Injury, Int. J.

Care Injured (2007) 38, 290—297

www.elsevier.com/locate/injury

The evaluation of trauma patients in Turkish Red

Crescent Field Hospital following the Pakistan
earthquake in 2005
Murat Bozkurt a,*, Ali Ocguder a, Ugur Turktas b, Mustafa Erdem b

a
Diskapi Yildirim Beyazid Research and Education Hospital, 3rd Orthopaedics
and Traumatology Clinic, Diskapi, 06100 Ankara, Turkey
b
Ataturk Research and Education Hospital, 1st Orthopaedics and Traumatology Clinic,
Bilkent, 06800 Ankara, Turkey

Accepted 17 October 2006

KEYWORDS Summary To provide better emergency and outpatient services in well-equipped

Pakistan; field hospitals, organisation and team and equipment selection are of utmost impor-
Earthquake; tance to meet the demands of the earthquake zone. In the planning stage, the
Field hospital; evaluation of data collected after the earthquake is essential.
Trauma On 14 October 2005, following the earthquake in the city of Muzafferabad of
Kashmir, Pakistan on 8 October 2005, Turkish Red Crescent Field Hospital was
established and equipped with health professionals. A total of 2892 patients were
treated and followed up. All the patients were prospectively evaluated. The profiles
of the patients transferred, operated, or followed up within this period were
documented. Furthermore, the patients who applied with post-traumatic musculos-
keletal trauma were also documented. Of 1075 patients, who applied to orthopaedics
outpatient clinic, 543 were female and 632 were male. The patients were evaluated
based on their fracture as follows: pelvis (n = 45), femur (n = 59), tibia (n = 87), ankle
and foot (n = 45), vertebra (n = 41), clavicle (n = 10), humerus (n = 38), forearm
(n = 20) and hand and wrist (n = 45).
Medical necessities in an earthquake zone are dynamic and change rapidly. Field
hospitals must be prepared for requested changes to their mode of activity and for
extreme conditions.
# 2006 Elsevier Ltd. All rights reserved.

* Corresponding author at: Tirebolu Sokak, Omrumce Apt.,
27/18, Yukariayranci, TR-06550 Ankara, Turkey.
Tel.: +90 312 5171719; fax: +90 312 5171720.
E-mail address: nmbozkurt@yahoo.com (M. Bozkurt).
Introduction
The primary objective in the first 10—14 days after
any disastrous earthquake involving many casualties

