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SICOT e-Newsletter

Issue No. 49 - October 2012

Orthopaedics in War-Torn Areas

An Orthopaedic Surgeon’s experience in Afghanistan
MSF – Kunduz Trauma Centre

Ihab M. Emran 
Assistant Professor of Orthopaedic Surgery - Cairo University, Egypt

Afghanistan has been characterized as a state torn with violence for many decades. Since 1979 the country has experienced major wars in which millions of Afghans have lost their lives and even more have been brutally injured. Eleven years after the last war in Afghanistan the political situation is far from stable and the violence between main actors still continues. With the growing conflicts, the Afghans have been trapped for decades in conditions of poverty and lack of access to medical treatment.

As violence continued across northern Afghanistan, MSF opened - in August 2010 - a specialized surgical trauma hospital in the northern Kunduz province. Amongst other projects in different areas of Afghanistan, the Kunduz Trauma Centre aims to provide high quality free surgical care to trauma victims thus reducing mortality and morbidity in the north east region of Afghanistan. This trauma centre obviated the need of victims with severe injuries to travel a long, expensive and dangerous journey to the capital, Kabul, or neighbouring Pakistan.

View of the Kunduz Trauma Centre

Going to Afghanistan as the first mission with MSF was a challenging experience. I had the privilege to join the team working in Kunduz Trauma Centre for a five-week mission as an expat Orthopaedic Surgeon from 1 August to 12 September 2012. The MSF Trauma Centre operates through the facilities of one Emergency room, two operating theatres, an intensive care unit, one outpatient department with dressing and plaster rooms as well as X-ray and laboratory/blood bank facilities. There are separate surgical wards for male and female patients with a current capacity of 58 beds. The trauma centre also provides physical rehabilitation by physiotherapists for in and out patients. The expat medical team, amongst other members, consists of an ER doctor, ICU doctor, two Anaesthetists, a General Surgeon and two Orthopaedic Surgeons.

The spectrum of cases seen by the Orthopaedic surgeon range from war wounded injuries due to bomb explosions, land mines, road side IEDs (Improvised Explosive Device) and gunshot injuries as well as the common injuries from road traffic accidents and other domestic injuries. Given the nature of injuries there is a wide spectrum of fractures from simple to complex to be dealt with; mostly open fractures with extensive soft tissue damage. Frequently, the limb injuries will be as a part of polytrauma patients with other head, chest and abdominal injuries. It is not uncommon for these injuries to be seen in a multiple casualty situation whether they are the result of bomb explosions or a bus collision.

The orthopaedic interventions possible during the first year since the beginning of the project, in addition to closed fracture treatment in adults and children, are basic management of open fractures applying the principles of soft tissue debridement and fracture stabilization with external skeletal fixation and wiring. Knowledge of the principles of management of war wounded in situations of limited resources, published by the ICRC, is helpful in having satisfactory outcomes in these devastating limb and trunk injuries.

Improvement of the orthopaedic surgical care, offered in the Kunduz Trauma Centre, to include internal fixation of closed fractures is currently underway with improvement in the OT setup, sterilization and providing a C-arm in theatres in the very near future. In addition, there is a considerable load of wound surgery for limb soft tissue injuries often requiring plastic reconstruction. Needless to say, given the nature of the injuries, upper and lower limb amputations are frequently being performed for the non salvageable mutilating limb injuries.

Since it started almost a year ago, the number of patients treated in the Kunduz Trauma Centre has steadily increased. This is due to the increased awareness of the population of Kunduz province and nearby areas of the unique services the MSF Trauma Centre offers to the victims of trauma without regard to their ethnicity or political affiliations.

The MSF Trauma Centre policy notice

The key to success of the MSF Trauma Centre in providing such services, as I witnessed during my mission, is a hard working team of expats and local staff in a well structured and organized project. During my mission, I had the pleasure to work in a team of 20 expatriate staff of 15 different nationalities, working together with about 300 national staff members. I witnessed a distinguishable team spirit and obvious cooperation between all members. This ensured everyone’s duties to be fulfilled in a professional and effective way.

MSF also ensures the working environment to be as optimal as possible for the expat staff being in a foreign environment with a noticeable different cultural background. Security issues with the local political unrest dictates strict guidelines to be followed for the safety of all staff from the moment they arrive in Afghanistan until the end of the mission. During my stay I never felt threatened or unsafe during work or outside the hospital in the living compound or during transportation from one place to another. Also the mental status and well-being of the expat team is well looked after with good housing conditions and available recreational facilities within the living compounds. The friendly spirit between all team members made it an enjoyable experience in spite of the stress expected at times from the hard work of dealing with victims of this kind of violence.

The experience as a whole in the MSF Kunduz Trauma Centre, for an Orthopaedic Surgeon, is a very rich one. Dealing with victims of violence and war injuries is very different from what one faces in day to day common orthopaedic practice. This is in addition to the invaluable humanitarian role of helping victims of multiple injuries in an area struck with violence for decades with a poor population sometimes not having access to basic health services. An overall travel and work experience I much cherish and look forward to repeat in the near future.