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Treating trauma in an Afghan battle zone

Fighting in the city of Kunduz in north-eastern Afghanistan ended on August 8. During the clashes, the international medical aid organisation, Médecins Sans Frontières (MSF) transformed its office space into a temporary trauma unit to treat the people wounded. That temporary unit is now closed and patients have been transferred to the nearly-completed Kunduz Trauma Centre that MSF had been building since 2018. A doctor in MSF’s Kunduz medical team describes their experience during the fighting and the work that continues.

OPINION: That first evening there was continuous bombardment and shooting, so we had to rush to the bunker, and we stayed there all night, without any sleep. Patients were not able to reach the trauma unit at that stage, because of the fighting in the streets.

The following morning, we heard that multiple victims were arriving in the unit, but we could not get there because of the fighting in the street between where we were staying and the unit. Our colleagues were asking for our help urgently because they had a patient who had a gunshot wound to his chest and stomach and needed to go to surgery very soon.

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A moment arrived when the guns were quieter, and it was possible to move – three of us ran across the street to the operating theatre. The patient had just lost their pulse, so we started chest compression while the anaesthetist was looking for an airway. I cut two holes in the chest – to make sure blood could drain out and allow the lungs to expand; meanwhile another colleague was trying to stop the bleeding below the sternum. We could tell pretty quickly that the bullet had probably hit part of the heart, and it rapidly became clear that there was no way that we could save him.

Hard days

That was the start of our day of hell and the first moment of our team being completely overwhelmed. There were a lot of other victims who came in and had to go to surgery: many with gunshot wounds, some injured by bomb blasts, and others caught in the crossfire.

A doctor in the Kunduz trauma centre examines a patient who has suffered a complicated fracture of their upper and lower leg due to a bomb blast.

MSF

A doctor in the Kunduz trauma centre examines a patient who has suffered a complicated fracture of their upper and lower leg due to a bomb blast.

It was a very long day. Many of our staff also could not reach the trauma unit. The night-shift staff worked through the day. Some would take naps and sleep while others worked, so we could keep staff going from morning and into the night.

At about 6:30 the next morning an ER doctor called me on the radio, saying “I need your help now”. As the fighting had receded a bit at that moment, I ran with the surgeon across the road. When we got into the unit it was crammed.

Four patients all needed emergency surgery – at the same time. We started life-saving surgery on two patients, while we were doing everything possible to keep the other two alive. The two who had to wait survived, and we proceeded to operate on them.

In the end one patient died, but three survived, which is impressive as they all had severe gunshot wounds and bomb blast injuries. At the same time

we still needed to assist other patients who had come in and needed care. This was a heavy day to get through.

“There were a lot of other victims who came in and had to go to surgery: many with gunshot wounds, some injured by bomb blasts and others caught in the crossfire.”

MSF

“There were a lot of other victims who came in and had to go to surgery: many with gunshot wounds, some injured by bomb blasts and others caught in the crossfire.”

An unexpected case

One of our patients was a young boy who was brought by his father to the ER with a bandage already on his arm. He wasn’t crying but was just silently looking ahead. I was supervising the ER along with the intensive care unit nurse. The boy looked comfortable . There was no immediate urgency for me.

Because his fingers sticking out of the bandage looked well circulated and warm, I took my time in demonstrating to the staff how to do a proper investigation of the hand for nerve damage. Strangely the boy didn’t seem to feel anything on his whole hand, which suggested all three nerves were cut.

I continued and gently unwrapped the bandage off his arm. I remember the moment the bandage opened, and I just saw a gaping hole in the forearm of this child. There was more of the hole than tissue remaining. His father told me that a stray bullet had hit the boy while he was playing.

I remember the faces of the staff. Their expressions just said; well I didn’t expect that! And nor had I. So we packed up the wound again and tried to stabilise the hand. For some reason the only thing remaining was the artery going all the way to the fingers, but the nerves were all broken.

Medically, we all agreed that amputation was probably the best option.The father didn’t agree with this. He wanted to give it a chance. We did our best to debride [clean] the wound and keep the tissue alive, and attached an external fixator, a metal bracket to hold the bones in place while mending, to try to let it heal for as long as possible. The boy’s hand is still there, but he will never have a good hand again. But the hand’s still there and that’s already something that we didn’t expect.

While the father has been very friendly, the little boy knows that if a doctor is coming close, that means there is going to be pain. He hasn’t smiled at any of us, but we can see him smiling at his father.

“What patients we see now is shifting from the very active gunshot and bomb blast injuries to complications with the war wounded who need follow-up from previous treatment ...”

Stig Walravens/MSF

“What patients we see now is shifting from the very active gunshot and bomb blast injuries to complications with the war wounded who need follow-up from previous treatment …”

Calm – but still busy

After the fighting had started to ease, we began to see more patients coming in. Many of them had already received some sort of emergency treatment at their nearest hospital.

We are also seeing an increase in patients being referred to us from provincial hospitals, where patients have had multiple surgeries. Quite often we go into surgery and realise that there are not many options for us to take – there is not much more we can do to try to save this person.

Moving to the new hospital

Here in Kunduz the rebuilding of our hospital has been going on for quite a while. Last month we transferred the patients from our temporary clinic to the hospital for the first time. It is a huge step to open the hospital, although it is not finished yet.

What patients we see now is shifting from the very active gunshot and bomb blast injuries to complications with the war wounded who need follow-up from previous treatment and also road traffic accidents, which are increasing sharply as society opens up again. Everyone here rides motorcycles without a helmet; when they fall, they suffer head traumas. As we don’t have neurosurgeons, sometimes there is little we can do.

Making it work

In the Kunduz Trauma Centre, we’re doing our medical work while the construction is still going on. But the speed at which the construction team and others are fixing things is quite amazing. They have a real approach of solving problems.

We saw a stretcher bearer going to get a patient and having problems passing the stretcher over the uneven ground because there was too much rubble. In no time, there were people putting concrete over the rubble. It’s quite incredible how all the construction team are helping so hard to fix all the problems the medical staff encounter.

We have the same support from the team who are responsible for the hospital compound. One of them is always on a bicycle, cycling from one department to the other, fixing things incredibly rapidly. The same applies for supply, you just see medical items and supplies suddenly appearing at the front step of the departments for us to treat our patients.

We have exams for staff going on; and we’re hoping to start recruiting mental health officers, which is something that we badly need.

And that’s how it feels at the moment – all the teams really helping each other, together, trying to just make it work.

Reference