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2006.10.013
Evaluation of trauma patients in the 2005 Pakistan earthquake
is the rescue of possible survivors under the debris.
In this period, search and recovery teams rescue
the survivors and transfer them to hospitals for
treatment. The period when the injured have a
chance to get real treatment is after the second
week of search and recovery activities in which the
pace and success rate of the mission is diminished.
In addition to the hospitals that have incurred little
or no damage and are in good condition, field
hospitals established by national and international
medical teams provide health services to the
injured and those with ordinary complaints in their
emergency rooms and outpatient clinics.1—4,6,9,11
To provide better emergency and outpatient ser-
vices in well-equipped field hospitals, organisation
and team and equipment selection are of utmost
importance to meet the demands of the earth-
quake zone. In the planning stage, the evaluation
of data collected after the earthquake is essential.
It is well known that the medical response to
disasters in developing countries has been poorly
documented.9 This study presents the profile and
documentation of the patients evaluated and trea-
ted after the massive earthquake (7.6 magnitude)
of 8 October 2005 in Kashmir, Pakistan and Muzaf-
ferabad, the capital of the state, and its vicinity
following the search and recovery operations, with
an aim to guide in the planning and organisation of
health services.
Patients and methods
On 9 October 2005, following the earthquake in the
city of Muzafferabad of Kashmir, Pakistan on 8
October 2005, a Turkish rescue team was involved
in search and recovery of survivors at the disaster
sites as well as retrieval of the dead from the ruins.
Turkish Red Crescent Field Hospital was established
on 14 October 2005 and equipped with health pro-
fessionals working in rotational basis of 2—3-week
periods.
In the Turkish Red Crescent Field Hospital estab-
lished in Muzafferabad, the second team working
between 20 and 31 October 2005 consisted of 13
physicians and 9 health care aids and worked with
the logistic, technical, and hospital staff of the
Turkish Red Crescent. Two orthopaedic and trauma-
tology specialists, one orthopaedic and traumatol-
ogy fellow, one nephrologist, one paediatric
specialist, one obstetrics and gynaecology specia-
list, one infectious diseases specialist, one otolar-
yngology specialist, one radiologist, and six
practitioners worked as members of Turkish National
Medial Rescue Team and were assisted by two anaes-
thetic technicians, two radiology technicians, two
291
laboratory technicians, one orthopaedic technician,
and five nurses. The team was under the supervision
of a senior orthopaedic and traumatology specialist
(MB). Turkish Red Crescent Technical Team provided
the service departments for energy, food, commu-
nication, transport and other necessities. The cen-
tre contained a triage tent, dressing and patient
examination tent, outpatient tent, orthopaedic
intervention and plastering tent, laboratory tent,
roentgen tent, pharmacy tent, and sterilisation tent
as well as two operation tents where two operations
could be performed simultaneously and treatment
and follow-up tent of 50-patient capacity. The
patients arrived at the hospital themselves or by
air or land transportation provided by the local
government. Communication with the patients
was facilitated by eight interpreters working in
shifts and translating from Urdu to English. The
patients received at the triage were referred to
the outpatient clinics depending on the case and
further consultations were conducted at these
clinics. The patients that required surgical inter-
vention were operated under emergency operative
conditions. The patients requiring follow-up by
internal medicine as well as the preoperative and
post-operative patients were treated. In the in-
patient unit, different teams performed the dres-
sings of outpatient and inpatient cases. In a 12-day
period, a three-person health care team visited the
nearby villages twice for help and care in collabora-
tion with the Turkish Red Crescent team. In the
Turkish Red Crescent Field Hospital established in
Muzafferabad between 20 and 31 October 2005, a
total of 2892 patients were treated and followed up.
All the patients were evaluated prospectively. The
profiles of the patients transferred, operated, or
followed up within this period were documented.
Furthermore, the patients who applied with post-
traumatic musculoskeletal trauma were also docu-
mented.
Results
The second health care team that started to serve
12 days after the earthquake completed the treat-
ment and follow-up of 2892 patients within a 12-day
period. The gender distribution of the patients was
1522 male and 1370 female. The patients were
classified based on their systemic disorders as fol-
lows: musculoskeletal system injury (n = 1075),
respiratory tract disorders (n = 438), cardiological
disorders (n = 110), gastro-enterological disorders
(n = 328), urinary tract disorders (n = 207), soft tis-
sue infections (n = 276), dermatological problems
(n = 265), and others (n = 193).
292 M. Bozkurt et al.

Table 1 Detailed information of the surgically treated patients

Fracture Soft tissue
Localisation ORIF (n) External fixation (n) Amputation (n) Localisation Abcess drainage (n)
Femur 5 8 — Thigh 4
Tibia 2 9 3 Sacral 1
Ankle 2
Metatars 1
Humerus 2
Forearm 1
Radius distal 3
Metacarp 2

