Injury, Int. J. Care Injured (2007) 38, 290—297

www.elsevier.com/locate/injury

The evaluation of trauma patients in Turkish RedCrescent Field Hospital following the Pakistanearthquake in 2005

Murat Bozkurt a,*, Ali Ocguder a, Ugur Turktas b, Mustafa Erdemb

aDiskapi Yildirim Beyazid Research and Education Hospital, 3rd Orthopaedicsand Traumatology Clinic, Diskapi, 06100 Ankara, TurkeybAtaturk Research and Education Hospital, 1st Orthopaedics and Traumatology Clinic,Bilkent, 06800 Ankara, Turkey

Accepted 17 October 2006

KEYWORDSPakistan;Earthquake;Field hospital;Trauma

Summary To provide better emergency and outpatient services in well-equippedfield hospitals, organisation and team and equipment selection are of utmost impor-tance to meet the demands of the earthquake zone. In the planning stage, theevaluation of data collected after the earthquake is essential.

On 14 October 2005, following the earthquake in the city of Muzafferabad ofKashmir, Pakistan on 8 October 2005, Turkish Red Crescent Field Hospital wasestablished and equipped with health professionals. A total of 2892 patients weretreated and followed up. All the patients were prospectively evaluated. The profilesof the patients transferred, operated, or followed up within this period weredocumented. Furthermore, the patients who applied with post-traumatic musculos-keletal trauma were also documented. Of 1075 patients, who applied to orthopaedicsoutpatient clinic, 543 were female and 632 were male. The patients were evaluatedbased on their fracture as follows: pelvis (n = 45), femur (n = 59), tibia (n = 87), ankleand 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. Fieldhospitals must be prepared for requested changes to their mode of activity and forextreme conditions.# 2006 Elsevier Ltd. All rights reserved.

* Corresponding author at: Tirebolu Sokak, Omrumce Apt.,27/18, Yukariayranci, TR-06550 Ankara, Turkey.Tel.: +90 312 5171719; fax: +90 312 5171720.

E-mail address: nmbozkurt@yahoo.com (M. Bozkurt).

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2006.10.013

Introduction

The primary objective in the first 10—14 days afterany disastrous earthquake involving many casualties

rved.

Evaluation of trauma patients in the 2005 Pakistan earthquake 291

is the rescue of possible survivors under the debris.In this period, search and recovery teams rescuethe survivors and transfer them to hospitals fortreatment. The period when the injured have achance to get real treatment is after the secondweek of search and recovery activities in which thepace and success rate of the mission is diminished.In addition to the hospitals that have incurred littleor no damage and are in good condition, fieldhospitals established by national and internationalmedical teams provide health services to theinjured and those with ordinary complaints in theiremergency rooms and outpatient clinics.1—4,6,9,11

To provide better emergency and outpatient ser-vices in well-equipped field hospitals, organisationand team and equipment selection are of utmostimportance to meet the demands of the earth-quake zone. In the planning stage, the evaluationof data collected after the earthquake is essential.It is well known that the medical response todisasters in developing countries has been poorlydocumented.9 This study presents the profile anddocumentation of the patients evaluated and trea-ted after the massive earthquake (7.6 magnitude)of 8 October 2005 in Kashmir, Pakistan and Muzaf-ferabad, the capital of the state, and its vicinityfollowing the search and recovery operations, withan aim to guide in the planning and organisation ofhealth services.

Patients and methods

On 9 October 2005, following the earthquake in thecity of Muzafferabad of Kashmir, Pakistan on 8October 2005, a Turkish rescue team was involvedin search and recovery of survivors at the disastersites as well as retrieval of the dead from the ruins.Turkish Red Crescent Field Hospital was establishedon 14 October 2005 and equipped with health pro-fessionals working in rotational basis of 2—3-weekperiods.

In the Turkish Red Crescent Field Hospital estab-lished in Muzafferabad, the second team workingbetween 20 and 31 October 2005 consisted of 13physicians and 9 health care aids and worked withthe logistic, technical, and hospital staff of theTurkish Red Crescent. Two orthopaedic and trauma-tology specialists, one orthopaedic and traumatol-ogy fellow, one nephrologist, one paediatricspecialist, one obstetrics and gynaecology specia-list, one infectious diseases specialist, one otolar-yngology specialist, one radiologist, and sixpractitioners worked as members of Turkish NationalMedial Rescue Team andwere assisted by two anaes-thetic technicians, two radiology technicians, two

