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Injury, Int. J.

Care Injured (2007) 38, 290—297

www.elsevier.com/locate/injury

The evaluation of trauma patients in Turkish Red


Crescent Field Hospital following the Pakistan
earthquake in 2005
Murat Bozkurt a,*, Ali Ocguder a, Ugur Turktas b, Mustafa Erdem b

a
Diskapi Yildirim Beyazid Research and Education Hospital, 3rd Orthopaedics
and Traumatology Clinic, Diskapi, 06100 Ankara, Turkey
b
Ataturk Research and Education Hospital, 1st Orthopaedics and Traumatology Clinic,
Bilkent, 06800 Ankara, Turkey

Accepted 17 October 2006

KEYWORDS Summary To provide better emergency and outpatient services in well-equipped


Pakistan; field hospitals, organisation and team and equipment selection are of utmost impor-
Earthquake; tance to meet the demands of the earthquake zone. In the planning stage, the
Field hospital; evaluation of data collected after the earthquake is essential.
Trauma On 14 October 2005, following the earthquake in the city of Muzafferabad of
Kashmir, Pakistan on 8 October 2005, Turkish Red Crescent Field Hospital was
established and equipped with health professionals. A total of 2892 patients were
treated and followed up. All the patients were prospectively evaluated. The profiles
of the patients transferred, operated, or followed up within this period were
documented. Furthermore, the patients who applied with post-traumatic musculos-
keletal trauma were also documented. Of 1075 patients, who applied to orthopaedics
outpatient clinic, 543 were female and 632 were male. The patients were evaluated
based on their fracture as follows: pelvis (n = 45), femur (n = 59), tibia (n = 87), ankle
and foot (n = 45), vertebra (n = 41), clavicle (n = 10), humerus (n = 38), forearm
(n = 20) and hand and wrist (n = 45).
Medical necessities in an earthquake zone are dynamic and change rapidly. Field
hospitals must be prepared for requested changes to their mode of activity and for
extreme conditions.
# 2006 Elsevier Ltd. All rights reserved.

Introduction
* Corresponding author at: Tirebolu Sokak, Omrumce Apt.,
27/18, Yukariayranci, TR-06550 Ankara, Turkey.
Tel.: +90 312 5171719; fax: +90 312 5171720. The primary objective in the first 10—14 days after
E-mail address: nmbozkurt@yahoo.com (M. Bozkurt). any disastrous earthquake involving many casualties

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2006.10.013
Evaluation of trauma patients in the 2005 Pakistan earthquake 291

