dental examination. Vital statistics are recorded for each internee treated. Essential care should be given at this point. Other follow-up evaluations are dependent on the baseline health of the combatant population.

During internment, routine sick call is provided on a daily basis; this includes medication dispensing, wound care, and indicated minor procedures.

During transfer, release, and/or repatriation, another medical examination should be performed. Final documentation of any ongoing medical, surgical, or wound care problem is completed and forwarded to the gaining facility or to the appropriate medical records repository.


The internment facility must enforce field hygiene and sanitation principles.

Plan for personal hygiene requirements and protective measures (insect netting, insect repellent, sunscreen).

  • Coordinate with the supporting medical HQ for additional Preventive Medicine support (pest management, potable water, dining facility sanitation, and waste disposal) and Veterinary Services support for food safety as required.
  • For medicolegal purposes, a high-quality camera is important.

Medical Staffing

  • Dictated by the organizational structure of the facility. The same standard of care as that provided to US forces must be maintained.
  • Retained medical personnel should be utilized for care of their compatriots in conformity with the Geneva Conventions.


  • If possible, signed permission should be obtained for all surgical or invasive procedures.
  • In contrast to civilian medical photography, the patient’s identity should be absolutely clear in each photograph. This is invaluable should there be a claim of unnecessary surgery or amputation. With clearly identifiable photographs, the state of the wound for that patient can be demonstrated.

Any patient who requires amputation or major debridement of tissue should be photographed (face as well as wound images).

Internee Advocate

  • The military physician is the commander’s advisor for medical ethics. The physician should be alert for potential and actual ethical conflicts, and exert all efforts to remedy any perceived conflicts. As the patient’s advocate (in this case, the captured enemy soldier), the military physician and all military healthcare providers must maintain the patient’s health. They must also strive to maintain a “moral distance” from participating in any proceeding potentially adverse to the patient’s interest.


There is always an element of danger to the medical staff in treating internees.

Physical security will be provided by nonmedical personnel as designated by the appropriate leadership.

The security routine must be maintained at all times. Security personnel must accompany all internees whenever they are in a treatment area or holding area. In forward areas, it may not be possible to have separate and secure medical treatment/holding areas for internees. The limited size and compact layout of Level I and II MTFs and the forward surgical team normally necessitate that internees are treated and held in close proximity. To the extent possible, internees should be segregated from allied, coalition, and US forces.

If possible, medical equipment should not be taken into the patient wards for security reasons—ie, bring the patient to the equipment.

If an EPW is to be discharged back to the general EPW population, the physician should alert internment medical personnel of any special needs the internee may have.

Personal safety should never be taken for granted by the medical team, regardless of familiarity with internees and surroundings.

Appendix 1

Principles of Medical Ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture* and other cruel, inhuman or degrading treatment or punishment

Adopted by United Nations General Assembly Resolution 37/194 of 18 December 1982

Principle 1

Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained.

Principle 2

It is a gross contravention of medical ethics, as well as an offence under applicable international instruments, for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment.

Principle 3

It is a contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees the purpose of which is not solely to evaluate, protect or improve their physical and mental health.

Principle 4

It is a contravention of medical ethics for health personnel, particularly physicians:

(a) To apply their knowledge and skills in order to assist in the interrogation of prisoners and detainees in a manner that may adversely affect the physical or mental health or condition of such prisoners or detainees and which is not in accordance with the relevant international instruments;

(b) To certify, or to participate in the certification of, the fitness of prisoners or detainees for any form of treatment or punishment that may adversely affect their physical or mental health and which is not in accordance with the relevant international instruments, or to participate in any way in the infliction of any such treatment or punishment which is not in accordance with the relevant international instruments.

Principle 5

It is a contravention of medical ethics for health personnel, particularly physicians, to participate in any procedure for restraining a prisoner or detainee unless such a procedure is determined in accordance with purely medical criteria as being necessary for the protection of the physical or mental health or the safety of the prisoner or detainee himself, of his fellow prisoners or detainees, or of his guardians, and presents no hazard to his physical or mental health.

Principle 6

There may be no derogation from the foregoing principles on any ground whatsoever, including public emergency.


*1. For the purpose of this Declaration, torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted by or at the instigation of a public official on a person for such purposes as obtaining from him or a third person information or confession, punishing him for an act he has committed or is suspected of having committed, or intimidating him or other persons. It does not include pain or suffering arising only from, inherent in or incidental to, lawful sanctions to the extent consistent with the Standard Minimum Rules for the Treatment of Prisoners.

