Helping to Rebuild Afghanistan

Critical care as it is known in the United States does not exist in Afghanistan. Decades of war have left the country in physical and sociological ruins. Thanks to the help of many supporting nations, it is climbing out of this depressed state, but there still is a long way to go. The Taliban’s restrictions forbade women, including physicians and nurses, from working, and many healthcare professionals with the means to do so left the country. This drain of medical knowledge has yet to be renewed, as many are slow to return.

The Society of Critical Care Medicine’s (SCCM) critical care training program, Fundamental Critical Care Support (FCCS), is playing a significant role in rebuilding and educating the healthcare workforce in Afghanistan. Afghan doctors and nurses were offered FCCS courses for the first time in Kabul in February 2007. Thirty-four medical professionals from the Afghan National Army, as well as from the police and civilian sectors, were invited to attend the course, held at the Afghan army’s national military hospital. Society member Capt. Russell Gilbert, MD, deputy company surgeon with the Combined Security Transition Command-Afghanistan (CSTC-A), helped organize the course. The CSTC-A is a U.S.-led military entity in charge of building and training the Afghan National Security Forces, including the medical corps. The FCCS program is helping to build a strong and capable Afghan workforce, and the program is part of the long-term plan to rebuild this nation’s infrastructure.

Critical Care in a Critical State
Many intensive care units (ICUs) in Afghanistan are simply rooms with beds separate from other wards. Many do not have the state-of-the-art equipment associated with a modern ICU environment. These rooms have a few vital-sign monitors, and monitoring and maintaining adequate oxygen saturation of hemoglobin is not emphasized. Mechanical ventilation is not available routinely, making the practice of prolonged bag-valve mask support (if endotracheal intubation is available) fairly common. Equipment shortages lead to repeated use of ventilator tubing, and invasive hemodynamic monitoring is rare.

However, shortages of modern equipment are not necessarily the most pressing challenges for these ICUs. The relatively easy part in nation reconstruction is building and equipping. More challenging is the time-consuming and resource-intensive step of recruiting talented local and national individuals to the healthcare system. Modern equipment donated to the ICU goes unused, breaks and cannot be fixed. If the healthcare team does not have the proper training to utilize and maintain donated equipment properly, it may even be sold in bazaars. Equipping the team will only push the system so far. The team must possess the knowledge to use the equipment provided. Many of the individuals lack adequate training and mentoring because of the need to establish sustainable capacity quickly. The United States and coalition nations are helping to build military and civilian medical capacity by establishing the Afghan National Security Force Medical Corps (ANSF-MC). ANSF positions hospitals throughout the country to provide first-responder support for combat injuries and early resuscitative care during medical evacuation as well as trauma surgery and critical care for wounded Afghan soldiers and police. It is imperative to the success of the country’s healthcare program that doctors, nurses and others be trained in the fundamentals of critical care. They need these skills to save the lives of those injured during war and to elevate the standards of care in the civilian sector. The Society’s FCCS program provides an ideal way to streamline training while also providing adequate and ongoing mentoring to sustain this new workforce.

The First Successful Course
The students for this inaugural FCCS course were recruited from the four ANSF regional hospitals around Afghanistan and from the central national military hospital in Kabul as well as from local civilian hospitals in the capital city. All slide presentations were translated into Dari, the common language in Kabul, and were presented side by side with the slides in English. The course was held over three days instead of two to accommodate the translated material. Local media joined the course during the second day and televised reports throughout Afghanistan. In planning the course lectures, it was important to stress the current capabilities of the Afghan physicians and hospitals. While it is desirable to raise awareness of modalities not yet available, it is more important to emphasize and strengthen principles that could save lives now. Unavailable modalities were only introduced if they were obtainable and sustainable in the reasonable future.

FCCS: For, With and By the Afghans
The mentoring strategy initiated by the United States and the coalition focuses on building a strong Afghanistan. Those involved follow a mantra for building competence within the country: doing for them, doing with them and doing by them. A common mistake in nation building is creating projects and initiatives inexpensively and without long-term planning. Common missteps include lectures presented without follow-up, equipment donated without proper training and programs introduced without plans for sustained and recurring instruction as the infrastructure grows. FCCS offers something different. It can be adapted to fit the long-term goals of the rebuilding effort.

FCCS course organizers sought to perpetuate and sustain the course by identifying students who displayed the qualities needed to advance to instructor and course director status. This single FCCS course will not satisfy all the steps needed to improve critical care practice in Afghanistan. The CSTC-A will sponsor these students’ SCCM membership, and they will become course directors. This will ensure that the FCCS course is taught according to the mantra: for Afghans, with Afghans and by Afghans. FCCS is setting the stage for continuous improvement throughout this war-torn country’s healthcare system.