Visiting Kurdistan, North Iraq with EMERGENCY

Dr David Rowlands
Consultant Anaesthetist (Retired)
Llandudno General Hospital, Wales.

EMERGENCY, is a Milan-based, humanitarian organisation whose aim is to provide assistance to the civilian victims of war, the wounded and all those who suffer other consequences of war such as famine, malnutrition, or the absence of medical care.

Founded in 1994, EMERGENCY has worked briefly in Rwanda, runs a mine awareness programme in Italy and has surgical hospitals in Sulaymaniyah and Erbyl in Kurdistan, North Iraq and another in Cambodia. Both of these countries are heavily mined.

After the Gulf War, the Iraqui Kurds were encouraged by the then US President, George Bush, to revolt against Sadam Hussain, but received no support when they were attacked. There was much suffering and loss of life and a mass exodus mainly to Iran and Turkey. After pressure from the then UK Prime Minister, John Major, a Kurdish safe-haven was established in northern Iraq by the United Nations. There are many political parties, the PUK and PDK each control part of the country. After intermittent internal fighting a peace agreement was signed on September 7th 1988, in Washington, DC.

In January 1996 I was fortunate (at the age of 74) to be able to go to Sulaymaniyah for six weeks to help set up the anaesthetic service in a nominal 50-bed surgical hospital which EMERGENCY had established within some disused buildings.

Sulaymaniyah is a city of about 750,000 people. Many buildings have been destroyed and the larger ones are occupied by refugees who live in squalor. Electricity is only available for several hours a day; cooking and heating is by bottled gas or kerosene. Food is plentiful but too expensive for some local inhabitants, until UN Resolution 986, since when free food has been supplied.

Although most Non Governmental Organisations (except the International Committee of the Red Cross and EMERGENCY) carry armed guards in their vehicles, life is reasonably safe, provided sensible precautions are taken. Night travel outside the city is avoided; a guard is taken if walking alone at night to avoid the occasional muggings. If shooting occurs one stays indoors. Many local inhabitants carry weapons which are fired by accident, in celebration or in family feuds, often with resulting injuries.

The local hospitals all need cleaning and much of the medical equipment is missing or unserviceable. Nursing care is poor and drugs have to be bought in the bazaar by patients.

In mid-July 1996 I returned for 3 months. The hospital was being enlarged, a third operating room was made and a new Intensive Care Unit was planned, when fighting broke out between the two main political parties. On the night of September 8th/9th many of the inhabitants of Sulaymaniyah (a city of mainly PUK supporters) fled towards the Iran border, being afraid of the arrival of Sadam Hussain's troops, who had helped the PDK capture Erbyl, the capital of Kurdistan. In spite of the lack of public transport, many of the staff came in during the course of the morning and all worked willingly and well for long hours. The Teaching, General and Maternity Hospitals had all closed, so our workload was increased by the road accidents, acute abdomens, etc., which were normally dealt with at these other hospitals. During September and October we admitted 500 patients (643 operations).

In spite of press reports, we were perfectly safe in Sulaymaniyah, although the city changed hands twice the fighting was some distance away, one party moving out before the other moved in.

Among the saddest casualties were the mine injuries (about 20 per month) and injuries to children caused by holding a shell or bullet in their left hand, hitting it with something in their right hand; losing the left hand and part of the right, and sometimes one or both eyes as well. Luckily, I had carried out an old portable operating eye microscope, which I had been given, which proved invaluable.

I returned for a month in July 1997, by which time additional building had taken place and the skills of the Kurdish staff had developed remarkably since the hospital opened. There was now a 7-bedded children's burns unit (a spot check showed 27 burnt children in the hospital, mainly from hot water, with a few from kerosene) which puts a considerable emotional and physical load on the nursing and medical staff. A Spinal Unit had also been opened. The physiotherapist visits the homes of patients before they are discharged from the Unit and the works department makes suitable alterations to their homes (ramps, altered water supply, etc.) so that the quality of life is greatly improved.

In October 1997 there was fighting between the PUK and the PDK helped by Turkey (unlike the 1996 conflict this was not reported in the British press) when 357 patients were admitted to the hospital in the month with 397 operations.

A Rehabilitation Centre was opened in Sulaymaniyah in February 1998, mainly for amputees. There is accommodation for 36, a school for literacy, maths and culture with vocational training courses in art and design, carpentry, leather work and metal work. Over 60% of the staff are themselves disabled. There is also a limb-making and fitting department and artificial arms are now available.

With the help of a generous grant from the Association of Anaesthetists of Great Britain and Ireland towards my travelling expenses, I returned in February 1998 to help with the opening of a purpose-built hospital in Erbyl, which had been built from scratch in under 6 months. Unfortunately, there were political problems which delayed the opening, but I was able to undertake some training, taking the Erbyl anaesthesia nurses to Sulaymaniyah for lectures and practical experience.

The new hospital in Erbyl. Constructed in six months.

The interior of the hospital, awaiting patients!

Anaesthesia is mainly given by anaesthesia nurses who have a 12-18 month course. Some are very experienced, having been in the armed forces during the Iran/Iraq war and are well able to deal with major laparotomies for bullet injuries and serious mine injuries. The nurses in Sulaymaniyah (PUK governed) are used to working without an anaesthetic doctor present, while in Erbyl (PDK controlled) the Iraqui rule that an anaesthetic doctor is present in the hospital when general anaesthesia is being undertaken is strictly enforced.

Anaesthesia

Instead of using an oxygen-driven Manley Multivent, as the local hospitals prefer, the draw-over method with an Ambu bag and valve and an Oxford Miniature Vaporiser is used as oxygen supplies are sometimes short (only 10 cylinders at one time in Sulaymaniyah during the fighting of 1996). An oxygen concentrator is available. Induction is with thiopentone or ketamine - diazepam, intubation (if needed) with scoline followed by pancuronium and maintenance with halothane or intermittent ketamine. Ketamine drips are sometimes used but recovery can be delayed as the nurses do not always accurately count the rate of the drops. Disposable endotracheal tubes are cleaned and re-used. Analgesics are difficult to obtain, pentazocine being the strongest available. Lignocaine (with preservative) is in 50 ml bottles. Much of the equipment has been salvaged from the UK and carried out by international staff.

During my visits, I spent time setting-up equipment, super-vising the work of anaesthesia nurses and giving talks on matters that had arisen during their anaesthetics, and on topics which the nurses suggested.

Perhaps the most important thing I have done on my visits to Kurdistan is to impress on all the anaesthetic nurses the importance of checking the sucker, the oxygen, the equipment, the drugs and the patient before starting the a naesthetic. (On one occasion the Maternity Hospital next door sent over to borrow a laryngoscope as they had started a Caesarean section and theirs did not work!)

I formed half of the Appointments Committee which appointed 3 surgeons for the Erbyl Emergency Hospital. Perhaps anaesthesia has come into its own at last!

I am grateful to all my Kurdish friends and colleagues for their kindness and help on my visits and for all the enthusiasm of the anaesthesia nurses, without which I could have accomplished nothing.

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