Page 157 - JSOM Spring 2018

By May 1980, there were 1 million registered refugees in Paki-
stan; a peak of 2.8 million was reached in August 1986. To-
gether with estimated nonregistered refuges, the total number
probably peaked around 3.4 million.

By 1982, Pakistan’s Red Crescent could not cope with the in-
flux of weapon-wounded casualties from the conflict in neigh-
boring Afghanistan and 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
nongovernment organizations (NGOs) to operate from inside
Afghanistan, so Peshawar was the closest ICRC could get to
dealing with casualties from the war.

An old post office in the city of Peshawar, close to the east-
ern end of the Khyber Pass and 30 miles from the Afghan
border, was transformed into a 60-bed hospital with radiog-
raphy, a laboratory, two operating rooms (ORs), a kitchen,
and more. 3

ICRC supplied two teams at a time, which consists of a general
surgeon, an OR nurse, and an anesthetist or anesthesia nurse.
Other necessary personnel were local Pakistani employed by
Pakistan’s Red Crescent. The hospital, The ICRC Hospital
for Afghan War Wounded catered to all wounded, civilian
and military, as well as wounded prisoners or war (POWs)
from Afghanistan. The ICRC surgical teams were deployed 3 to having modern equipment and organization on hand. Sud-
months at a time. denly, I was presented with a severely war-wounded patient in
severe respiratory distress with all the septic symptoms. I had
With the intensifying war in Afghanistan, the hospital over- no electrocardiograph, and only manual blood pressure and
flowed during August and September 1985 during the first pulse measurements. He was unresponsive, his blood pressure
Battle of Zahwar in Paktia province and the two teams, a was way down, and he was tachycardic with severe cyanosis.
Swiss team and our Danish and Finnish team, was supple- With his six friends looking on, standing around the bed, I
mented first by an extra team and quickly thereafter by an whipped out an endotracheal tube and did a beautiful acute
ICRC field hospital with three more surgical teams. endotracheal intubation and started ventilating him. Only
then did I realize how wrong I was! What was I going to do
The ICRC hospital can be compared with civilian hospitals, now? No ventilatory support, no ICU monitors and trained
which are isolated in an area of conflict (i.e., minimal re- nurses, limited supplies of drugs, and a patient dying in my
sources, and so forth). They differ from typical military hospi- hands—with his friends still looking on with great interest. It
tals because they are not a part of echeloned care, but work, was then I understood that I had just received a profound les-
at the same time, as hospitals of first contact and referral hos- son: Modern anesthesia and intensive care have no place in an
pitals, implying that primary surgery, secondary surgery, and NGO hospital with limited resources. But what could I now
basic reconstructive surgery are conducted in the same hospi- do with my poor patient? I shouldn’t have intubated him! My
tal. This poses great challenges to personnel working under ethical dilemma solved itself with the patient expiring within
these conditions, because they must have broad knowledge 10 minutes. His friends all accepted this and at the same time
and experience in all areas of surgical and postoperative care, appreciating what I had done for their friend. This was my
including wound surgery, amputations, fracture management, second lesson: The Afghanis were extremely accepting of their
thoracotomies, and basic plastic surgical techniques. fate and had a different cultural understanding of loss.

The ICRC hospital had limited availability of blood, no ven- NGO surgery in general, and in the Peshawar hospital dur-
4,5
tilatory equipment, no intensive care unit, minimal laboratory ing this period specifically, has been well written up with most
6
services, and only plain radiography. Because of these limi- aspects well described. At this time, the ICRC had already
tations and special conditions in the hospital, triage and the compiled a handbook on war surgery that was the foundation
planning of surgery were of utmost importance, and the re- our work in Peshawar and that handbook has been continu-
strictions encouraged the use of simple methods of treatment ously revised. ICRC has also now handbook on austere anes-
7
and improvisation to provide adequate care. thesia that can be highly recommended. 8
I had just arrived in Peshawar with my team after a week of As an anesthetist, I planned preoperative preparation, anes-
ICRC introductions in Geneva, Switzerland. It was my first thesia itself, and the postoperative phase together with the
or second day on duty and everything was still very strange. surgeon. The intent of the ICRC program also includes teach-
The language and culture, the hospital setting with patients I ing and supervising host-nation health personnel. Therefore,
couldn’t understand, the heat, and, especially, no real knowl- during the daytime, I mentored a Pakistani anesthetic-nurse
edge of the necessary limitations of care. I was a young, Dan- trainee. Because of the influx of patients and the number of
ish, university-hospital anesthetist in training and was used delayed wound closures needing to be performed, it was not

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