Introduction
On 8th October 2005 an earthquake at 7.6 on the Richter scale tore across the fault line in Northwest Pakistan. In minutes 100 000 people lost their lives and 70 000 (est.) were injured. This occurred in an area of severe poverty and poor infrastructure, to a stratum of society without political status or national power. The towns and villages were densely populated and housing cheaply constructed or perched on mountainsides. The devastation was absolute and initially under-reported.
I watched a surgeon on the BBC News telling a reporter that you could not put dollars on wounds – he needed doctors.
Another told reporters that he had amputated 100 limbs so far.
I joined a team of doctors from Yorkshire and went to Pakistan arriving 7 days after the earthquake.
I arrived to find hundreds of severely injured patients, the majority needing plastic surgical reconstruction and myself as the only plastic surgeon in the region.
WHY THE VICTIMS NEEDED PLASTIC SURGERY
The public concept of plastic surgery equates to cosmetic surgery, but in fact plastic and reconstructive surgery is a speciality based on the techniques used to reconstitute parts and restore function. The restoration of appearance is a secondary goal to function.
Injuries to limbs have two components. There is the bony injury and the soft tissue injury. Severe injuries particularly of the types seen in earthquake zones not only break or shatter bone but also destroy the flesh covering these bones.
As a plastic surgeon my job is to rebuild the soft tissue support. This starts by cleaning and then debriding a wound to control infection and remove dead tissue. Then using a range of techniques healthy flesh is brought in to close the wound, creating an environment in which bone healing can occur.
These techniques may be simple direct skin closure, skin grafting, local flaps (an area of flesh is rotated into the tissue defect from an adjacent healthy area), a distant flap (an area of healthy of flesh is used to cover the defect by attaching the defect to the healthy area temporarily) and a free flap in which microsurgery is used to transfer a piece of tissue from one part of the body to another. In addition damaged nerves and tendons are repaired, as without these function will not be present.
This approach is essential as open complex injuries of this type will become infected, further extending damage and leading inevitably to amputation. It is important at this stage to recognise and preserve tissues that can be salvaged, whether that be a particular nerve or the whole limb.
In the aftermath of the earthquake hundreds of victims were left with severe life or limb-threatening wounds. The infrastructure to treat them even before the earthquake would have been extremely limited. Add to this that the majority had no status, funds or fixed abode and that public healthcare is grossly under-resourced and riddled with corruption. The pending harsh winter added a sinister deadline.
Initially mainly orthopaedic and general surgeons set about debriding wounds, fixating bones and amputating limbs. The evidence that I consistently found was that these surgeons were inexperienced. These would have been difficult injuries to treat in the UK and would have required experienced consultant input. No plastic surgeons were available. The reasons for this are as follows:
Few understood the size of the problem
Few understood the need for plastic surgery to reconstruct these large tissue defects
Pakistan has very few plastic surgeons and only one group was within 100 miles. They were snowed under with transferred patients. Others were unwilling to travel and work in this area initially.
There were very few local sites for such surgeons to work
This meant that patients remained untreated and that their wounds were rapidly becoming infected.
I had put together supplies and instruments for the task and our total relief cargo approached 1 tonne on the first trip.
Our team arrived at Abbottabad one week after the earthquake. Abbottabad is 50km from the capital Islamabad and 50km southwest of the earthquake epicentre. The town had sustained earthquake damage.
This was the nearest large town to the victims and the only one with adequate infrastructure for reconstructive surgery. It had become flooded with injured patients, filling the corridors of the University Hospital.
Whatever our preconceived plans, on arrival, having witnessed the chaos and enormity of the problem, our team had to focus on the immediate surgical treatment of casualties and calling in more plastic surgeons.
I watched a surgeon on the BBC News telling a reporter that you could not put dollars on wounds – he needed doctors.
Another told reporters that he had amputated 100 limbs so far.
I joined a team of doctors from Yorkshire and went to Pakistan arriving 7 days after the earthquake.
I arrived to find hundreds of severely injured patients, the majority needing plastic surgical reconstruction and myself as the only plastic surgeon in the region.
WHY THE VICTIMS NEEDED PLASTIC SURGERY
The public concept of plastic surgery equates to cosmetic surgery, but in fact plastic and reconstructive surgery is a speciality based on the techniques used to reconstitute parts and restore function. The restoration of appearance is a secondary goal to function.
Injuries to limbs have two components. There is the bony injury and the soft tissue injury. Severe injuries particularly of the types seen in earthquake zones not only break or shatter bone but also destroy the flesh covering these bones.
As a plastic surgeon my job is to rebuild the soft tissue support. This starts by cleaning and then debriding a wound to control infection and remove dead tissue. Then using a range of techniques healthy flesh is brought in to close the wound, creating an environment in which bone healing can occur.
These techniques may be simple direct skin closure, skin grafting, local flaps (an area of flesh is rotated into the tissue defect from an adjacent healthy area), a distant flap (an area of healthy of flesh is used to cover the defect by attaching the defect to the healthy area temporarily) and a free flap in which microsurgery is used to transfer a piece of tissue from one part of the body to another. In addition damaged nerves and tendons are repaired, as without these function will not be present.
This approach is essential as open complex injuries of this type will become infected, further extending damage and leading inevitably to amputation. It is important at this stage to recognise and preserve tissues that can be salvaged, whether that be a particular nerve or the whole limb.
In the aftermath of the earthquake hundreds of victims were left with severe life or limb-threatening wounds. The infrastructure to treat them even before the earthquake would have been extremely limited. Add to this that the majority had no status, funds or fixed abode and that public healthcare is grossly under-resourced and riddled with corruption. The pending harsh winter added a sinister deadline.
Initially mainly orthopaedic and general surgeons set about debriding wounds, fixating bones and amputating limbs. The evidence that I consistently found was that these surgeons were inexperienced. These would have been difficult injuries to treat in the UK and would have required experienced consultant input. No plastic surgeons were available. The reasons for this are as follows:
Few understood the size of the problem
Few understood the need for plastic surgery to reconstruct these large tissue defects
Pakistan has very few plastic surgeons and only one group was within 100 miles. They were snowed under with transferred patients. Others were unwilling to travel and work in this area initially.
There were very few local sites for such surgeons to work
This meant that patients remained untreated and that their wounds were rapidly becoming infected.
I had put together supplies and instruments for the task and our total relief cargo approached 1 tonne on the first trip.
Our team arrived at Abbottabad one week after the earthquake. Abbottabad is 50km from the capital Islamabad and 50km southwest of the earthquake epicentre. The town had sustained earthquake damage.
This was the nearest large town to the victims and the only one with adequate infrastructure for reconstructive surgery. It had become flooded with injured patients, filling the corridors of the University Hospital.
Whatever our preconceived plans, on arrival, having witnessed the chaos and enormity of the problem, our team had to focus on the immediate surgical treatment of casualties and calling in more plastic surgeons.