Detailed documentation of the patients with
musculoskeletal injuries has been provided in
Table 1. The diagnosis, the surgery method and
operative materials used, and operation time of
43 patients have been presented in Table 2.
Of 1075 patients seen in the orthopaedic out-
patient clinic, 543 were female and 632 were male.
The age distribution of the patients were as follows:
363, under 15 years of age (33.76%); 225, between
the ages of 15 and 30 years (20.93%); 418, between
the ages of 30 and 60 years (38.88%); 69, over 60
years of age (6.41%). Trauma patients suffered from
open fractures (n = 63, 5.86%) or injuries. Twenty-
five of these patients (2.32%) suffered from infec-
tions.
Our centre was the first point of application for 59
(5.48%) of the patients with femoral fractures, 87
(8.09%) of the patients with fractures of the tibia, 38
(3.53%) of the patients with humeral fractures, and
20 (1.86%) of the patients with forearm fractures.
None of these patients had received any previous. Of
these patients, 13.58% were treated by health care
providers who were not physicians. Four patients
with open fractures had wide soft tissue infection

Figure 1 (a—c) Different types of open fracture fixation attempted by the use of a hard substance containing mud or
clay, a common belief for treatment of these kind of wounds by the people of the area.
Evaluation of trauma patients in the 2005 Pakistan earthquake 293

Table 2 Localisations of the fractures and malunions

Fracture Malunion
Localisation n Localisation n
Pelvis fracture 45
Femur fracture 42 Femur malunion 17
Intertrochanteric 5
Subtrochanteric 9 Subtrochanteric 4
Femur shaft 24 Femur shaft 11
Supracondylar 4 Supracondylar 2
Tibia fracture 45 Tibia malunion 20
Proximal 7 Proximal 2
Medial plateau 4
Middle 34 Middle 11
Distal 22 Distal 7
Foot and ankle fracture 34 Foot and ankle malunion 11
Bimalleolar 10 Bimalleolar 5
Lateral malleolus 13 Lateral malleolus 4
Calcaneus 3
Metatars 5 Metatars 1
Phalanx 3 Phalanx 1

Vertebra fracture 41
Lumbar 35
L1 16
L2 13
L3 6
Thoracic 5
T12 4
T11 1
Cervical 1
C4 1
Clavicular fracture 10
Proximal 1
Orta 7
Distal 2
Humerus fracture 26 Humerus malunion 12
Proximal 8 3
Humerus shaft 14 8
Supracondylar 4 1
Forearm fracture 20
Proximal 3
Middle 11
Distal 6
Hand and wrist fracture 45
Radius distal 23
Scaphoid 7
Metacarp 7
Phalanx 8

due to fixation attempted by the use of hard sub-
stances containing mud or clay, a common belief for
treatment of this kind of wound by the people of the
area (Fig. 1a—c). Two of these cases had to be
amputated below the knee, and one was amputated
above the knee. One case, however, received wide
debridement and external fixation and was trans-
ferred to Islamabad for further reconstruction.
Details of treatment modalities are presented in
Table 3.
294 M. Bozkurt et al.

Table 3 Treatment modalities of the fractures

Fracture Conservative treatment (n) Surgical treatment (n) Transfer to another centre (n) Total (n)
Pelvis 35 10 45
Femur 36 13 10 59
Tibia 63 14 10 87
Ankle-foot 42 3 45
Vertebra 41 41
Clavicula 10 10
Humerus 36 2 38
Forearm 19 1 20
Hand-wrist 40 5 45

Unusual and earthquake-specific injury types

were also noted. Four cases applied with drop hand
without significant bone or soft tissue lesion (Fig. 2a
and b). Another common lesion type specific for
earthquake was injuries to the scalp with severe
defects due to collapsing roofs. Eleven children
presented to the outpatient clinic with open wounds
in the scalp (Fig. 3a and b).
In the time period described (second group), two
infant (18 months of age and 26 months of age)
deaths occurred due to pneumonia and septic
shock.

