"In March, the number of violence-related cases admitted to our emergency room has significantly increased," said Pale. "One evening early in March, two armed groups were fighting each other on the city streets and our emergency room admitted 30 gunshot victims in a matter of four hours. Sixteen were admitted to the hospital, five were rushed up to the operating room. It's just an example of how explosive the situation can be."

In Nigeria's densely populated, oil-rich Niger Delta region, the struggle to control power and natural resources has sparked sporadic and deadly outbreaks of violence among a fragmented network of political and criminal armed groups. The overall lack of functioning and accessible emergency medical services in the region prompted MSF to open a trauma center in October 2005 at the 70-bed Teme Hospital in Port Harcourt, the bustling capital city of Rivers state.

"The vast majority of the cases we treat are life-threatening emergencies," said Joe Pale, MSF Field Coordinator in Port Harcourt. "If needed, we can rapidly increase the current bed capacity from 70 to 110 beds using MSF field tents."

Teme Hospital deals with violence-related injuries, including gunshots, stabbings, beatings and sexual violence as well as other trauma cases, such as road and domestic accidents and burns.

While other medical facilities exist in Port Harcourt, large parts of the population cannot access medical services because they cannot afford the fees or because the facilities lack medical supplies and staff. As in other countries, massive wealth derived from abundant natural resources &#— oil, in Nigeria's case &#— contrasts with widespread poverty and inadequate medical services. The MSF trauma center therefore fills a gap in emergency medical care in the region.

Increased pre-electoral tensions

"In March, the number of violence-related cases admitted to our emergency room has significantly increased," said Pale. "One evening early in March, two armed groups were fighting each other on the city streets and our emergency room admitted 30 gunshot victims in a matter of four hours. Sixteen were admitted to the hospital, five were rushed up to the operating room. It's just an example of how explosive the situation can be."

The number of gunshots victims admitted to Teme Hospital increased from 38 in February to 72 in March. However, most of the admissions took place in the first two weeks of March. During the following weeks, the number of violence-related admissions remained relatively low in comparison, with no major fighting reported.

Emergency preparation and mass casualty plans

In the lead-up to the election period in Nigeria, the team reviewed and improved their emergency preparedness plan, ensuring that necessary medical supplies were pre-positioned and that staff were familiar with the latest procedures. Having a mass casualty plan enables the hospital to deal with instances when the number of patients exceeds the normal capacity. But it requires difficult decisions.

"During a mass casualty, you need to adapt your triage criteria, which means assessing the severity of injuries and providing care according to the chances of survival. This allows patients who have the highest chances of surviving to survive," said Dr. Bern-Thomas Niang'wa, the manager of Teme Hospital. "Unfortunately, for patients who are too injured to be managed, you can only provide palliative care while you focus on the ones you can save."

This requires all the departments to coordinate and even change their functions or roles to ensure that we provide the best quality of care as possible to as many patients as possible.

Surgical care to victims of trauma: introducing internal fixation in MSF protocols

Every month, 150 to 200 surgical procedures are performed in the two operating rooms of the trauma center. From dressing changes and debridements (surgical removal of dead or contaminated tissue) to laparotomies (abdominal surgery) and high-end orthopedic surgeries, the range and number of surgical operations have significantly increased since the project began in October 2005.

In January, MSF started performing internal fixation for open bone fractures, a new development for the organization, which normally performs surgery in conflict areas where sub-standard conditions do not allow for more complex surgical methods. The procedure consists of inserting a metal component inside a limb or inside a bone to reunite broken segments of bone.

Internal fixation, commonly practiced in developed countries, requires a sterile environment, specific surgical equipment such as real-time x-ray, and metal plates, pins, rods, wires, or screws. It has significant advantages over external fixations: it reduces the length of hospital stays, allows patients to return to normal function faster, and diminishes the incidence of nonunion fractures.

"The introduction of internal fixation has allowed us to improve the quality of care and to clear space in our wards," said Dr. Niang'wa. "Given that in a setting like Port Harcourt we can guarantee conditions for safe procedure, we thought this is a right step in improving the quality of care and in introducing new techniques in our programs," said Dr. Niang'wa.

Integrating physiotherapy to the trauma care

Another major improvement to a typical MSF surgical project was the integration of a rehabilitation program.

"We see a lot of patients in traction or with a cast who stay in bed for extended periods of time," said Barbara Frederick, a physiotherapist with MSF. "They are at risk of losing mobility because of the consequences of the trauma and of the surgical intervention. By providing physiotherapy early, we are able to significantly reduce sequelae, conditions resulting from injury, such as muscle atrophy."

MSF's objective is to get patients standing upright earlier, which will allow them to regain mobility and to resume their daily lives faster. A similar physical rehabilitation program was set up in Port-au-Prince, Haiti, in 2005, which provided a model for establishing a physiotherapy care component the in Port Harcourt program.

Since October 2005, more than 4,500 patients have been admitted to the emergency room of the Teme Hospital, among them more than 1,100 for violence-related trauma, including 380 gunshot victims. MSF surgical teams have performed 1,700 operations for acute emergencies.

MSF in Nigeria

MSF has worked in Nigeria since 1996. Currently, 42 international staff are working alongside some 348 national staff. In Lagos, MSF has established a comprehensive HIV/AIDS program, providing care to more than 1,500 people infected with HIV.

Over 1,000 patients are receiving the antiretroviral (ARV) medicines they need at General Hospital Lagos. MSF has been running the Teme Hospital trauma center since November 2005.

In northern Nigeria, MSF also responds to emergencies including epidemics of measles, meningitis.