A session on Saturday afternoon went into the complex and controversial area of medicine and migration, with the first part on critical care in disaster zones covered by Dr Elma Wong of NHS Worcestershire Acute Hospitals, Worcester, and the University of Birmingham, UK. Dr Wong has completed multiple tours of duty with the international medical aid organisation Médicins Sans Frontières (MSF), including most recently in Yemen.
Dr Wong said that the provision of critical care in disaster zones varies greatly, based on human resources (quantity, competencies and training), logistics (physical structure, equipment, drugs and medical devices) and ancillary services (radiology, surgery, transfusion).
She said: “The types of injuries we see from high velocity weapons are devastating; poly-limb amputations and fractures, major vascular injuries, blast injuries of the chest and abdomen. Damage control resuscitation (DCR) is a systematic approach to the management of severe trauma patients that starts in the emergency room and continues through the operating room and the intensive care unit. Damage control surgery, along with permissive hypotension and haemostatic resuscitation, is integral to the concept of DCR.”
She highlighted her sadness at a common feature she has seen in the wars in Syria and Yemen: the indiscriminate attacks in civilian areas by airstrikes and suicide bombers, causing mass destruction and casualties. She said: “An important strategy in our facilities is the effective implementation of a mass casualty plan. Integral to this process, is creating space in the hospital, decisive triage and coordinating appropriately resourced treatment zones.”
Dr Wong highlighted the brutal reality of dealing with the casualties you have in the best way that you can with the resources that you have, and the fear of not knowing when those casualties might stop in a mass-casualty event. She also stressed the importance of staying calm and correctly triaging patients to the correct zone for further care, using a coloured zone system that most doctors and nurses find easy to use.
She concluded: “Key to the successful implementation of any critical care service is the training and development of the national staff. Through this process, safe standardised sustainable care can be provided.”
In his talk on refugees and their impact on healthcare systems, Professor Jan-Thorsten Gräsner (Director of the Institut für Rettungs- und Notfallmedizin, University Hospital Schleswig – Holstein, Germany) addressed the issues faced by Germany due to its large influx of migrants in recent years.
“During 2015 to 2017, Germany received a high number of refugees. For different reasons, more than 5.000 refugees arrived in Germany on one day, and more than 1 million in one year. Due to this, regular medical infrastructure was overloaded and in some regions not able to handle different levels of medical care and treatment for such a high number of people,” explained Professor Gräsner. “The levels of medical needs varied between acute care, examinations ordered by law for refugees based on German regulations, treatment of chronic diseases or hospital treatment. A multi-professional team with doctors, nurses, medical technical assistants, and radiographers was needed to handle the situation.”
Since financial reimbursement for hospitals was unclear and based on different political responsibilities, with the migrant population having a wide range of care needs, the German healthcare systems was burdened in an unexpected way. Based on a first growing network with different medical and logistic caregivers, the situation was transferred from chaotic to structured.
Professor Gräsner discussed the logistics of mass screening of the new migrants, which involved the re-opening of old hospital buildings, bringing retired doctors back into the workforce to help, and trying to ensure everyone could have screening procedures such as a chest X-ray. In the end, tuberculosis was found to be no more common than it would be in German nationals, and other infectious diseases were also rare. This was vital, because it helped calm local residents who felt their precious local health resources were all being diverted to assist the new migrants.
The final presentation on ‘the rights of refugees: what should we do, what can we do?’ was given by Ayesha Christie, a barrister based at Matrix chambers in London, specialising in refugee and human rights law.
Ms Christie discussed a case involving Judge Pinto de Albuquerque of the European Court of Human Rights, who stated in a powerful dissenting judgment in 2015, “Refugees, migrants and foreign nationals are the first to be singled out in a dehumanised and selfish society. Their situation is even worse when they are seriously ill. They become pariahs whom Governments want to get rid of as quickly as possible”.
She addressed the legal rights of refugees and foreign nationals suffering from serious mental or physical illnesses, that help them to be protected from expulsion. She covered recent developments in the European Court of Human Rights and the Court of Justice of the European Union that have enhanced protections for vulnerable persons, and discussed the ways in which lawyers and doctors can work together to uphold the rights of refugees.
While on the one hand, judges have acknowledged the suffering of individual patients who would almost certainly face undignified and painful deaths if returned to their countries of origin, they have also been acutely aware of opening the floodgates to many new cases of people trying to stay on the basis of their deteriorating, or potentially deteriorating, health. Ms Christie explained that the UK Supreme Court is currently trying to decide how to apply recent case law in order to get this balance right.