Surmounting an Assault: Hospital Staging in Disaster, Structural Damage, and War

Published on April 18, 2016
Military attacks on hospitals have become all too frequent around the globe. Being prepared for them will help ensure your patients’ safety – and your own.

Attacks on health care workers and facilities have increased in recent years. In October 2015, US aerial forces attacked the Médecins Sans Frontières (MSF) Trauma Center in Kunduz, Afghanistan, resulting in 42 deaths, including 24 patients and 14 members of MSF’s staff. Among the staff casualties were the hospital’s deputy medical director, an emergency room physician, an ICU doctor, and several nurses. Patients in the intensive care unit burned to death in their beds. The attack – which garnered widespread international condemnation – resulted in a rare apology, first from the US commander in Afghanistan and then from President Obama himself. Another MSF facility was bombed in Yemen in January, following the attack on two other Yemen hospitals in previous months.

In its “Attacks on Health: Global Report,” released in May 2015, Human Rights Watch documents other instances of violence against health care workers and facilities. The HRW report shows that the assaults predominate in 13 countries where regional conflict or civil war is underway — and, thus, where medical care is needed most (see map).

The possibility of violence in or out of a war zone requires vigilance and preparedness on the part of emergency physicians. We must be aware of the dangers, protect ourselves against them, limit risk, and have an action plan in the event of emergency. We must ensure that our patients are taken care of even when we have to evacuate or move to temporary facilities. And we must “surmount”—a term from an old French word that means “to rise above or go beyond.” To muster through or carry on is what we do regardless of facility or patient status.

Hospitals are protected under international humanitarian law, and may only be attacked if there is clear evidence of coordinated military activity within the facility outside its humanitarian function. Except in cases when troops come under heavy fire from a medical building, such an attack can be initiated after the personnel there are warned and have reasonable time to respond and/or evacuate. Unfortunately, laws are violated. In remote locations, the destruction of a healthcare facility means the difference between life and death for the people of the region as well as a loss of livelihood for hospital workers and their families.

"A soldier, sailor, or airman will risk everything in battle if they know they have a medical backstop. Denying the enemy a medical facility is a strategic, albeit illegal, target that affects their ability to recover during battlefield conflicts. It is a psy-op that attacks their will to fight."

A soldier, sailor, or airman will risk everything in battle if they know they have a medical backstop. Denying the enemy a medical facility is a strategic, albeit illegal, target that affects their ability to recover during battlefield conflicts. It is a psy-op that attacks their will to fight. So hospitals and mobile surgical units can therefore become prime targets, despite the protections they receive under international law. Should you take up arms to defend your facility? If you’re in the military medical corps, the answer is yes, but as a civilian your duty remains with your patient.

The Kunduz tragedy serves as an example of the challenges and situations that hospital staff face during and after an assault; it provides a training lesson for how you can prepare to surmount an assault on your own facility. MSF has always maintained neutrality, and not only insisted on its facilities as weapons-free zones but also that patients must remove all rank and identifying features on uniforms they wear on arrival. These are key policies to maintain in areas of conflict to avoid violence within the facility itself and to ensure that military forces cannot claim that the hospital was harboring armed combatants engaged in military activity. A variation of this policy would be applicable when working in inner cities, where gang colors and other signifiers are worn. Without question, weapons should be made safe (unloading guns and putting them on safety), collected from patients, and turned over to authorities when possible. I recently disarmed an inpatient who kept a pistol under her hospital bed pillow. I left the weapon with the floor charge nurse, who put it with the patient’s other valuables until her discharge. It is inevitable that hospitals, clinics, and their personnel will be attacked in the future. As physicians, we must discourage military forces of all sides—whether government or paramilitary—from assaulting healthcare facilities and personnel. It’s important to register our outrage at such instances of violence, in order to ensure the safety and well-being of patients and ourselves.

