After a disaster

Global reach

Pete Skelton woke up at home in Orpington on 6 February to an alert that a 7.8 magnitude earthquake had struck Turkey and Syria overnight.

‘We had an emergency meeting at WHO that morning and it was clear already that this was a devastating event, and it was going to be incredibly complicated. A huge area of Turkey [was] affected, with parts of the affected area in Syria under government control and parts controlled by other authorities with very little access to the worse affected people.’

Pete described his background as ‘a little bit strange’, with a first degree in medical anthropology. After graduating he worked abroad for a year each in India, in HIV and AIDS, and Ghana in West Africa, with street children and refugees using sport to do health education.

Reflecting now on that 22-year-old: ‘I felt a little bit of a fraud. I’d come straight out from university; I’d been really lucky to get this opportunity to go and work abroad and I was learning a lot more from the people that I was working with.  

‘So, I decided that I wanted to get some more tangible skills, something that I could have as a very, very concrete skill that I can then use with the idea of coming back, and doing more work.’

He got a place on the two-year accelerated pre-registration physio (MSC rehabilitation science) course at the University of Brighton with tutors ‘who were really interested in international work and very supportive of me coming back.’

After finishing training Pete returned to Ghana and spent a couple of months volunteering in a hospital where he knew some of the staff while waiting for his professional registration to come through, ‘working more or less as a student under their supervision, happy to be a spare set of hands. I learnt a lot and they were very welcoming.’

‘It’s difficult, because I think it’s not something that I’d necessarily recommend to people to do generally. I knew the country very well, I’d been working there previously, I already knew the staff in the hospital very well, I had a few friends there, so it was easier to come in, not just showing up in a country.’

Haiti earthquake

Pete did his junior rotations at Whittington hospital in London for two years, and before starting as a band 6, he deployed with an international organisation to Haiti.

There, post-earthquake, amongst ‘absolute devastation’ Pete delivered direct care as an emergency physio to ‘overwhelming’ numbers of people with limb injuries and complex fractures.

His NHS job was held open – ‘they allowed me to take an extended break basically.’ He acknowledges that it was unusual to have such a supportive manager, ‘but if people see the benefit of the work, not just in terms of the benefit of you going and taking skills abroad but what we bring back I think that adds a lot.’

The possibility of health professionals going overseas actually benefits the NHS, stresses Pete. ‘It’s not a one-way street. Working in low resource settings you get a lot of exposure to conditions we don’t see regularly in the NHS and gain skills that benefit the NHS.’

Those include cross-cultural working, the ability to work under pressure, exposure to mass casualty situations, and emergencies ‘that we think we’re immune to here. But actually, we’ve seen terrorist attacks, fires, Covid-19 – the UK is far from immune.

As rehabilitation providers we don’t necessarily consider how we are set up to respond to emergencies in the UK – but we should all be prepared – and skills gained supporting international responses can be really useful here.

Recommending people do several years of clinical work before going overseas, Pete also stressed the importance of working with recognised organisations that ‘know the country, know the context, know how to look after their staff.’ And, yes, there are some that have not. 

‘As soon as you get an emergency - especially now with 24 hours news - everybody wants to be able to help and the challenge is how to help in the most effective, responsible way and that is typically by supporting organisations that are already there or have a long track record.’

The best thing for most people to do is give support by raising money for them or raising awareness of the work they are doing, ‘not getting on a plane and travelling.’

Pete spoke of ‘terrible’ examples, from Haiti: ‘We had people showing up for two or three days, not letting the hospital know that they were there, providing dangerous care that was outside of their scope of practice and then we find them doing things that were not only ineffective but sometimes dangerous.’

Minimum standards

Things have improved since Haiti after which the WHO began its emergency medical team initiative where Pete works now.

WHO developed minimum standards for national and international medical responders coming to emergencies.

‘The big game changer from the rehab side of things was it said that if you’re a medical team and want to provide surgery you need to include a full multi-disciplinary team, and that includes rehabilitation, staff and equipment.’

Pete’s work next took him to Libya for a year, then back to the NHS, before working for seven years as rehabilitation lead for the UK Emergency Medical Team. With rehabilitation professionals now routinely part of emergency medical teams, Pete’s job now is to lead the continued strengthening of rehabilitation in emergencies with the World Health Organization – with a focus on integrating rehabilitation into emergency preparedness. 

