Innovation: Mobile Unit Surgical Trailer – “War will not wait”

11 Sep 2017
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In conflict zones, our teams need to be able to move fast, providing life-saving surgery to people wounded in fighting or explosions. But setting up an operating theatre takes time, and maintaining sterile conditions can be challenging. Logistics manager Piotr blogs about developing a new approach…
On my last day in Iraq, I’m asked what I think about the project I’ve been working on. Without any reflection, I say, enthusiastically – awesome!! So how would I describe it in one full sentence? And I realise that it is impossible to describe in one sentence what we have done in this project. Because Project MUST is professionally and personally the best thing that I have ever done in my life.
Because I’ve had the opportunity to be there throughout the project, from the build, to the decision of where to send it and where to deploy it. Because the decisions were the right ones, which was because of all the wonderful teams and people that I’ve been working with. And finally, because of the patients, who on this project I’ve worked with closely.
In MSF we have to be flexible. At the end of October 2016, my departure for my next MSF assignment was cancelled at the very last moment.
I work as a logistics manager, which means that I am responsible for the technical part of projects. My cancelled assignment meant I would have the next few weeks in the cold part of the year back home. But a few days later I received a phone call saying that one of MSF’s emergency teams was starting to build MUST – the Mobile Unit Surgical Trailer, and I could join them while waiting for my new assignment. So, just three days later, I joined the team in our partner company’s facility in the Netherlands to start working on MUST.

In conflict zones, the need for surgery can be very great, but the frontlines can also shift quickly. Our teams need to be operating close enough to where the people are to be able to treat them in time, but also need to keep our staff and patients safe, which can mean evacuating if the fighting gets too close.

So finding permanent structures our surgeons can work in is not always feasible, while temporary structures like tents are difficult to keep sterile. The idea of MUST is to have a ‘plug and play’ solution – it would be prepared and ready to go whenever needed, hardy enough to withstand tough conditions in the field, and sterile, to avoid infections.

Objectives: to build a full, independent, mobile surgical clinic based on five containers and set on trailers. Independent operational time for the clinic: 24h at least. That means all the water, electricity and supplies to do 10 operations in one day. Deployment time: 2h. And most important - delivery time: 16 days. Yes, only 16!! Doesn’t it seem crazy? Yes, a bit, but then I realised the reason – the Battle of Mosul had started in Iraq and war will not wait. The clinic will be going there.

The Battle of Mosul had started in Iraq and war will not wait. The clinic will be going there

In the first few days of the project I already know that I’m lucky. The team I am working with is very experienced, with all the technical and medical experience to make it happen. The plan is already done: the core is a 40 foot container designed to be the operating theatre. Then one for the intensive care unit, a third for sterilisation, a fourth for the pharmacy and a fifth for storing logistic stock.
The containers were pre-prepared by our partner company. They are sterile, equipped with water treatment systems, with two tanks each for clean and grey water, air conditioning, antibacterial floors and lights. We have to define which of MSF’s kits to use to make the hospital fully functional. The kits are sets of equipment needed to resolve different logistics problems.
We install the operating table and lights, fitting the anaesthesia machine and other medical equipment to be handy and easy to use in field. We fit and test an autoclave for sterilization, hospital beds, and uninterruptable power supplies (UPSs) as electrical backup for the operating theatre and blood banks. For lifting patients, we use standard trailer lifts.
Inside the operating theatre on the MUST.
The electrical heart of the MUST is a 41kVa generator. We have one more as a spare. They are installed in cages on front of the containers with solid diesel tanks with a capacity of 330 litres each, providing 3.5 days electrical autonomy in total. Well insulated for vibrations and noise, they do a great job in the field.
The real headache is fitting all of the additional equipment in the fifth container. We need to take four tents, including an inflatable one with full equipment.
Inflatable tents go up very fast – it only takes 10 minutes to deploy using a generator and an electric blower.
The purpose of these is to give the medical team a general triage tent, a tent for patients with less severe injuries (this is known as a ‘risk’ or ‘green case’ tent), a surgical triage tent and a referral tent. All of the logistics ‘families’ need to find space inside as well – that includes electrics, water and sanitation, IT, and some stuff to assure reasonable team life. We put all this equipment and general tools in separate boxes with packing lists for ease of finding exactly what is needed when unpacking. They are then stored on shelves installed inside the container.
Compacted logistics stock.
We work 11-12 hours every day, non-stop. And guess what? We do it – we accomplish general construction and packing in 16 days.
Now it’s time to go back to the office and get working on shipment and a user manual for MUST. The guys finish it in a couple of weeks and it is the best user manual I’ve seen in MSF. Reading this manual, any MSF logistician could deploy MUST in the field, step by step, without training. And they could find solutions for most potential technical problems. Impressive.
The day after my return home I receive a phone call: am I interested in going to Iraq as a Technical Logistic Manager with MUST? I say yes without any doubts or hesitation. I really want to see how it works on the ground.

