The Kunduz Trauma Center (KTC), located in northeast Afghanistan, was opened by Médecins Sans Frontières (MSF) in August 2011 to serve the community caught in the frontlines of the ongoing conflict. It has a linear structure of healthcare delivery: from patient admission via the emergency room (ER), to the operating theatre, to the intensive care unit (ICU), the general wards and outpatient department. There is even a physiotherapist to assist with rehabilitation of war victims and a psychologist for the staff and patients to seek mental health assistance from. X-ray, laboratory and blood bank facilities are also available, albeit with limited capacity. I would dare suggest that the KTC was the best trauma hospital in the country, or even in the region, and it was fully operated by MSF.
To provide quality and timely care to the victims of conflict, the KTC focuses only on trauma patients. Patients without an injury, whether from a road traffic accident, war-related incidents or even a fall, would be turned away. The local community knows this and the fact that they abide by this unspoken rule reflects the acceptance and respect they have for MSF's role in the community.
A large majority of the patients we see are the war-wounded - both innocent civilians, unlucky enough to be caught in the crossfire, and the fighters from whichever armed group (MSF does not take sides).
Mass casualty plan
The siren blared in the background as Dr Bashir, our local medical supervisor, attended to a child in the ER. He was not at all surprised to hear the siren break the tedium of a waiting room full of children who have minor road traffic accident-related injuries. An hour prior, there were unverified reports of a suicide bomb attack at the market of an adjacent town not too far from Kunduz. Multiple casualties were expected but unconfirmed. The siren was confirmation that the mass casualty plan (MCP) had officially been activated. Everyone jolted into action without a hint of panic. Dr Bashir took his position at his designated red area in the resuscitation room of the ER. Suddenly, Drs Ares, Omar and Joya - the ER doctors who were off duty that day - appeared and donned their coloured vests. They came once they had heard the initial rumours. Like so many others, they chose to remain in Kunduz even when the fighting intensified. Instead of leaving for safety, they stayed to help their people.
The first wave of patients arrived via trucks, driven by well-intentioned members of the public who scooped up any casualty they saw. Dr Bashir went about his task of managing the patients who have been triaged red - those with penetrating thoracic and abdominal injuries, bowel eviscerations, mangled limbs, head injuries and the like; clearly, he had done this umpteen times before. The surgical team was subsequently kept busy throughout the night as well. We saw a total of 54 patients for that particular mass casualty incident (MCI) that evening.
Have a little faith
After the chaos died down, the nurses informed Dr Bashir about a category black patient who was still alive, surprising everyone. The triage category black patients (impending death and deemed unsalvageable) were placed in a special room, attended by doctors, nurses and mental health counsellors. This patient was a young man with a penetrating head injury, likely from shrapnel. We did not expect this patient to survive, but he was trying his best to prove us wrong. Dr Bashir immediately attended to him and handed him over to Dr Osmani, the resident ICU physician at KTC. I was a little hesitant about a patient with a very poor prognosis taking up a precious ICU bed. What if there were another MCI? But Dr Osmani insisted and told me to have a little faith. The other surprise was that there actually was an ICU bed available after the MCI.
Perhaps unsurprisingly, with the amount of time and faith that Dr Osmani dedicated to this particular patient, it was almost inevitable that he would somewhat recover. And he did. After almost a month of nothing more than nasogastric tube feeding of Plumpy'Nut and basic nursing and wound care, this young man woke up. You'd be forgiven if you thought this was a script for a medical drama. Dr Osmani's feeling of elation and accomplishment was beyond words. "I told you, I told you," he kept repeating. Truth is, we should have known better; this was not the first time Dr Osmani had insisted we admit a seemingly unsalvageable patient to the ICU.
Maybe, sometimes all we need is just a little faith, and a committed ICU physician with an empty ICU bed.
That fateful night
On the night of 3 October 2015, the KTC was directly hit by US airstrikes. The hospital was hit repeatedly during sustained bombings by the coalition forces. Theories are rife about the reasons for the attack, but the fact remains clear that a healthcare facility was targeted, putting the lives of the patients and healthcare workers at extreme risk. During the attack, MSF staff (many of whom returned to help despite it being their off day) were still working to save patients and fellow colleagues injured in the blast. One can only imagine what that night was like. 14 MSF staff members were killed in the bombings, including Dr Osmani; and it really doesn't help the grief to know that his body, along with some others, were burnt beyond recognition and never identified.
Dr Joanne Liu, President of MSF, said it best.
"This was not just an attack on our hospital – it was an attack on the Geneva Conventions. This cannot be tolerated. These Conventions govern the rules of war and were established to protect civilians in conflicts – including patients, medical workers and facilities. They bring some humanity into what is otherwise an inhumane situation."
That night, Kunduz lost their only active hospital. MSF lost years of hard work making the KTC what it was. KTC staff and patients lost their lives and others lost family members and friends. But there is hope. In a seemingly never-ending conflict, the KTC is being rebuilt and it's only a matter of time before it will resume operations to serve Kunduz once again.
For a blog entry posted by another active MSF doctor on that fateful night, visit http://msf-seasia.org/blogs/16924.