“This was the first time I was confronted with injuries caused by gunshots, grenades and mines, and they were often horrific injuries,” says Helmut Shoengen, an anesthetist and doctor who recently returned from working in Aden, Yemen, with Doctors Without Borders/Médecins Sans Frontières (MSF).
“We treated many severely injured patients—men, women and children as well—with gunshot wounds to their heads, chests, abdomens, arms and legs,” he says. “Grenade injuries were bad, because they often included burn injuries to the face.
“But the worst ones were the mine injuries where limbs would just be ripped apart.”
MSF began working in Yemen in 1986. High levels of poverty and unemployment combined with continuous insecurity made it difficult for Yemenis to access health care.
However, since outright conflict erupted in March 2015, many health facilities in Yemen have been damaged or destroyed, medical staff have fled, and transport has become extremely challenging due to high fuel prices and insecurity on the roads. MSF has provided urgent support to local hospitals through the Ministry of Health (MoH) and currently has more than 2,000 staff in Yemen.
In Aden, MSF has been running an independent emergency surgical center. Between March 2015 and March 2016, MSF alone received more than 8,000 injured.
But shifting front lines, severe political insecurity, lack of functioning medical facilities, and a dearth of ambulances have made it virtually impossible for many people caught in the conflict to access medical care.
“Occasionally patients would arrive from a long way away,” Shoengen says. “They would sustain an injury and then travel for a number of hours in pain. And once they arrived, often all we could do was amputate.
“And you could say these were the lucky ones because they had made it to the hospital.”
But while their lives were saved, their wounds created other complicating factors.
“During the ward rounds you could see how amputations of lower limbs often caused significant problems when it came to mental health, when it came to coping, and when it came to having the will to live, actually,” Shoengen notes.
Aden was Shoengen’s second placement with MSF. His first was in Jahun, Nigeria, in 2015. It was another surgical placement but a very different one.
“They are very, very different projects,” Shoengen says. “Both are established hospitals but Aden became an acute trauma center when the conflict began last year. In Jahun, we worked in a section of a Ministry of Health hospital that was ‘given’ to MSF. There we treated almost exclusively obstetric patients and newborns. The aim of the project in Jahun is to reduce maternal and neonatal mortality and take care of some gynecological emergencies as well.
“There you were just very busy,” he continues, “because every day 10, 20, sometimes more patients would come through the door, some of them in extremis, convulsing, bleeding, or having been in obstructed labor for days... So in Jahun there was a constant stream of patients coming in while in Aden they arrived more in waves. There would be a day or two where it would be quiet, where you would think ‘Oh, the fighting has finally stopped.’ But no, the next day there would be another wave and it would start all over again.”
The mass casualty scenario of Aden required the medical teams to triage patients into four categories: black for those who could not be saved; red for those needing urgent surgery or treatment; yellow for those whose treatment could wait up to 12 hours; and green for those that could walk, suggesting relatively minor injuries.
It also meant that there was no typical day. “While there were routine tasks,” explains Shoengen, “I knew I could be called out by the local doctors or nurses at any time, day or night – and I was, many times.”
Surgery and anesthetist placements with MSF are short, usually four to six weeks, and for good reason.
“It is exhausting working in the field,” Shoengen says. “You’re basically on 24/7, which is OK when it is for a limited time but difficult to sustain over a longer period.”
“These experiences remind you of how extremely well off we are with our easy access to unimaginably good health care. It’s very humbling.”
But both have their place. “It’s not that I think it’s better or makes more sense to work in an emergency setting than in a regular setting, because in a regular setting you do good work as well and you make a difference for one patient at a time. And that’s the same thing you do in an emergency setting.”
“You don’t change the world but you make a huge difference for that one patient you are treating at the time.”