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Fledgling Afghan army hospital improving daily but pace seen as 'glacial'
Canadian Press 2 days ago (31 October 2008)
KANDAHAR, Afghanistan — Two months to the day after the Kandahar Regional Army Hospital opened its doors to little fanfare, 48 battered and bloody Afghans were taken to the facility within a matter of 90 minutes in desperate need of urgent care.
It was Feb. 18 and a suicide bombing at an outdoor dog-fighting competition in Kandahar City had just killed 80 people and left scores more with horrifying injuries.
It had been dubbed the deadliest insurgent attack since the Taliban's ouster in 2001.
It was also the day the understaffed, ill-equipped, poorly-trained military hospital serving all of volatile southern Afghanistan wet its feet and proved itself a valuable asset to the country's fledgling health care system that still relies heavily on the medical staff and facilities of its international partners.
"It was a big incident and people were impressed. We did a great job," said Col. Abdul Baseer, who runs the 205 Corps hospital at Camp Hero, the Afghan National Army base next door to Kandahar Airfield where most of Canada's 2,500 troops are based.
The event set in motion a tripartite continuum of care that's becoming more efficient every day against all odds, despite a plethora of problems.
Mirwais Hospital, a civilian institution in Kandahar City with 425 beds, takes the bulk of non-military patients. But Afghan soldiers, police and civilians with injuries beyond the capabilities of Mirwais are increasingly sent to the Afghan army hospital.
Those with penetrating head and neck injuries and vascular problems are in turn sent to the Role 3 multinational hospital at Kandahar Airfield, as Camp Hero does not have a CAT-scan or proper intensive care facilities.
This new system is helping relieve pressure on Role 3, which faced a record number of admissions over the summer, the bulk of them Afghans.
"Essentially, we're sharing care here which allows us to maintain responsiveness and to deal with the record number we saw this summer," said Maj. William Patton, the Canadian Forces physician in charge of Role 3 during the fifth rotation of troops in Afghanistan.
"As we build up their capacity, they're able to handle more for us."
His staff regularly helped mentor their Afghan army counterparts both at Role 3 and Camp Hero, and they were always on hand to lend supplies.
"They've got a long way to go but they've come a long way in the eight months since we got here," said U.S. Air Force Lt.-Col. Edward Fieg, a physician mentor whose 15-member team is helping teach the Afghans how to run their hospital.
"When we got here they could do almost nothing. Now they're seeing traumas and operating. It's not without problems and limitations, especially on personnel and supply, but it's functional. It works."
Between January and September 2008, the hospital treated 12,204 outpatients, admitted 622 inpatients, juggled 19 mass casualty events, performed 142 trauma resuscitations, handled 504 elective surgeries, 188 emergency trauma surgeries and transferred 84 patients to Role 3.
The Afghan army has also conducted 45 Medevac helicopter operations and 311 Casevac missions - which involve transferring non-emergency patients via fixed-wing aircraft for ongoing care.
Technology and expertise aside, the US$10 million U.S.-built Afghan army hospital looks far more impressive than the cluster of tents and wood structures that is Role 3.
It's bright and spacious, and looks like any North American hospital. They have X-ray machines, an ultrasound, a lab, a $250,000 fluoroscopy machine and a high-tech water purification system.
That said, the Afghan army hospital often run out of bandages, medications and blood as Afghan soldiers are reluctant to donate despite attempts to pay them for it. The hospital also lacks other modern equipment.
There is a pharmacist and physiotherapist, a dental clinic and eye clinic.
As there are no female Afghan doctors or nurses at the army hospital, a group of female mentors run a clinic every Wednesday morning for the wives and children of the soldiers who live on base.
But the mentoring process is not without challenges. Finding doctors to practise in the dangerous region is one of the biggest.
The facility currently has three physicians, two of whom are fresh out of medical school. The senior doctor is an ear, nose and throat specialist with limited skills and a private practice in the city that takes him out of the remote hospital as many as three days a week, Fieg said.
The bulk of the 40-person staff take a day off on Fridays, the Islamic holy day, and generally only work until about 3 p.m.
To augment their capabilities, the government sends them a two-man trauma team each month comprised of a general surgeon and orthopedist. They come reluctantly, Fieg said, and often arrive late and leave before their month-long stint is up.
But he can hardly blame them.
Dr. Mohamed Hanif Niazai said the job is not one for which he volunteered. He has to leave his family in Kabul and shut down his private practice while he's in Kandahar. He's paid 20,000 afghanis or $400 to come to Camp Hero. He makes up to $1,600 a month back home.
Physician translators - Afghan doctors hired by U.S. contractors to interpret for coalition medical staff - can make twice as much as practising physicians in Kandahar.
"It's a good hospital," Niazai said. "I would suggest this hospital pay better wages. If they could pay doctors, people will come here."
Despite the lack of modern equipment, Fieg said the university educated doctors are skilled in surgical amputations, washing wounds, going after bullets and fixing fractures.
But they're also very proud and set in their ways. Fieg said that could be frustrating as a mentor who must lead from behind and make recommendations instead of orders.
