Notes From Afghanistan: Providing Care After an Earthquake

Peggy Dryden, RN, MSN, MBA

Disclosures

June 26, 2002

Editor's Note

This is the second article in our series, "eLetters: Corresponding With Nurses," with a follow-up email interview with James J. Gardon, Lieutenant Colonel (LTC), Army Nurse (AN), from the Coalition Joint Civil Military Operations Task Force (CJCMOTF)-Kabul, Afghanistan, following an emergency mission to a remote area in Afghanistan (Figure 1).

James J. Gardon, Lieutenant Colonel, Army Nurse.

Jim is leaving Afghanistan at the end of June 2002. We thank him for his efforts at rebuilding the medical infrastructure in Afghanistan, and we are pleased that Medscape had the opportunity to help (see Sidebar).

We welcome your recommendations of other nurses we should interview for this series. We are looking for nurses doing unusual jobs or practicing in unusual situations or settings. Please contact the editor at nurse-editor@webmd.net.

Question: Jim, you and your colleagues were called away from Kabul in late March to respond to an earthquake in the remote district of Nahrin in Baghlan, near the epicenter of the earthquake in the Hindu Kush mountains of Afghanistan. Could you describe the initial "call?" What was your initial impression of the severity of the disaster and the medical implications? Could you describe the helicopter ride -- your thoughts as you were flying to this reportedly remote and "devastated" area?

Response: The earthquake occurred at 7:26 PM (local time), Monday, March 25, 2002 about 100 miles/160 km from Kabul, where I'm stationed. We felt the quake in Kabul. The movement was strong enough to make me leave my office and stand outside in open ground. Our initial concern was for the immediate area of Kabul, where we could easily respond. There was only minor damage to the city. Unfortunately, though, 1 man died as the result of a wall falling on him. It wasn't until the following day that we were able to get any intelligence reports on the impact of the quake.

We discussed our potential response to an earthquake disaster the evening of the initial quake. Team members were identified for the mission in the event we were called to respond. The team included a Captain, an ER physician, a Major who is a Medical Service Corps officer and an RN in the civilian world, and myself, an Army Nurse Corps officer and team leader.

We monitored the military classified Internet for any intelligence reports, but as there were no US operatives in that particular area, there was no one to observe the situation. A team was moving into the area, but we had to depend on CNN and other US news reports to begin to gather information about the situation. Initial reports were dreadful, with reported thousands dead and many more injured and homeless. We continued to plan for our response late into the evening of the March 26 without official notification of any mission to assist. Preparation is the key to any response, and as we could be called to help, we wanted to be ready.

March 26 passed with a "maybe yes, maybe no" mission forecast. We spent most of the next day working on our project list requirements, and late in the afternoon, our command relayed to us that we should "stand down" from the mission. It looked like the military would not have to respond, as there were plenty of nongovernmental organizations (NGOs) involved in the immediate response.

A change of events occurred on March 28 when the Afghan Interim Government made an official appeal for assistance to the US Ambassador in Kabul. We received orders to execute the relief mission around noon and had less than 1 hour to be at the Kabul airport. I finished packing as I received only fragmentary information on the nature of the expected response. It never was too clear what we were to do when we got there. I was told that we would be delivering humanitarian assistance materials for the US Army and the United Nations, as well as providing on-the-ground assistance to the Minister of Public Health, who was in Nahrin with some of her staff.

Our team was a support section from the 489th Civil Affairs Battalion, composed of 1 officer and 4 enlisted men whose purpose was to help unload the supplies on our CH-47 helicopters (Figure 2) and the next day's sorties. Also, a noncommissioned communication officer was responsible for our radio and satellite phone system. The ground around Nahrin continued to shake every hour or two during the night. We slept out in the open, as we didn't bring any tents with us (our unit does not have any). We did share a security perimeter with an advanced party of the German Airborne hospital detailed from the International Security Assistance Force (ISAF) to assist.

Army personnel in the CH-47 helicopter, on the way to the earthquake area.

Question: When you arrived in the area of the earthquake, what did you see?

Response: The helicopter ride was the best of my 28-year Army career. I have flown many hours, doing medical evacuations and general flights. This trip was surreal. We flew out of Kabul airport with a UN team and their medical supplies, up to Bagram to refuel and take on more humanitarian aid, UN tents, US wheat, and excess cold weather Army issue clothing. We took off toward the Hindu Kush Mountains, roughly following the route up to the Salong Pass and Tunnel. We flew "NOE," which is short for "nap-of-the-earth," or a flight that is as close to the ground as a large, heavily loaded, double-bladed helicopter can safely fly. When you're flying at 150 knots (miles) per hour, tree top level is very close. One mistake by the pilot and we'd all be a large, smoking hole in the ground!

The scenery was incredible, and we were almost like kids at Disney World. We were at the most 100 feet off the ground, in 75-degree weather, climbing up into the mountains. Gradually, the villages we were flying over became smaller and moved apart. As the temperature fell and the snow-covered mountains were rising up on both sides of the helicopter, there weren't any villages to be seen, only the snow and the mountains. I don't know what the pilots saw up front, but all we could see were the walls of snow surrounding us and getting closer all the time! Just as we crested the pass, the temperature became uncomfortably cold, reportedly 10-15 degrees.