is the rescue of possible survivors under the debris. laboratory technicians, one orthopaedic technician,
In this period, search and recovery teams rescue and five nurses. The team was under the supervision
the survivors and transfer them to hospitals for of a senior orthopaedic and traumatology specialist
treatment. The period when the injured have a (MB). Turkish Red Crescent Technical Team provided
chance to get real treatment is after the second the service departments for energy, food, commu-
week of search and recovery activities in which the nication, transport and other necessities. The cen-
pace and success rate of the mission is diminished. tre contained a triage tent, dressing and patient
In addition to the hospitals that have incurred little examination tent, outpatient tent, orthopaedic
or no damage and are in good condition, field intervention and plastering tent, laboratory tent,
hospitals established by national and international roentgen tent, pharmacy tent, and sterilisation tent
medical teams provide health services to the as well as two operation tents where two operations
injured and those with ordinary complaints in their could be performed simultaneously and treatment
emergency rooms and outpatient clinics.1—4,6,9,11 and follow-up tent of 50-patient capacity. The
To provide better emergency and outpatient ser- patients arrived at the hospital themselves or by
vices in well-equipped field hospitals, organisation air or land transportation provided by the local
and team and equipment selection are of utmost government. Communication with the patients
importance to meet the demands of the earth- was facilitated by eight interpreters working in
quake zone. In the planning stage, the evaluation shifts and translating from Urdu to English. The
of data collected after the earthquake is essential. patients received at the triage were referred to
It is well known that the medical response to the outpatient clinics depending on the case and
disasters in developing countries has been poorly further consultations were conducted at these
documented.9 This study presents the profile and clinics. The patients that required surgical inter-
documentation of the patients evaluated and trea- vention were operated under emergency operative
ted after the massive earthquake (7.6 magnitude) conditions. The patients requiring follow-up by
of 8 October 2005 in Kashmir, Pakistan and Muzaf- internal medicine as well as the preoperative and
ferabad, the capital of the state, and its vicinity post-operative patients were treated. In the in-
following the search and recovery operations, with patient unit, different teams performed the dres-
an aim to guide in the planning and organisation of sings of outpatient and inpatient cases. In a 12-day
health services. period, a three-person health care team visited the
nearby villages twice for help and care in collabora-
tion with the Turkish Red Crescent team. In the
Patients and methods Turkish Red Crescent Field Hospital established in
Muzafferabad between 20 and 31 October 2005, a
On 9 October 2005, following the earthquake in the total of 2892 patients were treated and followed up.
city of Muzafferabad of Kashmir, Pakistan on 8 All the patients were evaluated prospectively. The
October 2005, a Turkish rescue team was involved profiles of the patients transferred, operated, or
in search and recovery of survivors at the disaster followed up within this period were documented.
sites as well as retrieval of the dead from the ruins. Furthermore, the patients who applied with post-
Turkish Red Crescent Field Hospital was established traumatic musculoskeletal trauma were also docu-
on 14 October 2005 and equipped with health pro- mented.
fessionals working in rotational basis of 2—3-week
periods.
In the Turkish Red Crescent Field Hospital estab- Results
lished in Muzafferabad, the second team working
between 20 and 31 October 2005 consisted of 13 The second health care team that started to serve
physicians and 9 health care aids and worked with 12 days after the earthquake completed the treat-
the logistic, technical, and hospital staff of the ment and follow-up of 2892 patients within a 12-day
Turkish Red Crescent. Two orthopaedic and trauma- period. The gender distribution of the patients was
tology specialists, one orthopaedic and traumatol- 1522 male and 1370 female. The patients were
ogy fellow, one nephrologist, one paediatric classified based on their systemic disorders as fol-
specialist, one obstetrics and gynaecology specia- lows: musculoskeletal system injury (n = 1075),
list, one infectious diseases specialist, one otolar- respiratory tract disorders (n = 438), cardiological
yngology specialist, one radiologist, and six disorders (n = 110), gastro-enterological disorders
practitioners worked as members of Turkish National (n = 328), urinary tract disorders (n = 207), soft tis-
Medial Rescue Team and were assisted by two anaes- sue infections (n = 276), dermatological problems
thetic technicians, two radiology technicians, two (n = 265), and others (n = 193).
292 M. Bozkurt et al.

Table 1 Detailed information of the surgically treated patients


Fracture Soft tissue
Localisation ORIF (n) External fixation (n) Amputation (n) Localisation Abcess drainage (n)
Femur 5 8 — Thigh 4
Tibia 2 9 3 Sacral 1
Ankle 2
Metatars 1
Humerus 2
Forearm 1
Radius distal 3
Metacarp 2

Detailed documentation of the patients with open fractures (n = 63, 5.86%) or injuries. Twenty-
musculoskeletal injuries has been provided in five of these patients (2.32%) suffered from infec-
Table 1. The diagnosis, the surgery method and tions.
operative materials used, and operation time of Our centre was the first point of application for 59
43 patients have been presented in Table 2. (5.48%) of the patients with femoral fractures, 87
Of 1075 patients seen in the orthopaedic out- (8.09%) of the patients with fractures of the tibia, 38
patient clinic, 543 were female and 632 were male. (3.53%) of the patients with humeral fractures, and
The age distribution of the patients were as follows: 20 (1.86%) of the patients with forearm fractures.
363, under 15 years of age (33.76%); 225, between None of these patients had received any previous. Of
the ages of 15 and 30 years (20.93%); 418, between these patients, 13.58% were treated by health care
the ages of 30 and 60 years (38.88%); 69, over 60 providers who were not physicians. Four patients
years of age (6.41%). Trauma patients suffered from with open fractures had wide soft tissue infection

Figure 1 (a—c) Different types of open fracture fixation attempted by the use of a hard substance containing mud or
clay, a common belief for treatment of these kind of wounds by the people of the area.
Evaluation of trauma patients in the 2005 Pakistan earthquake 293

Table 2 Localisations of the fractures and malunions


Fracture Malunion
Localisation n Localisation n
Pelvis fracture 45
Femur fracture 42 Femur malunion 17
Intertrochanteric 5
Subtrochanteric 9 Subtrochanteric 4
Femur shaft 24 Femur shaft 11
Supracondylar 4 Supracondylar 2
Tibia fracture 45 Tibia malunion 20
Proximal 7 Proximal 2
Medial plateau 4
Middle 34 Middle 11
Distal 22 Distal 7
Foot and ankle fracture 34 Foot and ankle malunion 11
Bimalleolar 10 Bimalleolar 5
Lateral malleolus 13 Lateral malleolus 4
Calcaneus 3
Metatars 5 Metatars 1
Phalanx 3 Phalanx 1

