Sunday, January 13, 2013

A Retired British Surgeon Talks About The Trauma Of Working In A Syrian War Zone

My battle to save the victims of Syria's bloody civil war: The retired surgeon who spent five weeks operating in a secret cave under constant fear of rocket attacks

For grandfather Paul McMaster, it was a risk worth taking to save lives - even though he would face mortal danger every day.
The retired surgeon, from Worcester, spent five weeks operating on victims of Syria's civil war in makeshift field hospitals in rebel-held territory.
Here Paul, 70, tells of the trauma of working in a war zone.
In the cramped confines of our dusty chalk cave, deep in the hilly heartland of north-west Syria, our makeshift field hospital was chaotic, crowded, hot and hectic. And all too often awash with blood.
Helicopters hovered low overhead, firing rockets across the remains of  the wrecked buildings where the elderly, along with the women and children who hadn’t fled to the refugee camps, cowered in fear.
I’ve worked in several war zones with the charity Medecins Sans Frontieres (MSF) – Sri Lanka, Ivory Coast and Somalia – and in those countries the danger came from  ground forces. But in Syria the threat was from the air. It was a much more oppressive type of danger.
And when the bombs go off, you see the fear on people’s faces. You feel crushed by it. And, to be truthful, very frightened.
Our cave was small – about a third of an Olympic swimming pool in size – and went down by about 15ft.  It had a very narrow entrance, then breeze blocks down to the first level. 
This was the triage area where we would ascertain who was in most urgent need of treatment.
Most of our casualties were civilians – the elderly, women, children and babies. Many had shrapnel wounds.
Others were fighters – from both sides as MSF is, of course, impartial – with serious gunshot wounds.

After a bombing there was often a great rush of people who would pour into the cave. Two or three would be badly injured, a dozen more might have less serious injuries.
People came in on stretchers made from corrugated sheets or doors, whatever people could find. Everyone had relatives with them and the numbers could get very big.
They were often immensely distressed and frightened, screaming, covered in blood, not sure if their relatives were alive or dead. There was an extremely chaotic component as the Syrians express themselves with wailing and a lot of crying out, which could be very difficult within the confines of the cave. One of our biggest struggles was to maintain control in this area.
On the next level down we had the portable operating theatre. This is an inflatable tent, a bit like a bouncy castle with an operating table in it. It doesn’t have any windows and is completely enclosed.
We tried very hard to keep it sterile as the surrounding area was, frankly, not. Was it up to the standards of a hospital? Of course not, but we did our best to keep it clean.
As well as the casualties of war, there were diabetics who had run out of insulin, children with asthma and women who needed caesareans. In all, in my five weeks there, we did about 100 operations.
I’ve got grandchildren, and it’s always the children that stick in my mind, the sheer distress of the babies and their mothers.
And the children themselves  are so solemn. I remember a girl, about eight years old, who had lost a couple of fingers on one hand. Medically, she was not difficult to treat, but to look at her face as she looked at her hand .  .  . she was so quiet.
We have screens that help us try to shield them, but the things they saw in the cave, the blood, the distress, no one should have to see – and certainly not children. They seemed like old men, they had lost their childhood. 
I had spent 35 years in academic surgery in the health service [mixing surgery, research work and teaching], both in Cambridge and, finally, as professor of surgery in Birmingham.
When I stepped down ten years ago, at 60, I knew I wanted to help in the developing world. Initially I worked in Kenya, then on projects with MSF in Burundi, Rwanda and the Democratic Republic of Congo, which was my first experience of a war setting.
After that, I did six months in Somalia. When I was told they were struggling to find experienced surgeons in Syria, I immediately said I would go.
In many war zones the surgery is not terribly complicated, it’s a lot of gunshot wounds to the legs.
The skill comes in dealing with very limited resources, such as shortages of blood supplies or no X-rays or electricity. 

Often we are using techniques from Napoleonic times. They are not sophisticated, but they are life-saving. The region we were in hadn’t had electricity for ten months. In the cave, we had an emergency fridge run by a small generator but it could only store blood for 24 hours.
The things they saw in the cave... no one should have to see - and certainly not children. They seemed like old men., they had lost their childhood
Wherever we are in the world, we have a ‘cold chain’ system for drugs and vaccines which must be kept in a temperature controlled environment. It keeps them at the right temperature from London, through airports, and on to their final destination.
Getting materials into Syria is  difficult; it has to be a clandestine operation as we have no permission from the government to be there.
We were constantly worried about running out of drugs and more basic things like detergents. The stars in all of this are our logisticians, the local people who find us supplies; who, when you say, ‘the generator’s running low’, miraculously find you a couple of cans of diesel. Although we’re a medical unit, without them we’d be unable to do anything.
The route into Syria for me and a colleague was to drive through Turkey, then we were picked up by two guides on the border. From there, it was a four-hour trek after we had climbed through the border’s barbed wire. We have four surgical teams working in the conflict zones in Syria.

In our cave we had me - the surgeon - an anaesthetist, an emergency nurse, two doctors, an inspirational Syrian nurse and 11 village women whom we were training to do basic nursing. There were no ambulances so the very severe casualties tended to die before they got to us.
Sometimes, after the casualties, the men with guns would arrive. At MSF we never allow weapons into the treatment area – no matter which side they are on. We did have prisoners from the government forces brought in for treatment and I went to see one after we had treated him. He was being well looked after.
After a while we had to leave the cave as it wasn’t secure enough. It was clear we were in great danger so moved our patients and team to a chicken farm. The new ‘hospital’ was a long, open building.
Once we settled in, we developed more of a routine because we were near a village which meant we could sleep on a mosque floor (the locals were happy with this arrangement).
In five days we created our inflatable operating theatre, a triage area, a sterilisation unit and outpatient and inpatient consulting areas. It was a staggering achievement.
We also sandbagged the west wall to give us more protection against the rockets fired from that direction. Ladies in the village baked us Arabic flat breads and we were given tomatoes and other vegetables and fruit. Otherwise we ate beans and rice.
Everyone, locals and us alike, had days when we struggled to cope with what we were seeing.
It was important in the clinic that we kept a close eye on each other. If anyone was struggling we immediately got them out.

We can’t risk having anyone with impaired clinical abilities. You really do need a clear mind to continue operating. I do worry for the people of Syria. I would see babies born and I couldn’t help but wonder what sort of world they were being brought into – what problems they would face growing up.
The people are immensely distressed; their upset is raw and personal. Everywhere you see anguish written on their faces.
It is very bleak indeed.

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