As we descended around the various passes, the snow became patchy, and the mud hut villages came into view again, but now the scene was different. As we neared Nahrin, the evidence of the magnitude of the disaster became apparent. There were many collapsed roofs, and more frequently entire homes destroyed, as well as entire sections of villages. We could see families camped out on the ground, some with tents, some with only quilts and blankets. The immediate area did not have significant damage, but the roof of the building next to what was to be our camp had fallen in. None of the many buildings around the area appeared to be occupied. We made our final approach to the relief center on the outskirts of Nahrin and landed.

As we made our way out of the helicopter to secure the site, a team from Medicines Sans Frontieres (Doctors Without Borders) ran up the ramp of the helicopter with a patient on a stretcher, placing her on top of the humanitarian assistance supplies before we could off load them! Apparently, the patient was 7 months pregnant and had sustained a severe head injury when the roof of her home collapsed. We confirmed that the Spanish Military hospital at Bagram would care for her, and off went our ride.

Question: When you arrived, what were the priorities in terms of need? What was your role? How would you compare this earthquake scene to other disaster relief you have done?

Response: There were at least 10 different NGOs on the ground when we arrived. The United Nations was attempting to coordinate the activities, but NGOs do what they do, sometimes with and sometimes without direction. We secured our site, established communication with the CJCMOTF in Kabul, discussed our actions and responsibilities with the UN director on the ground, made our contact with the Minister of Public Health, and went to the Medicines Sans Frontieres treatment area to lend a hand.

Our team physician immediately started seeing patients, with the Major and I assisting him. Patients were pouring in from all over the region. We cared for several patients simultaneously -- someone with a dislocated shoulder, another with a nondisplaced fracture of the forearm. These were the kind of problems (soft tissue injuries, contusions, fractures, and lacerations) we expected from the type of construction common to the area, heavy timbers supporting heavy mud and brick roofs.

I had to step back from my caregiver role and go to a UN coordination meeting. I did not know it at the time, but I would not engage in patient care for the remainder of my time in Nahrin. I was required to attend more than 6 meetings a day (and night) for the purpose of coordinating activities with the UN and the NGOs, in addition to supervising the off-loading of a total of 15 CH-47 helicopters loaded with humanitarian assistance supplies the US Army moved into the region. I say "supervise," but as the photograph (Figure 3) shows, there's a lot of physical labor in managing a humanitarian assistance supply drop. Literally tons of materials were brought in to the area. Fortunately, the British government representative on the ground volunteered to pay for a group of local men to act as porters for 2 of our 3 days there. The local military commander provided soldiers to guard the items we had to leave at the drop zone. At first, I was leery about permitting this; however, I felt we had no choice in the matter. I was physically exhausted from the altitude and the sheer effort of running around the site and off-loading all day. I saw no other option. For their efforts, the soldiers asked only for "meals ready to eat" (MRE) and water, which we gladly shared.

Nahrin, Afghanistan, the earthquake location.

Question: How long was your team in the area? What was the most difficult part of the assignment and how was it handled? How is your role as a nurse in a situation like this different from anything you faced as an ER nurse in the US?

Response: We were there 3 days and nights. On the second night, we had dinner with the Afghanistan Minister of Public Health (Figure 4) and her staff in her tent. We sat on rugs and pillows on the floor and ate communally, with our right hands. This is the custom of the people of Afghanistan, and I have eaten this way before, during the Gulf War. It really is a simple, unfettered way to eat.

Jim with the Afghanistan Minister of Public Health and her staff.

The most difficult time I had was dealing with the various organizations, such as the NGOs. There was an overwhelming sense that publicity was the priority, not humanitarian assistance. At times, there seemed to be more reporters than NGO staff. I helped the United Nations and the Minister of Public Health, both of which were gracious and understanding of our goals, objectives, and limitations.

Initially, in the tent with Medicines Sans Frontieres treating patients, it was like any other mass casualty situation: triage, triage, and retriage, then treat, treat, and treat. Actually, it reminded me of any given weekend in a downtown trauma center. But as my role became the US Army representative on the ground and I was responsible for the coordination of thousands of pounds/dollars worth of humanitarian assistance supplies and their allocation and distribution; well, it was almost overwhelming. However, the effort was successful for 3 reasons. First, experience as a soldier and an Army/ER nurse has taught me to expect the unexpected. Second, things were developing so fast, I couldn't take the time to think about whether I was handling it all correctly. Finally, in an emergency, just about any step in any direction helps out. Inaction, or the failure to make a decision, causes you to be a hindrance in these situations, so I just kept moving, deciding, and directing.

I was greatly relieved when my team Chief arrived on the last helicopter on the second day. The Chief was able to continue the relationship with the Minister of Public Health, with whom he had established a professional relationship in the months prior to the earthquake, leaving me free to deal with the UN and the NGOs involved in handling the various airlifted materials.

Question: What do you think the Medscape Nurses readers would be interesting in knowing about the earthquake relief effort?

Response: I believe that any Medscape Nurses reader would find this all fascinating, but I might be a bit inclined toward the subject! Honestly, the sheer impact of human suffering and the loss of life related to the earthquake are yet more blows to the people of this war-torn and abused country. I heard tragic stories of parents losing not 1, but 2, 3, or 4 children. I also heard stories of children, after receiving medical treatment, looking for their parents, only to be told they were already buried. Everywhere, there was catastrophe. But, through it all, people said thank you, thanks to America for coming to help.

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