Considering that such assaults continue to happen, you may be called on to protect yourself and your patients under a coordinated military attack. With that in mind, it’s essential to take the time to review your hospital’s disaster plan. What contingencies are in place in the event of an attack? How will healthcare and administrative functions be maintained if communication is compromised and parts of the hospital need to be evacuated? Who will be in charge? Does the disaster plan encompass a bomb or fallout shelter within the facility? Many hospitals are no longer single structures but multiple buildings on a campus, so certain staff and patients may need to evacuate from one building to another. Once hospital personnel and patients make safe passage to that hardened structure, it can serve as a disaster coordination center, in addition to serving as the fallout shelter.

Such disaster coordination centers, besides being an emergency supplementary medical care center, can also house computers and multiple communication system redundancies to allow contact not only with personnel in the facility but also with fire, police, and disaster services on the outside.

In Kunduz, the safe room was in the basement of the hospital. Up to a week before the attack, members of the MSF staff were staying there when not on duty, as a result of conflict that had spread into the city and its Taliban’s takeover on September 28. MSF staffers were also told to stay at the hospital because of a possibility that insurgent groups might kidnap them. Such situations provide a valuable touchstone for operating in conflict zones: hospital administrators should be consistently evaluating the safety of the surroundings, determining whether or not staff should be allowed to leave the facility. Because of the instability in some regions where MSF operates, its staff must remain on-site at all times, except when leaving the area altogether.

A central element of an evacuation plan is the movement of patients from threatened areas to safe rooms, or off-site, if there is security to protect an evacuation. Staff should move the most ambulatory first, followed by those needing assistance, and finally the bed-bound, starting with the most stable and then those with greater and greater medical demands. Ultimately, each hospital decides how to prioritize evacuees based on what will get the greatest number of patients to safety as quickly as possible.

Because of continued fighting between government and Taliban forces after the group’s takeover of Kunduz, the streets in the city were deadly. Mass casualty conditions ensued and the hospital census was soon in Code Black. By 10 pm on the day of the Taliban takeover, 137 wounded had been treated, 26 of which were children. On the 30th, there were over 60 Taliban combatants who were being treated in the hospital. The daily ED census surged from the low sixties to more than double that number. Gunshot wounds, head and abdominal trauma predominated. By October 1, patients were being transferred to MSF Chandara to manage the overflow. Surgical unit supplies were dwindling.

When there is a crisis at a medical facility, it’s essential to have backup supplies available. The hospital’s basement, disaster coordination center or fallout shelter should be well-equipped with sleeping cots, surgical kits, lights and tables, pharmaceuticals and food. The supplies should be adequate to meet personnel and patient needs for up to two weeks or more. In Botswana, while overseeing the construction and staffing of a new hospital, I made sure the loading dock provided basement access. Central supply and the pharmacy stock room were situated above the basement with a dumb waiter to shift supplies as needed. The A&E was adjacent to these areas. We also made sure that a separate generator was available for basement operations. Our primary concern was not aerial attack but tribal conflicts that spilled over onto the hospital grounds, either from direct assault or from patient-to-patient battle.

While the basement was being upgraded in Kunduz, a US government official contacted MSF on October 1, and asked if Taliban were “holed up” in the facility. This was the veritable shot across the bow. On October 2, MSF, concerned for facility safety, placed two additional MSF flags on the roof of the hospital to verify the facility location and stress its neutrality. It had repeatedly given the GPS coordinates of the Kunduz Trauma Center to various military and government authorities to ensure that the hospital would not be bombed.

In regard to facility demarcation, the UN General Assembly passed a resolution in December 2014 urging member states to develop clear and universally recognized identifying markings for healthcare staff and installations. This is another element of the protocol to protect medical facilities from attack. Consider the identifying features on the roof of your hospital, are they adequate? Is a Red Cross or Red Crescent clearly displayed? Is there a highly visible electric sign identifying the facility as a hospital? Flags? While these seem basic, it is surprising how often such features are absent in developing-world facilities.