Figure 2 (a and b) Drop hand without significant bone or Figure 3 (a and b) Severe scalp defects due to collapsing
soft tissue lesion. roofs.
Evaluation of trauma patients in the 2005 Pakistan earthquake
Discussion
Medical necessities in an earthquake zone are
dynamic and change rapidly. Field hospitals must
be prepared for requested changes to their mode of
activity and for extreme conditions. Dayan et al.3
reported that in the first few days, the medical
teams concentrated on treating injuries caused
directly by the earthquake. Surgical and orthopae-
dic staff as well as obstetrics and gynaecology are
the main medical disciplines needed at this
stage.3—5,7,8,12,13,15 In the later stages, a normal
distribution of disease is encountered and a mix-
ture of medical specialties must provide for the
regular medical needs of the people living in the
earthquake zone. Infectious diseases such as gas-
tro-intestinal and respiratory infections should be
anticipated as well as exacerbation of chronic ill-
ness because of the lack of appropriate medical
supplies.1—4,9
The hospital was set up 6 days after the earth-
quake on 14 October 2005 by the Turkish Crescent.
The observations of the second group working in the
area after the earthquake have been presented. In
the Turkish Crescent Field Hospital established at
the official invitation of the Pakistani government as
part of the common humanitarian efforts between
the two countries, a work program of a minimum 1-
year duration has been planned. Throughout this
period, health teams from the entire Turkish health
care team arrived at the area for 2—3-week periods
and provided health care services.
One the harsh environmental conditions, to the
motivational level of the teams tended to diminish
after a certain period; thus, interchanging short
periods (2—3 weeks) of work among the teams
seemed to present better service. The Pakistani
government facilitated the work of all the teams
arriving from different countries; for example,
many of our colleagues who arrived in the first team
without a visa were issued one on their arrival at the
airport. Turkish Military planes provided the trans-
portation of the teams to the region. Therefore, the
first teams arriving at the region conducted logistic
investigations to set up the hospital at locations
where it would be safe in the aftershocks, and
medical supplies, equipment, and infrastructure
needed were transported. All the personnel and
equipment were transferred from Turkey. The Turk-
ish Crescent team that served in the region had also
worked in the relief efforts for tsunami victims and
earthquakes in Turkey, so, they were highly experi-
enced. A generator was available in case of power
failure, and was put in use by the technical team.
The water system was reinforced by additional
water tanks that were regularly chlorinated. The
295
tent kitchens set up in the hospital and the cooks
met the food needs of the health care workers and
technical team at the hospital. Bottled drinking
water was available. Because the hospital existed
for a long time, when the team was replaced the
treatment of the patients was not affected or inter-
rupted. No ethical problems were encountered
between the patients’ relatives and the hospital
team.
Despite all the precautions, some medical sup-
plies were damaged during transportation, and
some supplies were missing; however, the Turkish
Crescent Team located in Islamabad, closest to our
field hospital, supplied most of the missing items.
Some other equipment (wheel chairs, stretchers,
etc.) was transported by military cargo planes
arriving from Turkey. Still other materials needed
were supplied from among the remaining medical
supplies after the hospital in Muzafferabad, which
had become uninhabitable due to the earthquake,
was evacuated, while others were provided,
upon their visit to our hospital, by the represen-
tatives of NGOs in areas like Karachi with higher
socio-cultural level where earthquake was not
felt.
Pakistani military forces provided the security of
the hospital. Volunteer health care personnel and
military doctors were assigned who could speak
English and Urdu. They translated for patients’
relatives, patients, and the health care team.
In the first 2 weeks after the earthquake in Paki-
stan, a significant number of patients presented
with musculoskeletal injury and infection. The lack
of a plastic and reconstructive surgery specialist in
the team was unfortunate. However, the same pro-
blem was reported for the largest local hospital in
Muzafferabad as well as for American, French, and
Canadian centres. The third team arriving from
Turkey included a plastic and reconstructive sur-
geon.
In delayed and malunion cases, correction was
