April 8, 2013
2013 © Google
Raghu Venugopal is a Canadian doctor who serves as medical team leader for Doctors Without Borders/Médecins Sans Frontières (MSF)’s Am Timan project in southeastern Chad, coordinating and optimizing MSF's core activities including pediatrics, malnutrition, obstetrics, HIV, tuberculosis, and outpatient mobile clinics. Raghu’s goal is to support the entire medical team to deliver the most efficient, compassionate, and professional medical care possible.
The desperate man asked me in French, “Doctor, what about my brother?” In rooms full of bloodied bodies on the ground, somewhere was this man’s brother.
A mass casualty incident hit Am Timan hospital. This man was looking for his brother amongst the 50 or so victims. An open-ended truck, full of people, had turned over. That is all we knew. Trucks and cars were then loaded with injured patients and brought to the hospital.
It was Friday night and I was on-call after a grueling week. My energy level was low and I needed to sit down to think as I did my evening rounds in the intensive care unit. The nurses and I were preparing a blood transfusion for a severely anemic child when the hospital head nurse burst into the room. He told me to come to the triage, now. I said, “Now?” He said, “Yes, now, there has been a large accident.”
I ran to the triage. There, I found complete mayhem. Police, military, crowds, screaming. Headlights illuminated the dust in the hot night air. I followed the crush of people into the triage department. It was like a war-zone. There were injured and bloodied people everywhere. All I could see were injured victims on the floor. Families tried to find their loved ones.
Triage was needed. But first, I needed help. I ran out to the MSF Land Cruiser and used the VHF [very high frequency] radio to call the base. I yelled to the radio operator, “Get our hospital nurse Eve and get my ultrasound.” I knew the portable ultrasound I brought from Canada would be key to diagnose intra-abdominal injuries needing to immediately go to the operating room.
I ran back to the triage department. Then, systematically, I got on my knees and examined every patient. First, were they breathing? Second, could they talk to me? Third, how was their abdomen when I palpated it? My pants were red and I kept changing examining gloves.
Quickly, I knew there were four severely injured patients. Two adults had massive head injuries and would not talk. Next, a young boy also had a serious head injury but would talk. Also, another young boy had a very badly broken leg.
My phone rang. Sigrid, our German midwife, had caught wind something was wrong and called me to see if everything was OK. I yelled into my phone, “Come now. Bring everyone. I’m not kidding. Get the surgeon. Now. Now.”
Minutes later, Eve, our nurse from Canada; Andrea, our nurse from Germany; Cristina, our medical coordinator from Spain; and Sigrid, our midwife from Germany arrived.
I sent Cristina with the two children to the intensive care unit. Sigrid moved patients to the operating room. The two serious head injuries and other orthopedic injuries went to the operating room. These patients included a woman with both arms broken. Another was a woman with an open arm fracture. One by one, they were moved through the thick crowds on stretchers. We ran out of stretchers and so just carried people in our arms. I ran to the operating room to see if things were going OK. Our Nigerian surgeon and I shook hands as he headed in for the first cases. Things were working out. The team was getting the job done.
I went back to the triage. Nurses had come in voluntarily to the hospital to help out. The Ministry of Health and MSF worked side by side to aid the injured. A man with severe facial injuries was bleeding heavily from his nose. I used some tongue depressors and tape and we stopped the bleeding. Nurses and I examined patients, turned them over, and wound closure was happening everywhere.
I went to the intensive care unit. We anesthetized the boy with the femur fracture and when he was asleep we straightened out his leg. We moved stable patients to the wards and crammed extra beds into the ICU.
Back to the triage. A desperate man asked me in French, “Doctor, what about my brother?” I told him I did not know anything about his brother, but we could find him together. We went from room to room and found his bloodied brother on the floor, alone. I found a large injury on the back of the brother’s head. We gathered six men and we picked up the brother and put him on a bed. We examined the man and I got Isidro, a Spanish MSF nurse, to close the head wounds in the maternity ward. The patient was agitated and unable to cooperate. With the permission of the brother, we anesthetized the patient and completed the procedure. We then carried the man to the surgical ward for observation.