laboratory technicians, one orthopaedic technician,and five nurses. The team was under the supervisionof a senior orthopaedic and traumatology specialist(MB). Turkish Red Crescent Technical Team providedthe service departments for energy, food, commu-nication, transport and other necessities. The cen-tre contained a triage tent, dressing and patientexamination tent, outpatient tent, orthopaedicintervention and plastering tent, laboratory tent,roentgen tent, pharmacy tent, and sterilisation tentas well as two operation tents where two operationscould be performed simultaneously and treatmentand follow-up tent of 50-patient capacity. Thepatients arrived at the hospital themselves or byair or land transportation provided by the localgovernment. Communication with the patientswas facilitated by eight interpreters working inshifts and translating from Urdu to English. Thepatients received at the triage were referred tothe outpatient clinics depending on the case andfurther consultations were conducted at theseclinics. The patients that required surgical inter-vention were operated under emergency operativeconditions. The patients requiring follow-up byinternal medicine as well as the preoperative andpost-operative patients were treated. In the in-patient unit, different teams performed the dres-sings of outpatient and inpatient cases. In a 12-dayperiod, a three-person health care team visited thenearby villages twice for help and care in collabora-tion with the Turkish Red Crescent team. In theTurkish Red Crescent Field Hospital established inMuzafferabad between 20 and 31 October 2005, atotal of 2892 patients were treated and followed up.All the patients were evaluated prospectively. Theprofiles of the patients transferred, operated, orfollowed up within this period were documented.Furthermore, the patients who applied with post-traumatic musculoskeletal trauma were also docu-mented.

Results

The second health care team that started to serve12 days after the earthquake completed the treat-ment and follow-up of 2892 patients within a 12-dayperiod. The gender distribution of the patients was1522 male and 1370 female. The patients wereclassified based on their systemic disorders as fol-lows: musculoskeletal system injury (n = 1075),respiratory tract disorders (n = 438), cardiologicaldisorders (n = 110), gastro-enterological disorders(n = 328), urinary tract disorders (n = 207), soft tis-sue infections (n = 276), dermatological problems(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 4Tibia 2 9 3 Sacral 1Ankle 2Metatars 1Humerus 2Forearm 1Radius distal 3Metacarp 2

Detailed documentation of the patients withmusculoskeletal injuries has been provided inTable 1. The diagnosis, the surgery method andoperative materials used, and operation time of43 patients have been presented in Table 2.

Of 1075 patients seen in the orthopaedic out-patient clinic, 543 were female and 632 were male.The age distribution of the patients were as follows:363, under 15 years of age (33.76%); 225, betweenthe ages of 15 and 30 years (20.93%); 418, betweenthe ages of 30 and 60 years (38.88%); 69, over 60years of age (6.41%). Trauma patients suffered from

Figure 1 (a—c) Different types of open fracture fixation attclay, a common belief for treatment of these kind of wounds

open fractures (n = 63, 5.86%) or injuries. Twenty-five of these patients (2.32%) suffered from infec-tions.

Our centre was the first point of application for 59(5.48%) of the patients with femoral fractures, 87(8.09%) of the patients with fractures of the tibia, 38(3.53%) of the patients with humeral fractures, and20 (1.86%) of the patients with forearm fractures.None of these patients had received any previous. Ofthese patients, 13.58% were treated by health careproviders who were not physicians. Four patientswith open fractures had wide soft tissue infection

empted by the use of a hard substance containing mud orby 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 17Intertrochanteric 5Subtrochanteric 9 Subtrochanteric 4Femur shaft 24 Femur shaft 11Supracondylar 4 Supracondylar 2

Tibia fracture 45 Tibia malunion 20Proximal 7 Proximal 2Medial plateau 4Middle 34 Middle 11Distal 22 Distal 7

Foot and ankle fracture 34 Foot and ankle malunion 11Bimalleolar 10 Bimalleolar 5Lateral malleolus 13 Lateral malleolus 4Calcaneus 3Metatars 5 Metatars 1Phalanx 3 Phalanx 1

Vertebra fracture 41

Lumbar 35L1 16L2 13L3 6

Thoracic 5T12 4T11 1

Cervical 1C4 1

Clavicular fracture 10Proximal 1Orta 7Distal 2

Humerus fracture 26 Humerus malunion 12Proximal 8 3Humerus shaft 14 8Supracondylar 4 1

Forearm fracture 20Proximal 3Middle 11Distal 6

Hand and wrist fracture 45Radius distal 23Scaphoid 7Metacarp 7Phalanx 8

due to fixation attempted by the use of hard sub-stances containing mud or clay, a common belief fortreatment of this kind of wound by the people of thearea (Fig. 1a—c). Two of these cases had to beamputated below the knee, and one was amputated

above the knee. One case, however, received widedebridement and external fixation and was trans-ferred to Islamabad for further reconstruction.Details of treatment modalities are presented inTable 3.

