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June 27, 2012 --
“They attacked the town,” said Dr. Jordy Cox, a Colorado-based trauma surgeon who was working in the Congo with Doctors Without Borders when civil war broke out in 2008. The rebels came but Dr. Cox’s medical team stayed. “We never left the hospital. There was actual fighting in the streets right next to us.” When doctors like Jordy Cox travel to conflict areas, they typically bring along kits of medical supplies, such as those provided by Doctors Without Borders. But that's not all. Detonating bombs and insurgent activity can destroy fundamental infrastructures, like power grids, that make treating patients a major challenge. To that end, doctors often bring along their own personal equipment and tools. That way if the power goes out or computers are nowhere to be found, they're prepared. Medical doctors with experience working in acute conflict areas describe here some of items they pack, just in case. ANALYSIS: Video Service Streams Live Reports from Syria
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Extra Tourniquets Dr. Jacques Bérès is a septuagenarian French surgeon who has already sneaked into Syria several times this year to perform life-saving operations on dozens of wounded people. He had to pack extra light since he was crossing the border illegally. "The risk is so important; it's impossible to have heavy luggage with you,” he said. One of the few things he did bring: a personal tourniquet. These devices apply pressure around a wounded extremity to control blood flow. “It’s such a pity to have to cry for a tourniquet in case of emergency bleeding.” Dr. Cox, who has worked for Doctors Without Borders in several conflict areas, also packs extra tourniquets. “Especially if I’m going to an area that I know is potentially going to have bombs and explosions,” he said. “It’s a way of temporizing injuries.”
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Lightweight Body Armor Whenever tensions increase and fighting spikes, Dr. Cox slips on his own personal body armor and puts a sterile surgical gown over that. “It’s a level 3A, so it will take a direct impact from a 45-caliber,” he said. “They’re nice and light and comfortable.” Dr. Cox said he’s careful not to make a big show of donning the armor. When underneath a gown, the vest is hardly noticeable. Despite its advantages, the armor won’t stop a direct hit from an AK-47, he added. That would go through the vest, through him, and out the other side.
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Binocular Loupes In Syria, Dr. Bérès was able to find enough supplies to perform dozens of emergency surgeries, but there was nothing available for specialized surgical procedures. “That’s normal in war conditions,” he said. One piece of equipment Dr. Bérès brought was his pair of binocular loupes, special small magnifying lenses fitted over glasses that are designed to help him perform microsurgery. Dr. Cox normally wears glasses so when he performs vascular surgery to repair blood vessels he puts on loupes as well. “I take them because they’re mine,” he said. “They’re my prescription.”
Microsurgery Tools Besides his binocular loupes, Dr. Bérès packed other tools needed for microsurgery that he knew wouldn’t be found easily in Syria. They include a needle holder and extremely thin microfilament sutures. “The very tiny, tiny stitch of microsurgery -- number 8- and 9-zeroes,” he said, “I used to not find them anywhere in the world.” Dr. Bérès performs microsurgery because he doesn’t like to just stop hemorrhaging and repair broken bones without paying attention to problems such as nerve damage or internal lesions to a liver. If he doesn’t address those injuries, they may never be addressed. “I don’t like to leave it,” he said. “It won’t be set up in the next month because people have to escape, to hide.”
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Dermatome Skin Graft Machine “Scalpels, and scissors, and needle holders, and stitches -- I will find it,” Dr. Bérès said. “I just have to bring very special brings which I would not find.” One of those instruments is a dermatome skin graft machine, a device that resembles a high-tech cheese slicer. With a lightweight dermatome, the surgeon can take skin grafts necessary for reconstituting burned areas. While Dr. Bérès was in Syria last spring, the regular army attacked twice so he had to work quickly and couldn’t stay in one location for long time. “Altogether I performed only 45 operations in Idlib in two different places,” he said. Before leaving the country, Dr. Bérès said he always gives the specialized equipment he’s brought to the people with whom he’s been working. It’s not fair to just show it to them, he said. “That’s not possible. We have to leave it.”
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Battery-Powered Headlamp The first rule in a siege, Dr. Cox has learned, is to shut off the water and power to a city. In the Congo while he was there, fighting was at its most intense. The city was in flames and there were no lights. “We’re operating with our head lights,” he said. “I always bring a very powerful head light.” Although he used to wear mountaineer headlamps, he now brings a battery-powered dentist’s headlight. During that siege, wounded patients kept arriving so the surgical team operated nonstop for about 24 hours before the three men sterilizing instruments said there were no more instruments ready. They all had to wait a few hours. “The machine went ding. The instruments were ready,” Dr. Cox said. “We started up again.”
