Surgery in a cave
Treating the wounded in
the Syrian civil war
British surgeon Paul McMaster recently returned from Syria, where he treated the wounded in an operating theatre set up by Médecins Sans Frontières/Doctors Without Borders (MSF) in a cave and then on a farm. Though McMaster has experience working in war zones, in Syria he found a “more oppressive type of danger”. He reflects on his experiences.
I flew into Turkey, and then we went up to
the low mountains near the border, where
we were picked up by a guide who took us
through forests and hills into Syria.
MSF has four surgical teams working in the
conflict zone in northwest Syria. Our team
was working in a cave. We went in through a
very small entrance. Inside, there was an
inflatable operating tent and six emergency
beds. Everything took place in that area, and
it was often hectic and difficult for people to
move around. Still, it was remarkable to have
created a sterile environment, with all the
right surgical equipment, in what was essentially
a dusty chalk cave.
We were staying 15 minutes away in a
very small village. Most of us were
sleeping on the floor in the basement
room of the mosque. The villagers were
happy for us to be there. Every day a lady
in the village cooked a whole lot of flat
bread, so we lived on that, and beans.
Quite a lot of the population had left
the area for refugee camps on the other side of the border in Turkey. But there
were still significant numbers of older
people, women, and children remaining,
and these are the areas that are being
rocketed and bombed from helicopters.
The helicopters travel around slowly and
hover over towns before dropping large
bombs and these things cascade down and
cause an enormous blast and destroy buildings.
The bombing of the towns and villages
was happening every day.
When they explode in the mountains,
the bombs create enormous explosions of
sound which reverberate through the hills
and are clearly very frightening for people.
On our last morning in the cave, several
landed within a couple of hundred metres
of us, shaking the cave and bringing down
dust. You didn’t quite know whether you
were better off outside or inside. It’s very
unsettling for everybody, especially for
wounded patients and children.
On our team there was a surgeon, an
anaesthetist, an emergency nurse, two
doctors, a Syrian nurse in her early 30s who
was just inspirational -- never tired, always
organised, always smiling – and about 11
young women from the villages who we
were slowly training to do basic nursing.
The majority of our patients were civilians – old people, women, children,
babies. Many had been wounded in
bombings and had shrapnel injuries.
Sometimes the injuries weren’t physically
serious, but emotionally and psychologically
they were very damaging indeed.
One night we were called in and there
were two distraught women with three
screaming babies. Their house had been
literally demolished by a bomb, and these
children had shrapnel wounds to their faces
– the wounds were not life threatening, but
they were in great distress and anguish.
Another night a man in his late 30s
was brought in by a very excitable crowd
of fighters. He’d been shot through his
chest, we had very limited blood supplies,
and his condition was so unstable that I
doubted he’d make it through the night.
But he pulled through and the determination
he showed was quite remarkable.
I remember another man who came in
with severe shrapnel wounds to his leg.
The blast had gone through his leg and
damaged the main nerve, but not the
main blood vessel. He had lost two or
three of his family in the blast. We operated
on him, but afterwards he lost all
motivation to get better – he’d lost his
home, he’d lost many of his family, and he faced a potentially crippling injury.
really very difficult for people.
Over the last five or six weeks, we did
about 100 operations and treated many
more casualties. We also saw diabetics who
had run out of medication, children with
asthma, women who needed Caesarean
sections. These people have had no access
to effective health care for over a year.
Some people might be able to make it over
the mountains to Turkey to get treatment,
but for many that’s just not an option.
When you’re faced with casualties, the
surgery is fairly straightforward. You do
what’s called damage limitation surgery to
stop haemorrhages and deal with damaged
internal organs. The difficulty came when
we moved to the reconstructive phase –
things like physiotherapy and rehabilitation
and more complex orthopaedics – this was
work we just couldn’t do in the cave.
You can get overwhelmed. When it
became fairly clear that medically we were
struggling to cope with the patients in the
cave, we closed it and transferred our
patients and the team to a new location. It
was a farm – so not a great upgrade.
The new hospital was a long, open
building, and in the space of just four or
five days, the logisticians managed to
create an inflatable operating theatre, an
emergency triage area, a sterilization unit,
an outpatient consulting area, and an
inpatient and recovery area – it was a
It wasn’t perfect, it still looked a bit like
a farm, but it created much more space to
treat casualties. We moved half the
patients on Thursday and the rest on
Friday, and by Saturday we were operating
in the new location.
I’ve worked in many difficult places
with MSF – war zones like Sri Lanka,
Ivory Coast, and Somalia – but while in
those countries it was dangerous on the
ground, in Syria the danger always comes
from the air. It’s a much more oppressive
type of danger, having a helicopter
hovering in the sky above you.
Many of the towns are like ghost towns, with the buildings blasted or destroyed.
There’s a hopeless, desperate air about the
place. Most people are living in cellars.
They’ve had no electricity for eight or nine
months. It’s very bleak indeed and winter is
beginning now. I think people are really
going to struggle, and the most vulnerable
will struggle most. For the civilian population,
trying to light little fires in their basements,
it’s going to be a very long, hard,
cold, dangerous winter.
Providing healthcare to Syrian refugees in Domeez camp, Iraq
As the crisis in Syria intensifies, people continue to flee to neighbouring countries. More than 50,000 Syrians have sought refuge in Iraq, including 42,000 in the Kurdistan region where many live in overcrowded camps.
Domeez camp, near the city of Dohuk in the Kurdish region of Iraq, was set up at the beginning of 2012 and is home today (November 2012) to nearly 15,000 Syrian refugees of Kurdish origin. Since May 2012, MSF has been running a 24-hour clinic in the camp, in collaboration with Dohuk’s Department of Health. Today, MSF is the camp’s main health provider, offering medical consultations and mental healthcare to the refugees, and providing training for local health staff. To date, MSF teams have provided over 20,500 consultations.
“Until June there were about 2,000 people settled in Domeez, and the camp was running well,” says Anja Wolz, MSF field coordinator in Dohuk. “But in August, the situation deteriorated because of a sudden massive arrival of refugees. With up to 1,000 people crossing the border each day, the camp quickly became overcrowded and, despite the efforts of the authorities, the level of assistance was clearly insufficient.”
For the past few months, major efforts have been made to improve the situation before winter starts. But with around 500 people crossing the border every day into Dohuk governorate, some of the newly arrived refugees in Domeez camp still have to share tents, blankets, mattresses and food with other families.
“I arrived with two of my children, but had to leave my husband and my two other daughters behind,” says a middle-aged Syrian woman. “We walked for more than six hours to cross the border. We don’t have our own tent yet, so we must share with another family. I have a kidney stone and it is very painful. Since we arrived here I have been lying down all the time because of the pain. I need surgery to remove the stone. Here, we Syrians suffer from sickness, but also from the difficult situation we have gone through.”
Most of the refugees in Domeez camp arrived with nothing, having left everything behind in Syria. Once in Iraq, they are issued with a six-month renewable residence permit by the Kurdish authorities, which allows them to look for work. Most find jobs as daily labourers. People who have been here for some time have begun to build extensions to their shelters and some have opened small shops within the camp.
Médecins Sans Frontières
international medical humanitarian
organisation that delivers aid to
people affected by armed conflict,
epidemics, natural disasters or
exclusion from health care in
more than 60 countries around
the world. Visit: www.msf-me.org
of upload: 22nd Jan 2013