Vertebra fracture 41
Lumbar 35
L1 16
L2 13
L3 6
Thoracic 5
T12 4
T11 1
Cervical 1
C4 1
Clavicular fracture 10
Proximal 1
Orta 7
Distal 2
Humerus fracture 26 Humerus malunion 12
Proximal 8 3
Humerus shaft 14 8
Supracondylar 4 1
Forearm fracture 20
Proximal 3
Middle 11
Distal 6
Hand and wrist fracture 45
Radius distal 23
Scaphoid 7
Metacarp 7
Phalanx 8

due to fixation attempted by the use of hard sub- above the knee. One case, however, received wide
stances containing mud or clay, a common belief for debridement and external fixation and was trans-
treatment of this kind of wound by the people of the ferred to Islamabad for further reconstruction.
area (Fig. 1a—c). Two of these cases had to be Details of treatment modalities are presented in
amputated below the knee, and one was amputated Table 3.
294 M. Bozkurt et al.

Table 3 Treatment modalities of the fractures


Fracture Conservative treatment (n) Surgical treatment (n) Transfer to another centre (n) Total (n)
Pelvis 35 10 45
Femur 36 13 10 59
Tibia 63 14 10 87
Ankle-foot 42 3 45
Vertebra 41 41
Clavicula 10 10
Humerus 36 2 38
Forearm 19 1 20
Hand-wrist 40 5 45

Unusual and earthquake-specific injury types


were also noted. Four cases applied with drop hand
without significant bone or soft tissue lesion (Fig. 2a
and b). Another common lesion type specific for
earthquake was injuries to the scalp with severe
defects due to collapsing roofs. Eleven children
presented to the outpatient clinic with open wounds
in the scalp (Fig. 3a and b).
In the time period described (second group), two
infant (18 months of age and 26 months of age)
deaths occurred due to pneumonia and septic
shock.

Figure 2 (a and b) Drop hand without significant bone or Figure 3 (a and b) Severe scalp defects due to collapsing
soft tissue lesion. roofs.
Evaluation of trauma patients in the 2005 Pakistan earthquake 295

Discussion tent kitchens set up in the hospital and the cooks


met the food needs of the health care workers and
Medical necessities in an earthquake zone are technical team at the hospital. Bottled drinking
dynamic and change rapidly. Field hospitals must water was available. Because the hospital existed
be prepared for requested changes to their mode of for a long time, when the team was replaced the
activity and for extreme conditions. Dayan et al.3 treatment of the patients was not affected or inter-
reported that in the first few days, the medical rupted. No ethical problems were encountered
teams concentrated on treating injuries caused between the patients’ relatives and the hospital
directly by the earthquake. Surgical and orthopae- team.
dic staff as well as obstetrics and gynaecology are Despite all the precautions, some medical sup-
the main medical disciplines needed at this plies were damaged during transportation, and
stage.3—5,7,8,12,13,15 In the later stages, a normal some supplies were missing; however, the Turkish
distribution of disease is encountered and a mix- Crescent Team located in Islamabad, closest to our
ture of medical specialties must provide for the field hospital, supplied most of the missing items.
regular medical needs of the people living in the Some other equipment (wheel chairs, stretchers,
earthquake zone. Infectious diseases such as gas- etc.) was transported by military cargo planes
tro-intestinal and respiratory infections should be arriving from Turkey. Still other materials needed
anticipated as well as exacerbation of chronic ill- were supplied from among the remaining medical
ness because of the lack of appropriate medical supplies after the hospital in Muzafferabad, which
supplies.1—4,9 had become uninhabitable due to the earthquake,
The hospital was set up 6 days after the earth- was evacuated, while others were provided,
quake on 14 October 2005 by the Turkish Crescent. upon their visit to our hospital, by the represen-
The observations of the second group working in the tatives of NGOs in areas like Karachi with higher
area after the earthquake have been presented. In socio-cultural level where earthquake was not
the Turkish Crescent Field Hospital established at felt.
the official invitation of the Pakistani government as Pakistani military forces provided the security of
part of the common humanitarian efforts between the hospital. Volunteer health care personnel and
the two countries, a work program of a minimum 1- military doctors were assigned who could speak
year duration has been planned. Throughout this English and Urdu. They translated for patients’
period, health teams from the entire Turkish health relatives, patients, and the health care team.
care team arrived at the area for 2—3-week periods In the first 2 weeks after the earthquake in Paki-
and provided health care services. stan, a significant number of patients presented
One the harsh environmental conditions, to the with musculoskeletal injury and infection. The lack
motivational level of the teams tended to diminish of a plastic and reconstructive surgery specialist in
after a certain period; thus, interchanging short the team was unfortunate. However, the same pro-
periods (2—3 weeks) of work among the teams blem was reported for the largest local hospital in
seemed to present better service. The Pakistani Muzafferabad as well as for American, French, and
government facilitated the work of all the teams Canadian centres. The third team arriving from
arriving from different countries; for example, Turkey included a plastic and reconstructive sur-
many of our colleagues who arrived in the first team geon.
without a visa were issued one on their arrival at the In delayed and malunion cases, correction was
airport. Turkish Military planes provided the trans- achieved by stabilising with unilateral external fixa-
portation of the teams to the region. Therefore, the tors. For easy application, self-drilling and self-
first teams arriving at the region conducted logistic tapping Schanz screws were preferred. Schanz
investigations to set up the hospital at locations screws were fixed to each other by radiolucent
where it would be safe in the aftershocks, and carbon rods. Under X-Ray control, the interventions
medical supplies, equipment, and infrastructure needed were performed and rigid fixation was
needed were transported. All the personnel and achieved. In open fractures with soft tissue defects
equipment were transferred from Turkey. The Turk- in particular, repeated debridement and dressings
ish Crescent team that served in the region had also were performed to encourage granulation tissue
worked in the relief efforts for tsunami victims and formation. The patients who could wait were trea-
earthquakes in Turkey, so, they were highly experi- ted by two plastic surgeons, who would arrive in the
enced. A generator was available in case of power following team, by grafting and flaps. However,
failure, and was put in use by the technical team. those who required urgent intervention or could
The water system was reinforced by additional not wait were transferred to Islamabad by military
water tanks that were regularly chlorinated. The helicopters.
296 M. Bozkurt et al.