  1. Torture constitutes an aggravated and deliberate form of cruel, inhuman or degrading treatment or punishment.

Article 7 of the Declaration states:

“Each State shall ensure that all acts of torture as defined in article 1 are offences under its criminal law. The same shall apply in regard to acts which constitute participation in, complicity in, incitement to or an attempt to commit torture.”

Appendix 2

Glasgow Coma Scale





Motor Response

Obeys verbal command


(best extremity)

Localizes pain






Flexion (decortication)



Extension (decerebration)



No response (flaccid)





Eye Opening




To verbal command



To pain








Best Verbal Response

Oriented and converses



Disoriented and converses



Inappropriate words



Incomprehensible sounds



No verbal response








Appendix 3

Theater Joint Trauma Record


Evidence-based medicine has become the goal of all specialties. Unfortunately, because of the realities of Combat Trauma, timely and accurate data collection and interpretation of results are difficult. Quality information on casualties for combatant commanders is essential because it facilitates optimal placement, utilization, and resupply of scarce medical resources, and rapid identification of new trends in wounding and treatment. Accurate, aggregated theater information is necessary to shorten quality improvement cycles in deployed treatment facilities.

Furthermore, these data placed on a website could provide rapid feedback to the sending physicians, allowing individual follow-up on their patients. These concepts are not new: they are routinely employed in the > 1,000 verified trauma centers in the US. Application of these principles to the battlefield, using a limited set of jointly approved data elements is described below. This data collection effort is not designed to be an extra step. The proposed form can be used as the trauma chart (both battle and nonbattle injury) and sent to the next evacuation Level with the casualty.

Situational Awareness

The revolution in warfighting which has digitized the battlefield to display friendly positions, intelligence, and engagements electronically has not been equally applied to the casualty side of the equation. This places demands on medical organizations to provide online and continuously updated status and location information on killed, wounded, ill, and psychologically impaired combatants and noncombatants; which includes both the casualty loss to the unit and the return to duty patient. This need will only escalate, as medical situational awareness plays an increasing role in the tactical risk assessment process. At a minimum, commanders should be able to assess Killed In Action (KIA, died before reaching medical care/force wounded) and Died Of Wounds (DOW, die after reaching medical care/force wounded) in order to measure risk associated with operations and the capability of the medical force to control mortality.

Where admitted is defined as any casualty that stays at a Level II facility or above. These definitions do not include the carded for record category in the denominator.

A breakdown of casualties by type of injury and the major body regions (ie, face, head and neck, chest, abdomen and pelvis, upper and lower extremities, and skin) will enable an analysis of injury patterns that can be utilized to design interventions resulting in a decrease in morbidity and mortality.

Other Uses

Data on types of wounds, their causes, and appropriate procedures have potential value in constructing predictive models for medical force development and placement, logistical delivery systems, and research on improved medical interventions. The history of improvements in medicine and surgery are grounded on the battlefield, and dissemination should not be limited to the isolated innovator with a personal spreadsheet for documentation. Individual providers at individual medical treatment facilities (MTFs) have long recorded clinical data and observations. This Joint Theater Trauma Record effort is an extension of their efforts.

Minimum Essential Data

In addition to recording the standard contents of the postprocedure note (ie, who did what, on whom, why, and a plan), the standard data components of a trauma registry are especially helpful (eg, demographics, circumstance and mechanism of injury, pre-hospital monitoring and care, hospital monitoring and care, outcome, participants, direct assessment against standards). Figure A-1 (see next four pages) is a sample form that can serve as both the trauma chart and the data entry source. These minimum essential elements have been agreed on by the US Army, Air Force and Navy. Data will be collated and placed on a website at the first Level IV facility in the evacuation chain.

Recommended Methods and Technology

The process to document emergency trauma care can be employed on either the immature or mature battlefield. This would entail utilizing paper or computer-assisted electronic technology, respectively. In the ideal environment, this would be a single step process. Reality is much different. It is important to recognize that documentation should occur at all Levels, while aggregation of data should occur at the first Level that can support such activity. At a minimum, paper documentation should be used for each casualty and the chart should accompany the patient to the rear as evacuation occurs. When electronic records are available, this process will be simplified.