People shot by snipers, victims of bombing, victims of the intense fight that is blazing a few kilometres away: these are our cases

So, three weeks later I am in Iraq. We sent MUST to Kurdistan by road. It means that I’m already there when everything arrives. The Turkish transport company did a great job and the containers are in great condition, nothing is missing. Now it’s time to make a few decisions about where and when will we deploy. These decisions are not easy to take because the situation in Mosul is changing very fast. Coalition forces take control of the east part of Mosul in middle of January 2017 and are preparing an offensive for the west side of Tigris River. In fact, it will be a month before the fight for west Mosul starts, but we don’t know that yet.
In Kurdistan at our coordination office I meet my new team who prove how lucky I am again. Very experienced, open-minded people who love working with MSF. Now we are working on checking all equipment, hiring and training staff, buying the last missing items. With my logistics partner we do a practice deployment of MUST in Kurdistan as part of a training for staff.
And finally the decision can be made – we are going to deploy MUST only 4 km from the front line, south of Mosul. It’s decided after weeks of consultations and strategic planning. Apparently MUST will be the nearest war trauma surgery hospital on the way south from Mosul. And as time will show, it will be very busy.
The project coordinator shows us the place, points and says, “here”.
MUST fully deployed.

This is what we have been waiting for over the last two months – a set deployment place and a green light to deploy. From this point everything goes at double-speed. We get to work preparing the ground, compacting, levelling, hiring a contractor for building walls and gates. At the same time the water and sanitation (WATSAN) work is ongoing, plus employing staff, implementing security rules, renting houses for office and team life… everything it takes to start up a new project.

We see broken villages with houses destroyed by rocket strikes, fights and looting

At the start we have to travel 40 km from our base to the hospital, and back again in the evening. Later, when the project is more developed, we stay in the hospital overnight. But at the beginning we spend one hour in a car each way going through country completely destroyed by the IS group retreating from the advance of the Coalition forces.
We see completely broken villages with houses destroyed by rocket strikes, fights and looting. Even roads are destroyed to not let others use them. But most touching for me is the view of burning oil wells. They are burning along the way, covering everything with dust and ashes. They can be seen from 100 kilometers away, but are the most impressive and depressing at the same time when passing alongside them from only a few hundred meters away.
Burning oil wells along road to Mosul.
We are ready. Containers are placed, levelled and connected, tents set up with full equipment, power supplied, water and sanitation solutions implemented, staff employed… We are happy and enthusiastic for one day. Because the next day the offensive starts and we realize fast why we are here. The ground shakes as the battle progresses toward Mosul; the sounds of shelling and explosions will be with us for the next weeks. It is time to show what MUST was built for.
For the next few weeks we receive many casualties almost every day. The sound of ambulance sirens mobilizes us to run to the entrance gate because all hands are needed. Beside logistician duties we help with patients’ transport from ambulance to clinic to ambulance. Each ambulance brings five to seven patients so our hospital is full soon.

We work 16 hours continuously almost every day

People shot by snipers, victims of bombing, victims of the intense fight that is blazing a few kilometres away: these are our cases, because we do only life-saving surgeries. Despite referring any non-life-saving cases elsewhere, the hospital is extremely busy. We work 16 hours continuously almost every day.
Surgical operations are ongoing 24 hours a day in shifts now. After surgery the patients stay in the clinic no longer than 24 hours and are then referred to another hospital. Beds are needed for the next patients. I don’t remember the precise number of patients and operations that we did during my stay in there. But I remember a lot of the faces of the people that we saved.
Piotr's MSF jacket at the end of his posting in Iraq.

How is MUST doing? Very well. Everything works properly, according to plan, revealing only a few small issues that need fixing each day. However, the biggest problem is the limited space in the operating theatre. This is a factor that will be crucial during planning for MUST2, but that’s a story for another time.

For now we are setting up a second inflatable tent in order to have a second operating theatre and to increase operational capacity. We have two international surgeons working alongside Iraqi surgeons. The teams are cooperating very well and everyone is helping each other. The spirit of this team running a hospital every day on maximum speed is unbelievable. I’ve come back from Iraq with a pack of friends currently spread around world but connected by a feeling of a job well done there.

Because one day I realise that it’s time to go home. Was this project tiring? Yes. Emotional? Very. If asked would I do it one more time? Definitely. Because despite of all of this effort, speed, emotion and tiredness, MUST gave me so much satisfaction to work on, and that will be hard to repeat, ever.