achieved by stabilising with unilateral external fixa-
tors. For easy application, self-drilling and self-
tapping Schanz screws were preferred. Schanz
screws were fixed to each other by radiolucent
carbon rods. Under X-Ray control, the interventions
needed were performed and rigid fixation was
achieved. In open fractures with soft tissue defects
in particular, repeated debridement and dressings
were performed to encourage granulation tissue
formation. The patients who could wait were trea-
ted by two plastic surgeons, who would arrive in the
following team, by grafting and flaps. However,
those who required urgent intervention or could
not wait were transferred to Islamabad by military
helicopters.
296
Another important responsibility of logistic teams
arriving after an earthquake is the determination of
hygienic and traditional habits of the people in the
area that may constitute health risks, and take
precautions as well as inform the people of the
health hazards. The methods used by non-medical
individuals in Kashmir to treat open wounds with
various substances significantly increased the risk of
amputation.
The majority of the patients were admitted with
fractures or injuries associated with the trauma
received during the earthquake.3,4,7—10,12—15
Following the initial shock of an earthquake,
patients usually gain access to field hospitals more
easily after the second week. Thus, closed reduction
and surgical treatment of these fractures may be
considered. External fixators that are easily
applied, cannulated screws and screw sets were
the most useful orthopaedic implants. In a period
such as the one described, a field hospital should
have specialists in orthopaedic and traumatology,
plastic and reconstructive surgery, infectious dis-
eases, general surgery, anaesthesia, paediatrics,
internal medicine, and obstetrics and gynaecology
as well as orthopaedic, anaesthetic, radiology, and
laboratory technicians and nurses. Furthermore,
the presence of an interpreter is highly needed
for patient—medical staff communication.
Although a team of military physicians may be
considered more appropriate because of their train-
ing for difficult conditions in field hospitals, civilian
medical teams that are trained to work in coordina-
tion with Red Crescent or Red Cross organisations
will provide better organisation of search and recov-
ery efforts and medical services from a particular
centre.
Field hospitals should keep the socio-cultural
level of the area it serves in mind. For example,
the religious and traditional values of Pakistani
people oppose examination of pregnant women by
male gynaecologist; thus, in the next team arriving,
there was a female gynaecologist and a female
midwife.
The experience we present could be a guide for
the period after search and recovery. In such dis-
asters, experienced and organised teams will assure
smooth operation of medical services.
Finally, our recommendations are: (1) if possi-
ble, a pioneer team should conduct a thorough
evaluation of socio-cultural and economic condi-
tions of the disaster area, which would aid in
proper planning and preparation; (2) the team
members should be informed as to the food,
drinking, shelter, bathroom facilities, and weather
conditions before their arrival in the area, and
precautions must be taken to ensure such services
M. Bozkurt et al.
(generator, water tank, tent, sleeping bag, bread,
water, chlorine, etc.); (3) the compatibility of the
team members, if possible, a pre-training session
under simulated conditions of a challenging envir-
onment in specially designed camps, and determi-
nation of team leaders ahead of time and enabling
their communication with the technical team lea-
ders are of great importance; (4) the transporta-
tion of medical equipment (sterilisation unit,
operation rooms, radiology units, etc.) should
be realised by the use of containers, and self-
sufficient infrastructure (generator, etc.) must
be available and regularly maintained.
Acknowledgments
We would like to extend our deepest thanks to Dr. Ali
Coskun, Dr. Ahmet Karadag, Dr. Hanifi Kurtaran, Dr.
Mehmet Kanbay, Dr. Cemal Bulut, Dr. Ikbal Cekmen,
Dr. Dogan Barbaros, Dr. Ahmet Yönder, Dr. Muhsin
Boga, Dr. Basri Cidan, Dr. M. Yasar Yilmaz, Emine
Seyhun, Pelin Gundag, Dilek Bozer, Yasemin Kaya,
Senol Sahin, Mehmet Sever, Hakan Gungor for their
great work in Turkish Red Crescent Field Hospital.
We would also like to thank Turkish Red Crescent
Pakistan Earthquake Team for their great contribu-
tion. We are grateful to the nurses, translators from
Pakistan and Pakistan army and government who
inspired the teamwork between Turkish and Paki-
stan medical staff.
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