In the line of fire
Conflict zones provide a unique challenge for those providing emergency medical services and repatriation to people working or living in such areas. Paul J. Brinkworth, RMSI operations co-ordinator, spoke to ITIJ about the everyday issues he faces when working in warzones or areas of political instability
First published in ITIJ 118, November 2010
Conflict zones provide a unique challenge for those providing emergency medical services and repatriation to people working or living in such areas. Paul J. Brinkworth, RMSI operations co-ordinator, spoke to ITIJ about the everyday issues he faces when working in warzones or areas of political instability
The term ‘conflict zone’ refers to an area where war or political instability is causing disruption to the essential infrastructure and services required by the community, such as government, social services, transportation, communication, sanitation, electricity, water, housing and healthcare; thereby requiring assistance from international organisations and people from outside of the affected community. The more remote the community or the area, or the more diminished the infrastructure, the more essential these outside services become.
Within the normal emergency medical system framework, continuity and definitive care is commenced immediately at the incident scene and continued through hospital emergency departments, intensive care units, specialty departments and rehabilitation, thus allowing patients to successfully re-enter the community. In contrast, conflict zones present the health service provider with many challenges in maintaining the provision and optimum standard of emergency stabilisation and onward medical evacuation services for expatriate personnel operating within these environments, all within unique conditions and within the limitations of the available resources.
Precious resources
To enable the provision of emergency health services and rapid response medical evacuation capabilities within a conflict zone, the company must have the resources and the clinicians operating on the ground within that environment. This itself provides many challenges, including: logistics for plant, equipment and consumables, security against insurgent attacks, ensuring the security of all patients receiving treatment and care, suitable accommodation, clinics and essential services including electricity, water, food and communication.
Some military hospitals on occasions only admit a patient for emergency stabilisation, for periods of up to 12 or a maximum of 24 hours
Aside from overcoming the obvious communication difficulties experienced with patients in remote locations due to unreliable or nonexistent telecommunication infrastructure, incompatibilities between the military and civilian communication networks, continual dampening of mobile phone coverage areas to prevent bomb detonations, verbal language barriers with both physicians from international military forces and local hospital facilities must be overcome. The majority of local hospitals do not have access to Internet or email services and produce medical reports and documentation using the local dialect, resulting in delays with updating assistance companies while waiting for translations to be completed.
Communication and updates to international assistance companies may also be disrupted for short periods, due to the limitations of or interruptions to communications infrastructure. On occasion, world time zones can cause delays with receiving ‘authorities to proceed’ on cases, resulting in missed opportunities to retrieve and or commence evacuations of patients out of theatre within initial timeframes.
Within major cities, road networks are inadequately maintained or severely damaged through detonations of improvised explosive devices (IED), over usage or they have incomplete surfacing and unfinished construction, which has resulted in quicker-than-normal deterioration, making it uncomfortable for patients and significantly more difficult to transfer spinal and other acute cases. Roads in remote locations are mainly unsealed, damaged by erosion and generally unable to be navigated by vehicles. Travelling out of a city or on remote road networks represents a continual threat of attack and ambush by insurgents or criminal elements, and risks injury to clinicians, patients and patient escorts from IED detonations.
Air care
Travel via air is not without its inherent challenges and dangers either. Airstrips located outside international airports and large military bases are unprotected against attack, and the majority are constructed from dirt, inconsistent in length and width, difficult to maintain and sparsely located. Uncontrolled airspace with no ground aviation radar coverage, instrument landing systems (ILS) to assist air ambulances on approach and landings or landing strip lighting exists within these locations. Therefore, flights into these areas are only achievable within daylight hours, which are greatly reduced during the winter months. Operators have to be aware that military fly-around zones, sudden closures of military airspace without warning and onset of military versus insurgent conflicts within the area, can all delay an aircraft from reaching the patient. Widespread laying and distribution of landmines, combined with areas littered with unexploded ordinance from previous and current conflicts, increases the risk of safely landing rotary aircraft in areas inaccessible by fixed-wing airframes and ground ambulances.
Within these environments, destabilised governments, changes in interim authorities, regional commanders and sudden changes in policies and procedures may have substantial impact on service delivery
Geography and harsh terrain, combined with extreme weather conditions, provide further challenges with movement by air. Air strips within desert regions at times suddenly close due to large dust storms lasting for days. Mountainous regions during winter months experience the worst weather imaginable – from snow dumps to blizzards, which temporally ground aircraft, thereby only providing narrow windows of opportunity to retrieve patients. Unforeseen, rapid closing in of weather fronts can at times prevent aircraft from returning, stranding clinical crews within harsh and dangerous areas, managing the patient until conditions clear.
Healthcare
Apart from the odd individual exception, local hospitals are poorly funded, overcrowded and under resourced, with little modern specialised diagnostic technology. They tend to be reliant upon support from aid organisations and non-government organisations, to assist with the supply of medications and equipment. Building disrepair and breakdowns in essential services, including electricity and water, greatly impact on the quality of deliverable patient care. Family and relatives attend to nursing duties of admitted patients, and presently no system exists for ongoing education or implementation of current best medical practice with local doctors in these environments. Within some regions, and particularly within the conflict areas of the Middle East, there are no hospital facilities for patients suffering from burns trauma or psychological conditions.
Increasingly greater numbers of individual civilian expatriates presenting to international military hospitals are being denied treatment and admission, as their primary role is for the provision of healthcare to military service personnel. Some military hospitals on occasions only admit a patient for emergency stabilisation, for periods of up to 12 or a maximum of 24 hours.
Within these environments, destabilised governments, changes in interim authorities, regional commanders and sudden changes in policies and procedures may have a substantial impact on service delivery. There is usually no warning or publication with procedural changes, as they are disseminated to the local authorities via word of mouth and, in some cases, interpreted incorrectly or adjusted to an individual’s benefit, prior to implementation. These constant changes and misinterpretations open up the opportunity for widespread corruption among individuals in positions of power and within local authorities and departments. Instead of working towards a greater good and benefit for all, the current cultural trend is to live for the now, personal gain and wanting power, and this, in combination with poor structure and reporting capabilities within local authorities, allows individuals to instantly change procedures and cause extensive delays in an attempt to extract bribes.
Some religions and indigenous belief systems prevent medical treatment of local female patients by male clinicians, unless permission is obtained from a senior family member or husband. Particularly within remote areas, religious leaders are the main source of guidance and education to members of the local community, and therefore, have substantial influence regarding the local acceptance of humanitarian medical assistance from international organisations operating within their locations.
Some religions and indigenous belief systems prevent medical treatment of local female patients by male clinicians
In reality, medical service providers face many challenges when operating within conflict zones and the remote isolated areas of these nations. Challenges never remain stagnant within these environments as dynamics are continually shifting, changing and evolving as the levels of conflict either increase and or decrease. Over time, once hostilities cease, governments stabilise and the essential infrastructure and services are rebuilt, other challenges will replace the ones that currently exist.