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Basic Handbook In the United States, doctors are surrounded by nurses, systems and computer assistance. But in a developing country, having a medical handbook with basic reference information can be helpful, said Dr. Emmanuel d'Harcourt, the senior health director for the humanitarian aid organization the International Rescue Committee. Dr. d'Harcourt, a pediatrician by training, has relied on a Johns Hopkins Hospital guide to pediatric diagnosis and treatment called the Harriet Lane Handbook. The book is named after Lane, who acted as first lady to her uncle, President James Buchanan, and left a generous endowment for invalid children to the hospital. “That’s more for my personal need as a clinician,” Dr. d'Harcourt said. He got the book while in medical school at Johns Hopkins. “It helps you with things like how much fluid to give a kid according to their weight.”
Pulse Oximeter Doctors Without Borders has medical standards that mimic those used in Western medicine. “It’s amazing how much quality care they provide despite the fact that we’re in extreme conditions,” Dr. Cox said. For example, the use of antibiotics in the field is highly regulated by clear scientific data. In addition to his body armor, headlight, tourniquets and loupes, Dr. Cox also brings a pulse oximeter, a small, noninvasive tool for measuring a patient’s oxygen level. “MSF has their own but I just like to have my little guy that I can carry with me,” he said. Dr. érès didn’t want to place too much emphasis on the specialized medical equipment that he packs. “The tools are not important,” he said. “The importance is to be with them during the bombing, or just after to help them. That’s all.” EXCLUSIVE INTERVIEW: On Edge in Syria's Capitol
Medical researchers say they have discovered a possible “vaccine” for post-traumatic stress disorder that could protect soldiers in battle by regulating one of the body’s own hormones.
Scientists at the Massachusetts Institute of Technology report in a new paper that ghrelin, a hormone produced during stressful situations, primes the brain for PTSD. They believe that by controlling ghrelin, they can also prevent the formation of PTSD after traumatic events.
“You would get a shot, and for a year it would lower your ghrelin levels,” said Ki Gossens, assistant professor of brain and cognitive sciences at MIT, and an author of the paper in the journal Molecular Psychiatry, which is appearing this week. “When you were deployed and exposed to the stress of combat, your ghrelin levels would go up and the vaccine would combat that. That should reduce the incidence of PTSD. Right now, we don’t have anything to prevent it.”
Scientists had previously known that ghrelin makes you hungrier and dubbed it the “hunger hormone.” It was the target of research by drug companies who wanted a cure for obesity, but none of that work was successful. However, Gossens said her group has found that ghrelin also may make people more susceptible to PTSD.
During their experiments, the researchers found that when rats were given a drug to stimulate ghrelin levels in the blood, they became much more susceptible to fear than normal rats. By blocking the receptors on the cells that interact with ghrelin, the researchers reduced fear to normal levels in the chronically stressed rats.
Gossens said that ghrelin operates alongside the brain’s other “fight or flight” neurochemical system, which is controlled by the hormones cortisol and adrenaline. That signaling route is known as the hypothalamus-pituatary-adrenal pathway, or HPA.
“What we are suggesting is that the ghrelin pathway operates in parallel,” Gossens said. “We think the emotional disorders (such as PTSD) following trauma exposure are the result of elevated ghrelin rather than HPA. It gives us a completely new set of targets to treat PTSD.”
Gossens believes that since many ghrelin-related anti-obesity drugs have already passed federal human safety trials, it would give them a leg up on developing some kind of vaccine for PTSD. However at least one researcher said blocking ghrelin might have harmful side effects.
“As to the ‘vaccination’ issue, it is premature to talk about that and probably also not a good idea,” said Bruce McEwen, director of the neuroendocrinology laboratory at Rockefeller University in New York in an e-mail. “Ghrelin is a hormone and also a neuromodulator that stimulates appetite and also enhances aspects of cognitive function. A systemic vaccination might not even work and could ... make people anorectic and impair other aspects of physiology by blocking good actions of ghrelin.”
Despite these reservations, McEwen said that the MIT paper “advances our knowledge by introducing a new player, ghrelin, in the fear and PTSD-related behavior story.”
That might be some good news for sufferers of PTSD, a condition that has affected nearly 250,000 service members who fought in Iraq and Afghanistan since 2001.