Enab Baladi – Jana al-Issa

Despite its weak capabilities and the number of injuries exceeding the usual capacity, the response of the medical sector in northwestern Syria to the earthquake disaster was impressive, but at the same time, it opened the door to questions about the medical effects on the injured themselves as a result of working according to an emergency response plan.

Such plan mandates the use of the minimum possible medical equipment to ensure patient safety due to the absence of the luxury of completing surgeries as they should academically.

The number of injured exceeded 12,000 people during a short period of about the first five days after the earthquake occurred, which hit southern Turkey and northern Syria on February 6, and the lack of equipment imposed “rationalization” in the treatment plan for some of the injured in terms of antibiotics or other therapeutic drugs such as intravenous fluids (serums), which may leave future effects on their health or the location of their injury.

As a result of the multiplicity of degrees of injuries, the effects of the emergency response on earthquake victims are also considered to be uneven, as these effects depend on the severity and size of the injury and the extent of the patient’s need for therapeutic or surgical equipment.

Disability, amputation and death

Dr. Abdulkarim Ekzayez, a specialist in epidemiology and building health systems in the context of wars and conflicts, said that the health system in northern Syria was not ready for the arrival of large numbers of people with “muscle injuries” or fractions to its facilities, and therefore the number of medical devices and the volume of disposables are very few compared to these numbers.

The supply chains of these materials were also disrupted during the first days of the disaster, as most of them came to the region through the border crossings with Turkey, in addition to the damage to some medical warehouses in the north as a result of the earthquake.

This also affected the ability to treat the injured and forced the doctors to change the treatment plan for the patient by relying on less effective plans. For example, instead of fixing the fracture well with plates, it was fixed with an external fixation device, Dr. Ekzayez told Enab Baladi.

Changing the treatment plan to non-ideal plans to deal with the lack of equipment affects the body, either directly, like when the affected limbs are subject to amputation or threaten the patient’s life in the long run, the member of the Executive Board of the Syria Public Health Network, said.

In the case of crush injuries, and in order to preserve the integrity of the limbs, the doctor may sometimes have to amputate them, but in the case of fundamentally changing the plans for bone fractures, this may result in permanent disabilities due to defective fusion, or a bigger problem may occur represented by bone infections, which the patient may suffer for many years, or it may lead to generalized infections that could be fatal, according to Dr. Ekzayez.

Defective fusion is a description of fused fractures with non-anatomical positioning of the fracture pieces, and the deformation here may cause functional disability regardless of its degree in several ways, including an abnormal joint surface, rotation, and angulation of the fracture pieces, overlaying of bone pieces or bony loss, in addition to movement in the adjacent joints. Defective fusion usually results from inaccurate fracture alignment or ineffective fixation during the healing phase. Mild deformity can cause serious disability when the defective fusion is within or adjacent to a joint, and rotational deformity can cause severe disability that often requires surgery to manage.

The shortage of fixation devices, whether in orthopedic or neurological surgery, has led to the inability of medical staff to deal with open fractures and crushing injuries appropriately, and therefore many of these injuries will cause permanent disabilities for some of those affected, said Dr. Ekzayez, adding that the absence of specialized devices and equipment, whether in the search and rescue phase, or in the medical sector in northwestern Syria, led to the loss of lives, either through the delay in extracting the injured from under the rubble or due to the lack of sufficient medical equipment and devices to accommodate the large number of the quake injuries.

All survivors from under the rubble need medicines and daily medical consumables, such as intravenous fluids and antibiotics, as most of them suffered crush injuries and wounds that require antibiotics to prevent infection.

However, the lack of sufficient quantities of antibiotics and medical disposables prevented some of them from being saved, which led to their death, according to Dr. Ekzayez.

Moreover, the absence of dialysis devices and equipment in northern Syria led to the death of a number of people who emerged from under the rubble because of their need for dialysis as a result of their exposure to kidney failure resulting from the dehydration that afflicted them as a result of their staying under the rubble for days without water or fluids.

Different causes of deaths

The decline in support for the medical sector in northwestern Syria before the earthquake reached a difficult level, and it recorded a deficit in providing basic consumables for emergency operations, especially equipment for orthopedic and neurological surgery. The director of the offices of the Syrian American Medical Society (SAMS) in Aleppo, Dr. Osama Abu al-Ezz, told Enab Baladi.

