Bulletin of the World Health Organization

Quake victims reach help too late to save crushed limbs

The Pakistani government and WHO have appealed for US$ 27 million, but raised just under half of that for the area’s immediate health-care needs.

A doctor attends to a patient's right arm in the hospital in Mansehra.
Khabir Ahmed
Dr Mohammad Shoaib attends to Mazhar Ali's right arm in the hospital in Mansehra.

When Mazhar Ali, 22, was finally airlifted to the District Headquarters Hospital, Mansehra, a frontline hospital for the injured of the devastating 8 October earthquake in northern Pakistan, doctors told him it was too late to regain full use of his arm.

Ali was brought by helicopter to the hospital from his home in the remote mountain village of Paras in Balakot, one of the areas worst hit by the earthquake. He is one of countless patients who were airlifted from that area to hospital since the earthquake.

He said he had no one to talk to and had no idea where his family members were, but that he was lucky to be alive. “I don’t have any place to go. Our house … completely collapsed and four members of my family have died,” Ali said.

“We didn’t know whether we would survive. We relied on burning wood we had gathered from our collapsed roof to warm ourselves. We had no food except for corn [on the cob],” he said, looking at his paralysed right arm with an expressionless face. More than 73 000 people died, about 69 000 people were seriously injured and a further 59 000 suffered minor injuries in Pakistan as a result of the quake, which had a magnitude of 7.6 on the Richter scale and was the most powerful to hit south Asia in 100 years. More than three million people need emergency shelter to survive the harsh Himalayan winter, Pakistan’s government said.

Half of the 564 hospitals and dispensaries in the quake-hit area were completely destroyed, while a further 74 were partially damaged, according to WHO. But even before the earthquake, the health-care system in some particularly poor areas was inadequate.

Pakistan’s Ministry of Health (MoH) estimates it needs US $651 million to rebuild the health-care system, including construction of quake-resistant hospitals. Meanwhile, WHO and the Pakistani government have appealed for US$ 27 million and so far raised 45% of that for immediate health-care needs.

Ali suffered a crush injury to his right arm after his family home collapsed on him. Relatives rescued him from the rubble of their home the same day, and Ali spent seven nights in the open in freezing winter temperatures with the rest of his family before he could be taken by helicopter to the hospital to have his injury treated.

While waiting to get airlifted to help, his right arm developed compartment syndrome. At the hospital, the orthopaedic surgeon, Dr Mohammad Shoaib said that because of a prolonged disruption of blood flow to the nerves and muscles of his right arm, his arm would not regain full movement.

Many victims of the earthquake suffered crushed limbs and developed similar deformities to those experienced by Ali because they did not receive surgery soon enough. “Those who did present early could not be operated because we did not have [operating] facilities to take care of trauma patients,” Shoaib said.

Once they received surgery, at best these patients regained some movement after the long wait, and, at worst, their gangrenous limbs had to be amputated.

Although the District Headquarters Hospital, Mansehra was built recently, it did not offer orthopaedic services before the quake. After the earthquake, the hospital walls developed cracks and the building was declared unsafe for use. Doctors and nurses had to provide first aid to thousands of patients in the open.

Patients receiving care in a refugee camp.
WHO/C. Black
More and more people have been leaving their devastated villages to seek refuge in tents in towns like Mansehra.

“Patients were lying on the floor, on the road and in beds in the open. For the first few days, power supply remained disconnected as well as the phone service,” Shoaib said. “There were no bandages, so we used ordinary cloth we purchased from the cloth shops”.

Dr Ishtiaq Ali Khan, a general surgeon at the hospital, said that shortly after the quake hit a constant stream of patients arrived at the hospital seeking help. He and his colleagues were under immense strain because they did not receive any outside help — including supplies of life-saving drugs and equipment — for the first few days.

They called their colleagues in Lahore to come to help them. Four days later they and their colleagues set up an operating theatre. Thanks to local donors as well as UN agencies, international nongovernmental organizations (NGOs) and donor governments, the hospital received more supplies of medicines and equipment.

Since then, they have performed more than 500 major operations and more than 9 000 injured people have been seen to by local, national and international health-care workers at the hospital. Several wards have been set up in tents, the latest one by international NGO Médicins sans Frontières.

“We were all very exhausted and simply unable to cope with the growing number of patients needing immediate surgical interventions,” Khan said, describing the first few days. About a month after the earthquake struck the workload started to decrease, he said.

In the nearby town of Balakot, close to the earthquake’s epicentre, makeshift field hospitals have been established by Pakistan’s army, by relief workers sent by the United Arab Emirates as well as by international NGOs, such as Oxfam and Save the Children.

According to Pakistan’s government, more than 50 temporary field hospitals and mobile clinics are currently operating in the eight quake-hit districts, including Muzaffarabad where the 400-bed Combined Military Hospital collapsed, killing over 200 patients.

The shortage of doctors, nurses and other health-care workers in the affected areas is a major challenge that is hindering efforts to provide much needed primary health care including vaccination services.

As a result, cases of vaccine-preventable diseases, such as measles, are on the rise. After crush injuries, acute respiratory tract infections are the second-leading reason for contacts with doctors in health facilities reporting to the Disease Early Warning and Surveillance (DEWS) system, said Haroon Afridi, an epidemiologist at the Aga Khan University, Karachi.

“Before the earthquake, there was no DEWS in this area. It is now slowly developing,” Afridi says. The winter has just begun to set in, and doctors said they were starting to see more cases of diseases associated with malnutrition, lack of shelter and clean water than of crush injuries.

Khabir Ahmad, Mansehra.

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“We are all very exhausted and simply unable to cope with the growing number of patients needing immediate surgical interventions.”
Dr Ishtiaq Ali Kahn, a general surgeon.

“Those who did present early could not be operated because we did not have the facilities to take care of trauma patients.”
Dr Mohammed Shoaib, orthopaedic surgeon.