Until a few years ago, Lower Dir, on the border with Afghanistan and the tribal areas of Pakistan, was the scene of fighting between the military and armed opposition groups. The security situation in the area remains volatile, and bomb blasts, clashes and targeted killings still take place today.  “I still remember there was a big bomb blast in April 2010, about 300 metres away from our hospital. Within a few minutes, dozens of injured patients were already outside the emergency room. We needed to quickly identify who needed to be attended first,” recalls Dr Muhammad Zaher, who is working with Médecins Sans Frontières (MSF) as assistant medical focal person in Timergara, in the Lower Dir district of Khyber Pakhtunkhwa (KPK) province, northwestern Pakistan.

Traffic accidents are another major cause of serious injury in this rugged and hilly region. “The roads are very bad,” explains Dr Zaher. ”Each small passenger van here usually carries up to 25 or even 30 people. When there is a car crash, it can easily cause many injuries.”

A routine triage system

MSF has been supporting the District Headquarter (DHQ) Hospital in Timergara since 2009. The team has implemented a new routine triage system in the emergency department, and has also developed a plan to deal with the arrival of many people in need of emergency care.

Handling such incidents is a race against time. The mass casualty plan allows medical staff to rapidly identify and prioritise patients’ medical needs based on a few vital signs. Patients are then categorised: green means the patient is stable and can wait for few hours, yellow means he or she can wait for an hour, red means lifesaving treatment is required within one minute, while black means deceased or beyond help. ‘Red’ patients are immediately sent to the resuscitation room. “This allows us to provide good quality medical care to a maximum number of patients and save a maximum of lives within a minimum of time,” says Dr Zaher.

A routine triage system, using the South African Triage Score (SATS), has also been implemented to improve day-to-day patient care in the emergency department. Upon arrival, every patient receives an initial screening, where staff measure blood pressure, heart rate and clinical conditions to help prioritise patients’ medical needs. In the first three months of 2012, a total of 12,162 patients passed through the triage system, and 3,271 patients were treated in the resuscitation room.

Serious lack of good specialised healthcare

There is a serious lack of good-quality specialised healthcare in Lower Dir, and MSF staff are also providing emergency surgery in Timergara for patients from all over the district. Most patients in a serious condition are referred to the DHQ hospital, while some are sent to neighbouring districts, such as Upper Dir and Bajaur Agency.

“I got shot by my business partner. I was in a hilly area bordering with Afghanistan. The road was rough. I was put on a bed carried by people for an hour and then sent to nearest Samar Bagh Tehsil hospital by car for another hour. Having given me IV [intravenous] fluids, they referred me here,” says Anwar*, who had emergency surgery in Timergara’s DHQ Hospital to remove the bullet and shrapnel in the groin, and is now receiving post-operative care.

“We borrowed 5,000 PKR [€ 43] from the doctor in Samar Bagh hospital. We thought we would need to pay for the surgery here. We are glad that it’s free of charge. Otherwise, even if we sold our house and all the cattle, we would still not have enough money to pay for it,” says Anwar’s uncle.

MSF currently supports the emergency department, emergency surgery, and the mother-and-child department in the DHQ Hospital in Timergara. Mental healthcare is also provided to patients in these departments. All the medical care provided by MSF is free of charge.