“Before the earthquake, hospitals relied on the patient himself to secure this equipment, either at his own expense or through the sponsorship of a “charitable organization,” adds the doctor who specializes in general surgery.

During the response to the earthquake, all health facilities consumed their entire strategic stock, despite its scarcity in general. After the first days of the earthquake, they reached a critical threshold of depletion of medicines and disposables.

All hospitals in the region suffer from a limited number of beds for intensive and surgical care, and as a result of many earthquake victims’ need for these beds.

Dr. Abu al-Ezz says that some hospitals were forced to place these patients in intensive care units from other specialties, such as cardiology and others, but the lack of competence of the staff in this department and the lack of sufficient experience to deal with patients’ symptoms led to difficult results.

Most of the patients who are in critical condition, such as those with brain and spinal trauma, need a trained staff with sufficient experience to deal with this type of injury, which was not available due to the lack of intensive care beds in most facilities, according to the doctor.

One of the biggest obstacles to responding to those injured as a result of the earthquake is the absence of important investigative medical devices, most notably CT devices. For example, more than 50 patients were reported to a hospital operating in the region during the first hours of the earthquake, who had severe neurological injuries, and as a result of the presence of only one CT imaging device in the hospital, the injured were forced to wait in a long line, says Dr. Abu al-Ezz.

The doctor believes that a number of the earthquake victims died while waiting for their turn for a CT scan, as a result of most of them suffering complex neurological and orthopedic injuries that sometimes require the follow-up of more than one doctor at the same time.

The CT device is a scanning device that operates in a circular motion, linked to a high-performance computer that analyzes the comprehensive image and allows identification of damage that may have occurred to the organs of the body. The CT also detects the presence of lesions in one of the internal organs and allows examining the anatomy of the patient’s body before performing surgeries, most notably neurological and orthopedic.

Psychologically and medically, needs pile up

The needs of the earthquake victims in northwestern Syria during the current and coming period, whether those who have been exposed to direct health or even psychological harm, are diverse.

Dr. Abdulkarim Ekzayez and Dr. Osama Abu al-Ezz believe that one of the most important needs of the injured in general is psychological support at a time when the health system in northwestern Syria is not equipped at all in this regard.

There are only three psychiatrists in the area, while tens of thousands of people, and perhaps more, need psychological support as a result of their exposure to surgery or psychological trauma due to being pulled out or their relatives from under the rubble.

Specialists believe that the psychological response is also related to improving the patient’s general conditions, as it is not possible to support the person psychologically while he is in the open, meaning that the next stage requires improving living conditions in terms of shelter, food, and minimum means of living that allow the person to recreate his life again, in addition to psychological support.

Earthquake patients also need physical medical follow-up, as people with crush injuries, for example, need more than two months to undergo successive operations to get rid of dead tissue to prevent the death of other parts around it.

Dr. Abu al-Ezz believes that the situation of patients injured as a result of the earthquake does not depend on their initial and first-aid treatment in hospitals only but rather requires the provision of subsequent services represented in dealing with medical complications that may occur to them, especially physiotherapy, which witnessed clear neglect in support during the last period as a result of the decline in the number of traumatic injuries resulting from the war.

At this stage, attention must be paid to the physiotherapy service in a manner commensurate with the great need after the severe injuries as a result of the earthquake, and to provide it in a way that makes it easy for patients to reach it according to the most affected areas and residential communities, and inside the camps, which requires large financial funding because of the expensive requirements it requires. 

Physiotherapy for the injured helps to avoid many important complications that may befall patients as a result of their injuries, including mobility impairment, fusion, calcification of joints, and others.

On February 20, The UN Deputy Special Envoy to Syria, Najat Rushdi, said that it is expected that about 8.8 million people affected by the earthquake in Syria will need some form of humanitarian assistance.

According to the latest figures by the World Health Organization (WHO), about seven hospitals and about 145 health facilities were damaged in Syria as a result of the earthquake, many of them in northwestern regions of Syria, which have been devastated by war over a decade, and are more vulnerable to aftershocks.