They're inclined to give antibiotics for a head injury or withhold morphine to someone in pain for fear of causing addiction, he said.
He's seen them mistaken a pulmonary embolism for hypoglycemia, treat wounds with isopropyl alcohol and give anesthesia to a patient in shock.
"They say the hardest thing in the world is to know how to do a thing well and watch somebody else do it not so well and not say anything," he said.
As for the nurses, they have an even longer way to go.
"You can invest a lot of time and energy into saving a wound but if a wound is not kept clean and the patient is not given analgesia and medication, all is for not," Patton said. "Afghanistan is waiting for a Florence Nightingale to transform the profession of nursing."
Enter U.S. Air Force Lt.-Col. Susan Bassett.
The grandmother and chief nurse, who's affectionately known as "Mama" among her Afghan proteges, said Afghanistan is practising 1940s-style "functional nursing."
It's task oriented. One nurse is in charge of dispensing medication, another does the cleaning while yet another transports patients to X-ray or the lab.
"Curiously, they are very dedicated to doing their function and absolutely do not step out of their lane into anybody else's function whatsoever," she said.
There's also very little pride in being a nurse.
Asmadine the charge nurse laughed when asked why he entered the profession. He said wanted to be a doctor but couldn't hack it in school.
Bassett said nurses receive nine months of schooling when they learn how to put in an IV, a catheter and nasal gastric tube, though they never practise on patients.
They're not taught a thing about anatomy or physiology and don't know why they're doing what they do, Bassett said. That could put patients at risk.
"They know to turn off a button but they don't know if a patient's lung resistance goes up, how to adjust the ventilator 'cause they don't understand that that's going into a patient's lungs," she said.
Bassett is creating a series of 40 classes to establish a baseline level of knowledge. Each 15-minute module will address things like temperature, heart rate, turning patients and medications.
"They don't know it but it sets a standard," she said, adding each nurse will get a badge for their uniform once they've completed the program.
"Once I've told them when a pulse is slow you do this, I'm going to hold them to that."
Already she is making progress.
They're now ordering and distributing medications in a more organized fashion that incorporates the expertise of the pharmacist. They are checking vital signs more regularly and they are finally starting to chart the medications and care they deliver.
They still, however, lack bedside manner and actually prefer not to engage patients - something Bassett attributed to their "help yourself culture."
Patton thinks the hospital could one day be on par with its regional counterparts in Pakistan and Iran.
"I can see that occurring over the course of a decade or so but again, that's so much reliant on stability, good governance (and) justice," he said.
Canadian Press 2 days ago (31 October 2008)
KANDAHAR, Afghanistan — Two months to the day after the Kandahar Regional Army Hospital opened its doors to little fanfare, 48 battered and bloody Afghans were taken to the facility within a matter of 90 minutes in desperate need of urgent care.
It was Feb. 18 and a suicide bombing at an outdoor dog-fighting competition in Kandahar City had just killed 80 people and left scores more with horrifying injuries.
It had been dubbed the deadliest insurgent attack since the Taliban's ouster in 2001.
It was also the day the understaffed, ill-equipped, poorly-trained military hospital serving all of volatile southern Afghanistan wet its feet and proved itself a valuable asset to the country's fledgling health care system that still relies heavily on the medical staff and facilities of its international partners.
"It was a big incident and people were impressed. We did a great job," said Col. Abdul Baseer, who runs the 205 Corps hospital at Camp Hero, the Afghan National Army base next door to Kandahar Airfield where most of Canada's 2,500 troops are based.
The event set in motion a tripartite continuum of care that's becoming more efficient every day against all odds, despite a plethora of problems.
Mirwais Hospital, a civilian institution in Kandahar City with 425 beds, takes the bulk of non-military patients. But Afghan soldiers, police and civilians with injuries beyond the capabilities of Mirwais are increasingly sent to the Afghan army hospital.
Those with penetrating head and neck injuries and vascular problems are in turn sent to the Role 3 multinational hospital at Kandahar Airfield, as Camp Hero does not have a CAT-scan or proper intensive care facilities.
This new system is helping relieve pressure on Role 3, which faced a record number of admissions over the summer, the bulk of them Afghans.
"Essentially, we're sharing care here which allows us to maintain responsiveness and to deal with the record number we saw this summer," said Maj. William Patton, the Canadian Forces physician in charge of Role 3 during the fifth rotation of troops in Afghanistan.
"As we build up their capacity, they're able to handle more for us."
His staff regularly helped mentor their Afghan army counterparts both at Role 3 and Camp Hero, and they were always on hand to lend supplies.
"They've got a long way to go but they've come a long way in the eight months since we got here," said U.S. Air Force Lt.-Col. Edward Fieg, a physician mentor whose 15-member team is helping teach the Afghans how to run their hospital.
"When we got here they could do almost nothing. Now they're seeing traumas and operating. It's not without problems and limitations, especially on personnel and supply, but it's functional. It works."