Again and again I went back to the triage. The situation was stabilizing. Victims were being triaged, treated, and admitted. Wounds were being closed and pain was being treated. Three doctors with the Ministry of Health worked in the operating room. The intensive care ward and other wards were filling with patients.
The triage was getting under control but we needed to get more patients off the floor, repair their injuries, and admit them to the wards. The nurses and I decided to share the load of remaining patients with all the adult wards. We asked men and women standing around to help us carry the injured to the wards.
Many hands made the work light. As we arrived in the wards with patients we carried in our arms or by stretcher, I gave a one-sentence summary to the attending nurse of the injuries and the medical care needed.
The rest of the team was working hard. Eve was making sure dressings and pain medication were available. Sigrid was keeping the operating room under control and supervising deliveries at the same time in the maternity ward. Johanna, our doctor from Sweden, was helping in the intensive care unit. Oliver, our German supply logistician, made sure there were extra blankets available.
In one return to the triage, I met the head nurse from the Ministry of Health. He thanked me like never before. It was just the way he said “thank you” that I know he’ll never forget this night when we all came together to deal with this mass casualty incident.
The night went on. Eventually things started calming down. I started to have difficulty standing up, I was so exhausted—emotionally, physically, and mentally.
I knew the next day would be difficult, so at some point in the night, Eve, Oliver, and myself left the hospital. I collapsed in a chair at the base. Amidst all the human suffering, the team had responded amazingly.
I went to bed with my three phones, still on-call for the hospital. I worried about what kind of delayed injuries might occur—ruptured spleens or slow-bleeding liver injuries.
My phones did not stop ringing in the night, but surprisingly, it was not for trauma victims, but for all the other types of emergencies that happen in the night at the hospital. The most heart-warming moment in the night was at about 5:00 AM when Hasan, our pediatrics supervisor, called me. He had come to the hospital on a volunteer basis to help out. He informed me on the progress of some patients that were now stabilized and asked me “permission” to go home. I told Hasan his dedication to patient care was a model for us. I asked him to go home and rest. I assured him we would pay him over-time hours for his work—but I think he just wanted to hear he could go home.
The next day, we went back to the hospital to identify those still remaining with untreated or newly discovered injuries. The surgeon, head nurse, and I did the rounds of the hospital. We identified the sickest victims that we could potentially evacuate to the trauma hospital of the International Committee of the Red Cross in Abeche—a town about two hours away by plane flight. I called the Red Cross surgeon, Dr. Igor, and we agreed on the transfers.
Among the transfers was the initially “lost” brother. After the dust had settled and I could examine him again, the brother had significant neck pain and what seemed like a broken arm. The team was not entirely sure if the arm was broken. When I examined his arm, there was definitely pain around the area above where a wristwatch usually is worn.
I pulled out my portable ultrasound, which I was carrying on the hospital rounds. Using a special probe I brought from Canada, I showed the assembled team the normal bone where the patient had no pain. Then, where he had pain on physical exam, the bone was obviously abnormal and broken. Everyone crowded around the machine could see the broken bone. The surgical team agreed to put a splint on the broken arm. With all the brother’s injuries, we would transfer the patient to the Red Cross in Abeche.
In the past day, MSF had responded to an unexpected emergency. It was amidst our usual priorities to our patients. With our partners in the Ministry of Health we dealt with each trauma victim one by one. There were no fatalities and the whole Ministry of Health and MSF team had surged in the night to deal with the emergency. The MSF team felt good about the way we had responded and the positive patient outcomes.
As a doctor, in MSF work and in Canada, family members tap me on the shoulder and ask for my attention all the time. It’s hard to know if it is an emergency or a less serious concern. The man who was looking for his brother was just one of these worried family members the night of this critical event. Everyone who has lost their brother or their sister deserves a helping hand. That is what we are here to do.
Farewell for now from the house-call . . . to Chad.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)