Unexpected challenges: implementing an MSF emergency surgical response

The MSF team in Nigeria has a running joke: we are not just flexible, we are ‘elastic’.  Responding to an emergency is all about flexibility and being willing to shift priorities as new information comes to light.  In Makurdi, Benue state, southeast from the Nigerian capital, Abuja, an oil tanker exploded following a road traffic accident. The explosion resulted in over 100 dead and wounded, and we all knew we had to respond.  A sudden influx of this number of burns patients, who can needed complex and long-term treatment, would place stress on even the most efficient health system.  In this case, the local hospitals, including our partners at Benue State University Teaching Hospital (BSUTH), were already working close to their maximum capacity when the incident occurred. Within hours of the incident, the MSF team in Makurdi was in touch with our local partners asking what they needed and how we could help.

Before the explosion occurred, MSF activities in Benue included water and sanitation and primary healthcare provision for a population of internally displaced people (IDP). We were not providing inpatient care or surgery, but this accident happened in our ‘backyard’ and affected our local partners – so inaction was not an option.  Although the local hospitals had fully qualified surgeons and doctors able to handle the immediate triage needs, it was clear that they would need extra nursing staff and supplies (such as burn dressings, ointments and antibiotics) to treat that number of patients. Simultaneously, as the team on the ground provided direct support, MSF operations and medical departments in Amsterdam headquarters began formulating a plan to bring in extra resources, including medical supplies, financial support and both medical and logistics staff.  

Within days, we had essentially shifted from a project providing care for IDP into a highly specialised surgical intervention.

I first received news of the incident two days later, as I finished a field trip to Bangladesh. Along with the medical teams in Amsterdam and Nigeria, we began a preliminary plan for technical support: determining what human resources would be needed to support the Ministry of Health, as well as the availability of specialised equipment such as the electric dermatome, used for skin grafting procedures for burns patients.  My first phone call after landing in Amsterdam on a Friday night was to the pool manager for surgeons and anaesthetists, also working late from Berlin, to discuss who might be available to fly to Nigeria on short notice. Within a week of first hearing about the incident, my prior plans to visit Syria were put on hold, and instead I was on a plane to Nigeria – with the anaesthesia advisor following one day later – to support the new intervention.  

By the time I arrived, the MSF team on the ground had already made huge progress, with patients at the hospital receiving diligent care from the combined BSUTH-MSF team. Assessment of the patients revealed that many, although they had suffered extensive burns, were not too deeply burned, meaning the prognosis was quite good: with diligent nursing and wound care, complications like infection could be avoided.  Our Nigerian staff partners at BSUTH – including a full plastic surgery team – had already done a tremendous amount of work managing such a great number of patients, including performing emergency surgeries and providing intensive care. Plans were already in place to open a dedicated temporary burns ward, and the MSF counsellor and physiotherapist from our Noma project in Sokoto state were already busy working with patients.  Most of the injured were young men who had been trying to salvage fuel when the explosion happened.  They were receiving daily dressing changes – necessary to prevent infection, but often painful and stressful for the patient.  Our counsellor noted that the simple addition of music helped relieve a lot of anxiety, and soon the whole ward was singing along to support and provide a distraction for those undergoing their dressing changes.  Meanwhile, the physical therapist taught the patients simple techniques to prevent joint contractures: “relax, breathe, stretch, repeat.”  In addition, the MSF infection-prevention nurse was training the staff on dressing changes and hygiene.  After seeing the hospital, visiting patients and meeting with the hospital leadership, we made plans to create a small, dedicated operating theatre to accommodate the extra volume of patients requiring surgery.

It was such a large incident that the patients were scattered over several hospitals. Therefore, we set out to find as many of the remaining inpatients as possible.  In one day, I met every affected patient at all the outlying hospitals and got a sense of what their remaining medical needs entailed.  Everywhere we went, from the smallest inpatient hospital-clinic to the large federal tertiary care centre, known as the Federal Medical Centre (FMC), we found the patients being treated by diligent, caring Nigerian physicians who were making the best possible use of the resources available. I was impressed that despite the rural location and the lack of an emergency preparedness plan, the local hospitals had formed a well-functioning emergency response system, with the sickest patients being transferred for further management and those who could wait getting treatment at the smaller hospitals.  After seeing all of the patients, we met with Ministry of Health staff to form a comprehensive plan: transfer the remaining patients with surgical needs from the smaller hospitals to one of the two tertiary care centres, with MSF providing extra nursing and financial support and medical supply so that all patients received free care.  We would also plan a second partnership with the FMC to help support their care – already efficient – with extra nursing and infection prevention and control capacity. 

As the details of the overarching plan were finalised, it was ‘all hands on deck’ as the burns intervention became the MSF Nigerian team’s priority. Help arrived from the other MSF projects in the form of human resources and supplies.  A joint renovation effort ramped up to finish construction of the new wards, the new operating theatre, and improvements to water and sanitation structures including sterilisation, laundry and waste management.  Together, the BSUTH-MSF logistics, nursing, and water and sanitation teams worked tirelessly to get the infrastructure and processes in place.  By the end of our two-week stay, some patients were being discharged, while others were progressing to taking their first steps, with one even attempting dancing with some support from the physical therapist!

After two weeks, the new wards and operating theatre were almost ready to open, our partnerships were in the finalisation stage, and we had a plan that ensured every patient affected by this disaster received free, high quality care. Throughout it all, the team on the ground adapted to whatever the circumstances required: changes in strategy, new partnerships, new infrastructure and supply challenges.  Although the challenges in this type of setting may be unpredictable, the commitment of the MSF team in Nigeria is unwavering. Together with local partners, they have the elasticity to respond to whatever unexpected challenges come their way to ensure our patients get the best care possible.