Several hours before the attack on October 3, MSF Kunduz Trauma Center was in full swing. Outside it was quiet. Some reported it as too quiet. The flow of casualties had slowed, and, as in any ED, the staff was restocking and catching up. Two of the three operating rooms were in use. Suddenly, a series of airstrikes hit the main hospital building, leaving the rest of the buildings in the MSF compound comparatively untouched. Patients attempting to flee the hospital rather than seeking shelter in the basement were strafed with machine gun fire. Multiple explosions ripped through the facility. According to MSF, the ICU was hit first. The OR patients did not survive. MSF made multiple calls and sent numerous SMS messages during the attack to the US military, NATO, the UN, and Afghan authorities, but these were ineffectual in stopping the assault.

Once the attack stopped, all MSF staff in Kunduz went to work, after attempting to locate colleagues. The ED was destroyed, so triage was set up in the administrative building, and it became the makeshift ED and OR combined. The MSF coordinator contacted the Ministry of Public Health Provincial Hospital and ambulances were dispatched to the hospital so patients could be transported elsewhere. Armed conflict continued in the city, and ambulances sustained bullet impacts while exiting the Kunduz facility’s front gate around 6 am. By 9:30 am, MSF Kunduz Trauma Center was closed, and international staff were evacuated to the airport. It remains closed to this day.

It’s useful to note that not all hospital damage is due to war. Structural damage can occur from a hurricane or tornado strike—as when Hurricane Katrina made landfall—or from an irate or drunk patient losing control of their vehicle and driving into the hospital, as I saw once when working in the Virgin Islands.

In 2008, the UN took action to curb hospital and healthcare facility damage from natural disasters by directing the UN International Strategy for Disaster Reduction group to establish a Hospitals Safe from Disasters program. The plan involved creating and fielding teams to assess structural and nonstructural integrity of hospitals worldwide, and to make recommendations on construction that would reduce damage and destruction during catastrophic events.

These recommendations provide reference points for architectural design. For example, had “T” walls been placed in front of the entire structure of the hospital adjacent to the parking area where I worked in the Virgin Islands (a hurricane area), instead of just in front of the ER waiting room windows, the driver would have been stopped before his vehicle penetrated the load bearing wall.

While a hurricane, earthquake or tornado is a more likely scenario in your medical center, a terror-based explosion or attack is no longer out of the question. Even when there is severe structural damage, physicians and nurses must still take care of the patients in their charge. Evacuating them and continuing to provide care is required until you are released by administrative or government authorities. Waiting for outside support by fire rescue or FEMA is not an option. Where do you establish triage, decontamination, and a makeshift ED if your hospital is unsafe? Your disaster plan may be robust in answering these questions and if so, recharge your memory. If it is not, or merely addresses the potential scenarios in broad strokes, it’s worth developing it now rather than at zero dark thirty in the middle of the chaos. Does your plan include a disaster coordination center, an internal shelter, or an external shelter within the operations plan? Do you know which medical centers in the region can take your patients if healthcare is curtailed or canceled on site, and who you can receive patients from when those facilities fail?

Communication is always cited in disaster drills as a shortcoming. Several hours into the November 2015 terror attacks in Paris, Jean-Paul Fontaine, head of ED at the city’s Hôpital Saint-Louis, called the Services d’Aide Médicale Urgente (SAMU), or medical emergency services unit for Paris. The organization had still not been updated on the attacks. His only reports came from patients and onlookers that had arrived from the scene. In order to strengthen communication, work with your team. Is there a phone call chain for Code Black staff callups? Do you have walkie-talkies when phone lines fail, and is there redundancy in the system as well as other forms of communication? Do you have a disaster coordination center, and, if so, who will man it? Knowing the what, when, and how of all these questions is critical. Your life and the lives of your patients will depend on it.

A great resource for hospital evacuation planning:

e.g. Global, Research, or India
e.g. Features, Opinion, or Research
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