Another important responsibility of logistic teams (generator, water tank, tent, sleeping bag, bread,
arriving after an earthquake is the determination of water, chlorine, etc.); (3) the compatibility of the
hygienic and traditional habits of the people in the team members, if possible, a pre-training session
area that may constitute health risks, and take under simulated conditions of a challenging envir-
precautions as well as inform the people of the onment in specially designed camps, and determi-
health hazards. The methods used by non-medical nation of team leaders ahead of time and enabling
individuals in Kashmir to treat open wounds with their communication with the technical team lea-
various substances significantly increased the risk of ders are of great importance; (4) the transporta-
amputation. tion of medical equipment (sterilisation unit,
The majority of the patients were admitted with operation rooms, radiology units, etc.) should
fractures or injuries associated with the trauma be realised by the use of containers, and self-
received during the earthquake.3,4,7—10,12—15 sufficient infrastructure (generator, etc.) must
Following the initial shock of an earthquake, be available and regularly maintained.
patients usually gain access to field hospitals more
easily after the second week. Thus, closed reduction
and surgical treatment of these fractures may be Acknowledgments
considered. External fixators that are easily
applied, cannulated screws and screw sets were We would like to extend our deepest thanks to Dr. Ali
the most useful orthopaedic implants. In a period Coskun, Dr. Ahmet Karadag, Dr. Hanifi Kurtaran, Dr.
such as the one described, a field hospital should Mehmet Kanbay, Dr. Cemal Bulut, Dr. Ikbal Cekmen,
have specialists in orthopaedic and traumatology, Dr. Dogan Barbaros, Dr. Ahmet Yönder, Dr. Muhsin
plastic and reconstructive surgery, infectious dis- Boga, Dr. Basri Cidan, Dr. M. Yasar Yilmaz, Emine
eases, general surgery, anaesthesia, paediatrics, Seyhun, Pelin Gundag, Dilek Bozer, Yasemin Kaya,
internal medicine, and obstetrics and gynaecology Senol Sahin, Mehmet Sever, Hakan Gungor for their
as well as orthopaedic, anaesthetic, radiology, and great work in Turkish Red Crescent Field Hospital.
laboratory technicians and nurses. Furthermore, We would also like to thank Turkish Red Crescent
the presence of an interpreter is highly needed Pakistan Earthquake Team for their great contribu-
for patient—medical staff communication. tion. We are grateful to the nurses, translators from
Although a team of military physicians may be Pakistan and Pakistan army and government who
considered more appropriate because of their train- inspired the teamwork between Turkish and Paki-
ing for difficult conditions in field hospitals, civilian stan medical staff.
medical teams that are trained to work in coordina-
tion with Red Crescent or Red Cross organisations
will provide better organisation of search and recov-
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