Pakistani Physicians Have to Heal Themselves

The first victim arrived at the regional Ayub medical complex here soon after the ground stopped shaking from the magnitude 7.6 earthquake. A wall had collapsed on the boy’s chest and he was coughing up blood as doctors frantically tried to stick a breathing tube down his throat.

Soon, a 25-year-old woman arrived whose foot was so mangled it no longer resembled a part of her body. Even worse off were the victims whose relatives had chopped their limbs to release them from the twisted wreckage of homes and schools. Within the first 24 hours of the Oct. 8 quake, scores of shocked and exhausted Pakistani doctors performed more than 800 procedures on the lawn outside the medical center, which itself had been crippled.

Five days later, before the first foreign medical teams reached this city about 40 miles north of Islamabad and 25 miles from the quake’s epicenter, the local medical team had performed 6,000 procedures, including 130 amputations. They operated under makeshift tents and sometimes under the open sky.

The physicians slept little, stealing cat naps on the concrete parking lot. They ran short of antibiotics and anesthesia. Some, not knowing the fate of their own families, had tears in their eyes as they worked on patients.

And the wounded kept coming.

Over the days and nights, rainstorms would drive skittish patients inside the damaged hospital, only to be driven back out by one of the 1,000 aftershocks that struck every few hours.

In all, doctors say they lost fewer than 200 patients at the hospital. But only now, weeks after the tragedy, can they begin to fathom the scale of the disaster and the conditions they endured in those first adrenaline-filled days. In interviews, a half dozen of the physicians described the ordeal that lingers in their nightmares, as well as the lessons they learned responding to the natural disaster that took at least 74,000 lives in Pakistan and India.

“It was unbelievable, like a war zone,” recalled Mohammad Adeel Riaz, a 26-year-old surgery resident at the teaching hospital. “But wars are planned. Nobody ever dreamed of an earthquake like this.”

Several visiting American doctors expressed amazement.

“There are limits to human endurance, whether you’re a doctor or anyone else,” said Inam Hussain, a Chicago-area anesthesiologist visiting the hospital to assess its needs. “These people have gone beyond those boundaries.”

On the morning the earthquake hit, Riaz was dozing at the hospital following an overnight shift. The force of the 8:50 a.m. temblor rolled his cot across the room. Before the ground stopped moving 35 seconds later, Riaz ran into a hallway. There he realized that all the emergency doors in the 20-year-old hospital were locked. He scurried down seemingly endless corridors to the front door as the three-story building shook.

Once outside, he and other doctors began to realize the gravity of the disaster. About 60 patients managed to flee the facility, some on crutches, others carried by medical aides or pushed on hospital beds.

The physicians quickly forged a plan: If their hospital was not safe, they would build a makeshift facility outside. Immediately, medical students volunteered to dash back inside the still-quivering building for supplies. Others began to donate blood for the victims they all knew would soon arrive.

But first there were colleagues who needed help. One doctor broke his jaw and both arms after leaping in panic from the third floor. Another suffered severe internal injuries after being buried by a collapsed wall.

Within the first hour, three 25-doctor teams organized an impromptu surgical facility outside the 1,200-bed hospital. Hours later, they had constructed four operating theaters inside a large circus-like tent normally used for weddings. Nearby, 500 beds and cots were arranged in haphazard rows under the sky.

The preparations could not be made fast enough. As some doctors lugged out operating tables and lights, others attended to the first arriving victims, including students from an elementary school -- two dead, three severely injured and crying for their parents.

During those first terrible hours, doctors recalled, the boy that needed an oxygen tube died. One in five arriving victims required amputations -- fingers, toes or entire limbs. The cases came so fast that doctors were not able to follow procedures and consult with family members about the emotional and physical aftereffects of the surgeries.

So doctors discussed the procedures with bleary-eyed patients, stressing the extent of their injuries. Then they began their grim work.

For some victims, there was no alternative -- like the boy brought in on a blanket, his left foot hanging only by skin. Nonetheless, the amputations were grueling for Riaz and other doctors to perform.

“They are by far the hardest procedure you face as a doctor,” he said. “If you do not do them, the patient will die. If you do, you know their lives will never be the same.”

The doctors were aware of prevailing attitudes about deformities in their culture, and the discrimination that amputee children, especially girls, were likely to face. Said Riaz: “As you worked, you knew the girls would never find husbands and the orphans would never be adopted by families.”

The first day, there were amputations on patients wounded by falling walls and buildings. Soon after came the gangrene cases.

And then there was the man impaled through the chest by a 6-foot beam. Doctors first had to saw off the ends of the pole to maneuver the victim into the operating tent. He survived.

Some patients were operated on in their makeshift beds rather than on hospital gurneys. Even some Muslim women, who are usually cared for by female doctors, were eager to be seen by any physician they could find.

Each day brought 1,000 new patients. They came on foot and by mule, carried in blankets or on stretchers made of sticks and used clothing. Some victims were already dead, their families unable to accept reality.

Soon, doctors say, the backs of their necks began to spasm from the stress of performing so many surgeries. Fasting during the Islamic holy month of Ramadan, they did not drink or eat during the day and often became dizzy. But they pressed on with their duties.

Zia-ur-Rehman, the gray-haired director of surgery, worked alongside student and veteran doctors. He remembers the woman who awakened from anesthesia, “and at first she thought she had died and gone to paradise.”

It took only one day for the hospital to run out of medicine. Residents volunteered to run to local pharmacies to collect what they could find.

Temperatures dropped after dark. Patients moaned and called out in the blackness. In the days following the quake, the area was hit by severe rainstorms that included hail and high winds. Hundreds of terrified patients ran from their open-air beds toward the shelter of the damaged hospital.

When a sizable aftershock shook the building, most scurried back outside.

During the storms, the big tent under which surgeries were performed leaked. Doctors scrambled for containers to catch the water, and others held on to the ends of the canvas so high winds would not blow the tent down.

The region would be rocked by five aftershocks that ranged in magnitude from 5.7 to 6.2, and by emotional aftershock.

“People were in shock -- they had lost their homes and their children and their parents,” said Imran Taj, a 28-year-old doctor. “We needed psychologists. We didn’t have any. All we had were patients.”

Slowly, help and reinforcements began to arrive. Trucks brought medical supplies and blankets. A team of South Korean aid workers came on the sixth day and set up a clinic on the hospital property that continues to operate. One by one, Ayub’s doctors were permitted to leave the hospital to return home and check on their own families.

These days, many of the most serious cases have been moved to other facilities. The Ayub medical team has moved back inside the damaged hospital, but doctors are still afraid, pointing out walls that crumbled and floors that buckled and sank. Like other structures, the hospital still needs to be inspected for long-term damage.

Most physicians perform their normal rounds as though in a daze, caring for the new patients who continually arrive at the center, but thinking about those first hours after the quake.

Rehman, the director of surgery, is proud of his team, “They will now all be better doctors,” he said. “They worked under stress unlike any they had ever seen, doing in three or four days as many procedures as they would normally do in eight months.”

Syed Shahbaz Sultan believes he’s now prepared for anything medicine can throw his way. “I’m ready to work anywhere in the world,” said the young medical resident. “The earthquake was terrible. But it taught us all to become survivors.”