It was a warm noon in February in Complexo do Alemão when shooting suddenly started. Complexo de Alemão is a deprived and violent neighbourhood of Rio de Janeiro, one of the main cities in Brazil. The area is well known for regular clashes between local armed groups and the Rio de Janeiro police forces. The local population, approximately 150,000, lives trapped in the violence.

Since October, 2007, Médecins Sans Frontières (MSF) has been providing emergency and mental health care to the population living in the area.

"We visited Complexo do Alemão and we found out that, due to the peculiar violent situation, there were difficulties of access to quality and timely medical and psychological care for the inhabitants, especially during fighting," said Alberto Cristina, Head of Mission for MSF in Brazil. "Once the main needs had been assessed, we decided to open an emergency room".

When violence breaks out

Sonia was at home. She is 40 years old and she suffers from heart problems. After two hours of uninterrupted shooting close to her house she started feeling bad, could hardly breathe and felt palpitations. When fighting occured there was no means of transportation, Sonia could not move from her house. Her brother decided to rush to the MSF emergency unit with her medical records.

MSF runs an emergency room in the community of Fazendinha, located in the heart of the neighbourhood, where four main services are offered: emergency care, mental health services, referrals through MSF vehicles, and orientation to patients not fitting the MSF admission criteria.

Right away the MSF car went to pick up Sonia at home. When she arrived in the MSF unit, Sonia was given a red code. Her electrocardiogram showed a serious arrhythmia and the MSF medical team assisted her immediately.

Thanks to the defibrillator action, an acceptable heart rhythm was established. Once Sonia is medically stable, the psychologist approached her to provide mental health support. If she wanted to, she could come back to the MSF centre in order to discuss ways to better cope with her anxiety problems.

Eventually calm was restored in the neighbourhood and Sonia was transferred by an MSF car to a second level hospital, 20 minutes outside Complexo do Alemão.

Ongoing psyche care

In addition to emergency care, MSF offers psychological support to people living similar situations as Sonia, affected by the violence. It is the case of Maria, a young girl who was one of the direct victims in an attack several months ago. During the fighting many children were wounded, Maria was one of them. She was transferred to the hospital where she had to undergo surgery three times.

Today Maria has recovered from the external physical wounds but not from the most hidden ones. Maria regularly attends individual sessions with the MSF psychologist.

"In February we visited 776 patients. One of our goals is to reduce the time between the trauma and the hospitalisation", said Gianfranco De Maio, medical doctor for MSF in Brazil. "We need to treat the patient during the first 60 minutes after the time of the injury.

"I remember a patient our medical team assisted, a man wounded by gunshots. He arrived at the emergency unit in serious condition, we stabilized him and then we transferred him to the reference hospital."

MSF medical staff implement several techniques, such as the advanced trauma life support, establishing an efficient triage able to rapidly diagnose patients needs.

Since the start of its activities MSF has attended almost 3,000 patients; mainly for violent and accidental injuries, respiratory tract infections and suspected dengue fever.

All patients are screened before being treated, referred or transferred to other public medical structures.