Between January and September 2008, the hospital treated 12,204 outpatients, admitted 622 inpatients, juggled 19 mass casualty events, performed 142 trauma resuscitations, handled 504 elective surgeries, 188 emergency trauma surgeries and transferred 84 patients to Role 3.
The Afghan army has also conducted 45 Medevac helicopter operations and 311 Casevac missions - which involve transferring non-emergency patients via fixed-wing aircraft for ongoing care.
Technology and expertise aside, the US$10 million U.S.-built Afghan army hospital looks far more impressive than the cluster of tents and wood structures that is Role 3.
It's bright and spacious, and looks like any North American hospital. They have X-ray machines, an ultrasound, a lab, a $250,000 fluoroscopy machine and a high-tech water purification system.
That said, the Afghan army hospital often run out of bandages, medications and blood as Afghan soldiers are reluctant to donate despite attempts to pay them for it. The hospital also lacks other modern equipment.
There is a pharmacist and physiotherapist, a dental clinic and eye clinic.
As there are no female Afghan doctors or nurses at the army hospital, a group of female mentors run a clinic every Wednesday morning for the wives and children of the soldiers who live on base.
But the mentoring process is not without challenges. Finding doctors to practise in the dangerous region is one of the biggest.
The facility currently has three physicians, two of whom are fresh out of medical school. The senior doctor is an ear, nose and throat specialist with limited skills and a private practice in the city that takes him out of the remote hospital as many as three days a week, Fieg said.
The bulk of the 40-person staff take a day off on Fridays, the Islamic holy day, and generally only work until about 3 p.m.
To augment their capabilities, the government sends them a two-man trauma team each month comprised of a general surgeon and orthopedist. They come reluctantly, Fieg said, and often arrive late and leave before their month-long stint is up.
But he can hardly blame them.
Dr. Mohamed Hanif Niazai said the job is not one for which he volunteered. He has to leave his family in Kabul and shut down his private practice while he's in Kandahar. He's paid 20,000 afghanis or $400 to come to Camp Hero. He makes up to $1,600 a month back home.
Physician translators - Afghan doctors hired by U.S. contractors to interpret for coalition medical staff - can make twice as much as practising physicians in Kandahar.
"It's a good hospital," Niazai said. "I would suggest this hospital pay better wages. If they could pay doctors, people will come here."
Despite the lack of modern equipment, Fieg said the university educated doctors are skilled in surgical amputations, washing wounds, going after bullets and fixing fractures.
But they're also very proud and set in their ways. Fieg said that could be frustrating as a mentor who must lead from behind and make recommendations instead of orders.
They're inclined to give antibiotics for a head injury or withhold morphine to someone in pain for fear of causing addiction, he said.
He's seen them mistaken a pulmonary embolism for hypoglycemia, treat wounds with isopropyl alcohol and give anesthesia to a patient in shock.
"They say the hardest thing in the world is to know how to do a thing well and watch somebody else do it not so well and not say anything," he said.
As for the nurses, they have an even longer way to go.
"You can invest a lot of time and energy into saving a wound but if a wound is not kept clean and the patient is not given analgesia and medication, all is for not," Patton said. "Afghanistan is waiting for a Florence Nightingale to transform the profession of nursing."
Enter U.S. Air Force Lt.-Col. Susan Bassett.
The grandmother and chief nurse, who's affectionately known as "Mama" among her Afghan proteges, said Afghanistan is practising 1940s-style "functional nursing."
It's task oriented. One nurse is in charge of dispensing medication, another does the cleaning while yet another transports patients to X-ray or the lab.
"Curiously, they are very dedicated to doing their function and absolutely do not step out of their lane into anybody else's function whatsoever," she said.
There's also very little pride in being a nurse.
Asmadine the charge nurse laughed when asked why he entered the profession. He said wanted to be a doctor but couldn't hack it in school.
Bassett said nurses receive nine months of schooling when they learn how to put in an IV, a catheter and nasal gastric tube, though they never practise on patients.
They're not taught a thing about anatomy or physiology and don't know why they're doing what they do, Bassett said. That could put patients at risk.
"They know to turn off a button but they don't know if a patient's lung resistance goes up, how to adjust the ventilator 'cause they don't understand that that's going into a patient's lungs," she said.
Bassett is creating a series of 40 classes to establish a baseline level of knowledge. Each 15-minute module will address things like temperature, heart rate, turning patients and medications.
"They don't know it but it sets a standard," she said, adding each nurse will get a badge for their uniform once they've completed the program.
"Once I've told them when a pulse is slow you do this, I'm going to hold them to that."
Already she is making progress.
They're now ordering and distributing medications in a more organized fashion that incorporates the expertise of the pharmacist. They are checking vital signs more regularly and they are finally starting to chart the medications and care they deliver.
They still, however, lack bedside manner and actually prefer not to engage patients - something Bassett attributed to their "help yourself culture."
Patton thinks the hospital could one day be on par with its regional counterparts in Pakistan and Iran.
"I can see that occurring over the course of a decade or so but again, that's so much reliant on stability, good governance (and) justice," he said.