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Table 3 Treatment modalities of the fractures

Fracture Conservative treatment (n) Surgical treatment (n) Transfer to another centre (n) Total (n)

Pelvis 35 10 45Femur 36 13 10 59Tibia 63 14 10 87Ankle-foot 42 3 45Vertebra 41 41Clavicula 10 10Humerus 36 2 38Forearm 19 1 20Hand-wrist 40 5 45

Unusual and earthquake-specific injury typeswere also noted. Four cases applied with drop handwithout significant bone or soft tissue lesion (Fig. 2aand b). Another common lesion type specific forearthquake was injuries to the scalp with severedefects due to collapsing roofs. Eleven childrenpresented to the outpatient clinic with open woundsin the scalp (Fig. 3a and b).

In the time period described (second group), twoinfant (18 months of age and 26 months of age)deaths occurred due to pneumonia and septicshock.

Figure 2 (a and b) Drop hand without significant bone orsoft tissue lesion.

Figure 3 (a and b) Severe scalp defects due to collapsingroofs.

Evaluation of trauma patients in the 2005 Pakistan earthquake 295

Discussion

Medical necessities in an earthquake zone aredynamic and change rapidly. Field hospitals mustbe prepared for requested changes to their mode ofactivity and for extreme conditions. Dayan et al.3

reported that in the first few days, the medicalteams concentrated on treating injuries causeddirectly by the earthquake. Surgical and orthopae-dic staff as well as obstetrics and gynaecology arethe main medical disciplines needed at thisstage.3—5,7,8,12,13,15 In the later stages, a normaldistribution of disease is encountered and a mix-ture of medical specialties must provide for theregular medical needs of the people living in theearthquake zone. Infectious diseases such as gas-tro-intestinal and respiratory infections should beanticipated as well as exacerbation of chronic ill-ness because of the lack of appropriate medicalsupplies.1—4,9

The hospital was set up 6 days after the earth-quake on 14 October 2005 by the Turkish Crescent.The observations of the second group working in thearea after the earthquake have been presented. Inthe Turkish Crescent Field Hospital established atthe official invitation of the Pakistani government aspart of the common humanitarian efforts betweenthe two countries, a work program of a minimum 1-year duration has been planned. Throughout thisperiod, health teams from the entire Turkish healthcare team arrived at the area for 2—3-week periodsand provided health care services.

One the harsh environmental conditions, to themotivational level of the teams tended to diminishafter a certain period; thus, interchanging shortperiods (2—3 weeks) of work among the teamsseemed to present better service. The Pakistanigovernment facilitated the work of all the teamsarriving from different countries; for example,many of our colleagues who arrived in the first teamwithout a visa were issued one on their arrival at theairport. Turkish Military planes provided the trans-portation of the teams to the region. Therefore, thefirst teams arriving at the region conducted logisticinvestigations to set up the hospital at locationswhere it would be safe in the aftershocks, andmedical supplies, equipment, and infrastructureneeded were transported. All the personnel andequipment were transferred from Turkey. The Turk-ish Crescent team that served in the region had alsoworked in the relief efforts for tsunami victims andearthquakes in Turkey, so, they were highly experi-enced. A generator was available in case of powerfailure, and was put in use by the technical team.The water system was reinforced by additionalwater tanks that were regularly chlorinated. The

tent kitchens set up in the hospital and the cooksmet the food needs of the health care workers andtechnical team at the hospital. Bottled drinkingwater was available. Because the hospital existedfor a long time, when the team was replaced thetreatment of the patients was not affected or inter-rupted. No ethical problems were encounteredbetween the patients’ relatives and the hospitalteam.

Despite all the precautions, some medical sup-plies were damaged during transportation, andsome supplies were missing; however, the TurkishCrescent Team located in Islamabad, closest to ourfield hospital, supplied most of the missing items.Some other equipment (wheel chairs, stretchers,etc.) was transported by military cargo planesarriving from Turkey. Still other materials neededwere supplied from among the remaining medicalsupplies after the hospital in Muzafferabad, whichhad become uninhabitable due to the earthquake,was evacuated, while others were provided,upon their visit to our hospital, by the represen-tatives of NGOs in areas like Karachi with highersocio-cultural level where earthquake was notfelt.

Pakistani military forces provided the security ofthe hospital. Volunteer health care personnel andmilitary doctors were assigned who could speakEnglish and Urdu. They translated for patients’relatives, patients, and the health care team.

