Risks unavoidable and worth taking

At the Canadian-led Role 3 Multinational Medical Unit, we have had to take risks. When transferring Afghan patients home, to the Khandahar Regional Military Hospital or to Mirwais Regional Hospital, we often have to weigh the probability of successful convalescence against the possibility of complication, a “bounce-back” or death.

These risks have been unavoidable.

Without the use of Mirwais' 380 beds, we would not have been able to maintain the capacity required for new casualties. Likewise, without the collaboration of the Military Hospital, we would have been overwhelmed by recent civilian mass casualty events.

These risks serve a purpose: They enable us to maintain the readiness necessary to support Canadian, American, Coalition and Afghan troops in the field. Unlike Coalition wounded, who are rapidly moved through an outstanding air evacuation chain to world-class hospitals in Western Europe and North America, Afghan wounded are transferred to local hospitals — which presents a dilemma.

A gulf divides the medical capacity of these facilities from that of the Western-run and organized multinational medial unit. In transferring local nationals, we have to consider whether subspecialty care and nursing is available, whether appropriate pharmaceuticals are accessible and whether patient follow-up is feasible.

When facing these concerns, we have to keep in mind that, in Afghanistan, acceptable care is defined differently than in the developed world. Case in point: A man with a tibial external fixation reported to our facility months after his follow-up date, a radiograph confirming his clinically obvious non-union. Rare in the West, such a thing is all too common in a country with a poor telecommunication network, few roads and even fewer financial means.

Although we routinely deal with the local tertiary care hospitals, quite a few of our patients eventually receive care from community health posts run by community health workers. They represent the entry point into Afghanistan's healthcare network and are staffed by workers providing basic vaccination and acute care services to 1000–1500 people.

Constantly cognizant of the workers' extremely limited capabilities, our personnel have sought to increase their medical sophistication through a program of medical engagement. One of these outings uncovered a young boy with Pott's disease, again fairly rare in North America but more common in a country with an estimated 69 000 cases of tuberculosis in 2002. The boy ultimately received life and limb-saving surgery at the Role 3 at the hands of our Canadian and Dutch surgical teams.

Between the Community Health Post and the tertiary care hospital are the Basic Health Centre, the Comprehensive Health Centre, and the District Hospital, serving up to 30 000, 60 000 and 300 000 people, respectively.

The Basic Health Centre is a nurse-staffed outpatient clinic, while the Comprehensive Health Centre and the District Hospital are in-patient facilities with physicians, nurses, and ancillary personnel. Overseeing these is the Provincial Hospital, a slightly larger facility with greater surgical capacity and up to 4 times as many beds. Many of our patients from outlying provinces are eventually discharged to one of these centres or hospitals, one of which is logistically supported by several Role 3 personnel.

Despite this outreach, most of our engagement efforts center on the local tertiary care centers: Mirwais Regional Hospital in Khandahar City and the Khandahar Regional Military Hospital.

Indirect support is given to Mirwais through telephonic and electronic consultation. Patients are routinely transferred to and from the facility.

More direct support is difficult to deliver due to Mirwais' vulnerable location and the need for International Committee of the Red Cross workers, who are mentoring staff at the facility, to be seen as unaffiliated with the military or the Taliban.

The Military Hospital, on the other hand, is in a more secure area and is Afghan-staffed and United States–mentored. This has allowed for a robust partnership, and our members have provided medical education, clinical shadowing opportunities and consultative services to the hospital workforce. This collaboration recently culminated in a joint surgical effort, where a combined Afghan, Canadian and United States team placed a femoral intramedullary nail with good results.

Every medical procedure, transfers included, carries risk.

These risks are only justified by the potential for overriding benefit. In collaborating with the local health system, we have the potential to improve cooperation among our nations, to increase medical capacity and to make a difference in the lives of our Afghan friends that will long outlast our physical presence. It is a risk worth taking.