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Somalia: surgeons save lives far from home

30-12-2008 Interview

Mohammed and Amin are surgeons. For 14 months, they left their well-equipped hospital back home to work at Keysaney and Medina Hospitals in Mogadishu. During a brief stop in Geneva on the way home, they took time out to talk about surgery, Somalia … and football.

 Who were your patients?  

Three fifths had been wounded in the fighting. The remainder had been in traffic accidents or needed medical and elective surgery – skin grafts, for instance.

One factor affecting the types of patient we saw was travel. For instance, a broken leg is normally a simple thing to fix. But if someone’s had to walk for a week to reach help, you may well have to amputate.

 What types of operation did you carry out?  

In the 14 months we were in Somalia, we carried out 1,000 operations. Often, they involved wound debridement, which means cutting away dead and damaged tissue from around a wound so it can heal. Blast injuries often required us to remove a lot of tissue, which is one difference between war wounds and other types of injuries.

Another frequent operation was intubation, inserting a tube in the patient’s chest to let blood drain out. A simple job, but it saves lives. And then there were the laparotomies. That’s when you open up the patient’s abdomen to see what’s wrong and fix it. We did 100 of those.

We had to perform many amputations. Not just on casualties of the fighting, but also on medical patients. These included about 35 diabetes patients, which is tragic, because we could often have saved the limb if we had been able to treat them earlier.

Arms and legs accounted for the majority of injuries, followed by abdomen, head and chest.

And even though neither of us is an obstetrician, we had to carry out about 75 caesareans and other obstetrics-related operations, because all the usual hospitals were closed.

 What challenges did you encounter in dealing with your patients?  

It can be difficult to persuade people to undergo surgery. They prefer traditional medicine. When amputation is recommended they may postpone a decision, asking a more senior member of their clan for an opinion. We sometimes invited these senior figures to the hospital and involved a Somali doctor, to smooth the decision-making process.

We had diabetes patients preferring to die sooner than lose a leg. And caesareans required a signature from the woman’s husband, father or brother.

Other problems stemmed from a lack of information. A week after one operation we noticed that the patient was getting worryingly thin. Turned out he hadn’t eaten since the operation – he thought eating would damage the stitches!

 Did you have any particularly difficult days?  

We did once have to handle 25 patients simultaneously following armed clashes. Five had chest wounds and required intubations to survive. Three needed laparotomies, each of which took two hours. And one had to have a limb amputated, otherwise he would have bled to death.

As soon as we heard that fighting had broken out we started preparing. One surgeon handled triage and intubations, while the other stayed in the operating theatre.

All we could do was start with the most urgent case and work down the list. We began at 4 p.m. and finished at midnight. And that was after a morning’s ‘normal’ work. But you forget how long you’ve been working when you’re in the middle of it!

 What problems did you face in the hospitals in Mogadishu?  

Too few doctors and nurses. Initially there were five doctors, all general surgeons. One has now gone, leaving four, of whom one is 75 and another over 60. So succession planning is an issue. And there were no junior surgeons to provide support.

But a private medical university in Somalia is now training medical doctors for emergency and war surgery. A number were seconded to our hospital for training and to give support. This relieved some of the pressure, and meant that a new generation of surgeons was being trained.

There are only three anaesthetic nurses and no consultant anaesthetist. In total, there are just six theatre staff, and they have to cover day and night shifts, so there are never six on duty.

One nurse aged 70 does most of the plaster of Paris work. He’s highly professional. If anything happens to him there’ll be a huge problem, so we need to train a successor.

The Somali nurses are overworked, but they’re doing an incredible job; highly skilled and very professional and dedicated. They diagnose patients and alert doctors to problems, saving lives. And they have good memories; they recognized the operation scars left by different surgeons and could tell us ‘Dr so-and-so did that op.’ Still, they are having to look after wives and children in the midst of a food crisis and an armed conflict, and they only get one day off a week.

 What was the equipment like?  

Life-saving equipment was already OK when we arrived, but we recommended two items: a diathermy device to seal minor bleeding and a foetal sonic aid to listen to the heartbeat of unborn babies. Both items were purchased by the Qatar Red Crescent Society and flown in from Geneva.

The external fixator for stabilizing fractures was getting old, so the ICRC sent out a fixator from Geneva to replace it. Same with the skin graft knife. So we were pleased with the standard of equipment and the way ICRC headquarters responded to our requests for updated kit.

 How would you compare working in Somalia and working back home?  

We’d been used to a well-equipped teaching hospital, so working in Somalia was quite an eye-opener. On the one hand, we didn’t get as many patients at a time in Somalia, and the percentage of really serious cases was smaller. On the other hand, we didn’t have all the facilities or specialists we would have had back home.

For surgeons to run an out-patient clinic is unusual. But when there are so few doctors, everyone has to do everything. We held a clinic two days per week. Outpatient sessions went on forever, but these people started waiting at 5 a.m. and we just couldn’t turn them away.

We learned how to ask basic questions in Somali, which was a hit with the patients and brought us closer to them. Closeness was important, because many whom we couldn’t help medically came just for reassurance. Talking really does help!

 How was life in Somalia?  

Internet was important, as it enabled us to keep in touch with our families back home. The food was good and we got too little exercise, so we gained weight. But we did play football with the relatives, watched by the patients, who gave enthusiastic, highly partisan support. That helped establish contact with the community.

Surprisingly, considering the situation in Somalia, we encountered no security problems. We felt safe in the hospitals. But there was no life in Mogadishu. Everything has been destroyed and everyone was unemployed. And violence increased while we were there.

Culture differences kept us on our toes. For instance, you ask a Somali patient whether he’s in pain and he gives a sort of backwards nod and makes a tutting sound. In the Arabic-speaking world that means ‘no,’ whereas in Somalia it means ‘yes.’ But some things are international. Football is important, and people over there support Italy.

 How did you get on with the Somali surgeons?  

It took time for the Somali doctors to trust us. They wanted to see how we would deal with the lack of facilities, and we were younger than them, so they were afraid we might be using them for training. But they were interested by our methods and they soon realized that we did have experience and that this was an opportunity for sharing, in both directions. The Somali doctors at Keysaney were highly experienced in war surgery, and we were soon cooperating closely with them.

In fact, they made us very welcome. When we left, they gave us a wind-up radio, because they knew power cuts were common in our country!

How do you see the future of the ICRC-supported hospitals in Mogadishu?

We’re worried. Just before we flew out, Somali colleagues called at 7.30 a.m. saying ‘we need you’. There is a real need for expatriate support.

 And if you had to sum up your experience in one sentence?  

This was our first mission for the Red Cross and Red Crescent Movement, but it won’t be our last.

 Background  

Keysaney and Medina have treated over 2,500 war casualties since January 2008. Since August 2007, an ICRC-backed team of surgeons from the Qatar Red Crescent Society – including Mohammed and Amin – has been working at Keysaney Hospital, which is managed by the Somali Red Crescent.