In the first 2 weeks after the earthquake in Paki-stan, a significant number of patients presentedwith musculoskeletal injury and infection. The lackof a plastic and reconstructive surgery specialist inthe team was unfortunate. However, the same pro-blem was reported for the largest local hospital inMuzafferabad as well as for American, French, andCanadian centres. The third team arriving fromTurkey included a plastic and reconstructive sur-geon.

In delayed and malunion cases, correction wasachieved by stabilising with unilateral external fixa-tors. For easy application, self-drilling and self-tapping Schanz screws were preferred. Schanzscrews were fixed to each other by radiolucentcarbon rods. Under X-Ray control, the interventionsneeded were performed and rigid fixation wasachieved. In open fractures with soft tissue defectsin particular, repeated debridement and dressingswere performed to encourage granulation tissueformation. The patients who could wait were trea-ted by two plastic surgeons, who would arrive in thefollowing team, by grafting and flaps. However,those who required urgent intervention or couldnot wait were transferred to Islamabad by militaryhelicopters.

296 M. Bozkurt et al.

Another important responsibility of logistic teamsarriving after an earthquake is the determination ofhygienic and traditional habits of the people in thearea that may constitute health risks, and takeprecautions as well as inform the people of thehealth hazards. The methods used by non-medicalindividuals in Kashmir to treat open wounds withvarious substances significantly increased the risk ofamputation.

The majority of the patients were admitted withfractures or injuries associated with the traumareceived during the earthquake.3,4,7—10,12—15

Following the initial shock of an earthquake,patients usually gain access to field hospitals moreeasily after the secondweek. Thus, closed reductionand surgical treatment of these fractures may beconsidered. External fixators that are easilyapplied, cannulated screws and screw sets werethe most useful orthopaedic implants. In a periodsuch as the one described, a field hospital shouldhave specialists in orthopaedic and traumatology,plastic and reconstructive surgery, infectious dis-eases, general surgery, anaesthesia, paediatrics,internal medicine, and obstetrics and gynaecologyas well as orthopaedic, anaesthetic, radiology, andlaboratory technicians and nurses. Furthermore,the presence of an interpreter is highly neededfor patient—medical staff communication.

Although a team of military physicians may beconsidered more appropriate because of their train-ing for difficult conditions in field hospitals, civilianmedical teams that are trained to work in coordina-tion with Red Crescent or Red Cross organisationswill provide better organisation of search and recov-ery efforts and medical services from a particularcentre.

Field hospitals should keep the socio-culturallevel of the area it serves in mind. For example,the religious and traditional values of Pakistanipeople oppose examination of pregnant women bymale gynaecologist; thus, in the next team arriving,there was a female gynaecologist and a femalemidwife.

The experience we present could be a guide forthe period after search and recovery. In such dis-asters, experienced and organised teams will assuresmooth operation of medical services.

Finally, our recommendations are: (1) if possi-ble, a pioneer team should conduct a thoroughevaluation of socio-cultural and economic condi-tions of the disaster area, which would aid inproper planning and preparation; (2) the teammembers should be informed as to the food,drinking, shelter, bathroom facilities, and weatherconditions before their arrival in the area, andprecautions must be taken to ensure such services

(generator, water tank, tent, sleeping bag, bread,water, chlorine, etc.); (3) the compatibility of theteam members, if possible, a pre-training sessionunder simulated conditions of a challenging envir-onment in specially designed camps, and determi-nation of team leaders ahead of time and enablingtheir communication with the technical team lea-ders are of great importance; (4) the transporta-tion of medical equipment (sterilisation unit,operation rooms, radiology units, etc.) shouldbe realised by the use of containers, and self-sufficient infrastructure (generator, etc.) mustbe available and regularly maintained.

Acknowledgments

Wewould like to extend our deepest thanks to Dr. AliCoskun, Dr. Ahmet Karadag, Dr. Hanifi Kurtaran, Dr.Mehmet Kanbay, Dr. Cemal Bulut, Dr. Ikbal Cekmen,Dr. Dogan Barbaros, Dr. Ahmet Yonder, Dr. MuhsinBoga, Dr. Basri Cidan, Dr. M. Yasar Yilmaz, EmineSeyhun, Pelin Gundag, Dilek Bozer, Yasemin Kaya,Senol Sahin, Mehmet Sever, Hakan Gungor for theirgreat work in Turkish Red Crescent Field Hospital.We would also like to thank Turkish Red CrescentPakistan Earthquake Team for their great contribu-tion. We are grateful to the nurses, translators fromPakistan and Pakistan army and government whoinspired the teamwork between Turkish and Paki-stan medical staff.

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