‘We place a really strong emphasis on rehab and continuity of care.

‘Because when typically, people think about emergency preparedness they focus very heavily on pre-hospital care, emergency care, sometimes surgical care, and then what you tend to find is then the planning stops. And that’s the same anywhere in the world. So, a large part of my work is trying to make sure that as part of preparedness, we think of the whole package, from the point of injury or infection right the way through to definitive and ongoing rehabilitation. Because if you think of that surge, if it’s an earthquake, that surge hits an emergency department, and that gets all the attention, because that’s where everybody can see it but on rehab services, it’s a long-lasting impact.

‘No rehab service can absorb 107,000 people, which is what’s just happened in Turkey. So, we need rehab services to be prepared.

There’s a perception that now we’re two months after the earthquake we can start thinking about rehab for those 107,000 people.

‘But that’s too late. We need to be ready from the point when the earthquake hits. And if we’re talking about a conflict like the situation in Ukraine now, if you’re an emergency department near the frontline the waves of casualties undulate.

‘But from a rehab perspective those numbers are not going up and down but up and up and up because there is a cumulative effect – so conflicts create incredible pressure on rehabilitation systems. 

‘Emergencies can strike anywhere, and it is always the national staff, not the international responders, who are critical to the response.

‘Sending international teams is always a last resort. We need to recognise that rehabilitation services need to be prepared, and by and large around the world rehab are not well integrated into emergency preparedness.

‘So, during a response we’re always playing catch up. And so, we need to integrate rehabilitation services into the emergency management preparedness – and as we saw with Covid-19 that counts in the UK just as much as Ukraine or Turkey or anywhere else in the world, because we don’t know what kind of emergency we will face next – but we know that our rehabilitation services need to be prepared.’ 

Claire Dexter APP, MSK Derbyshire Community Health Service NHS Trust returned from the Turkey quake area last month:

‘I am privileged that my first deployment with UK-Med after six years on the on-call register was as part of the UK-EMT (Emergency Medical Team) second wave team (week 4-6) responding to the Turkish-Syrian earthquake. This claimed over 54,000 lives, displaced over

3.2 million and injured over 130,000 people, either directly by collapsing structures, or indirectly while extracting themselves, or rescuing loved ones, from beneath the rubble.

‘We provided a rather cold, muddy and windy tented primary care health facility in Turkoglu supporting a tented Turkish facility in the grounds of the hospital that is no longer safe to use as it was destabilised by the earthquake. Our medical team consisted of ED consultants, nurses, paramedics, GPs, maternity care and paediatric services, a physio and pharmacist as well as psychological support. 

‘My caseload was predominately working in a FCP/MSK triage role providing assessment and advice including x-ray imaging, strapping, POP, analgesia, and exercise as well as providing rehabilitation. Presentations varied from direct earthquake related injuries of delayed presentation of MSK problems for example “my wardrobe fell on my shoulder in the earthquake”, rib fractures and spinal injuries; indirect earthquake related injuries included falls over rubble, overuse injuries of the back/upper limbs while partaking in rescue, retrieval and clear-up, as well as acute exacerbations of chronic MSK conditions such as osteoarthritic secondary to cold uncomfortable sleeping arrangements (over 70 per cent of patients were temporarily residing in tents following the destruction of their homes).

‘The patients returning for rehab varied from those who had had a significant earthquake related injury for example post fracture/crush/minor amputation to those who had had routine orthopaedic surgery such as ACL reconstruction in the days prior to the earthquake. 

‘The days were long, the patients were so grateful despite having lost so much, the team was amazing, we had great interpreters and providing you are happy to go back to basics, experience regular aftershocks and rough it in a tent for a few weeks (including using the squatter loos!) I would highly recommend joining UK-Med. I felt I made a valuable contribution to the team and people of Turkoglu, it was an amazing experience I’ll never forget.’ 

ADAPT is the CSP professional network for global health

ADAPT supports physios working in low resourced or conflict settings. Members meet online for new webinars and discuss relevant journal articles. They host an extensive resource list and share international job opportunities and news. 

Each November, they hold an annual conference, attended by hundreds of physios globally to listen to the latest research emerging from the field. ADAPT also offer a £500 grant scheme for members to undertake projects in low and low middle income countries.

CSP professional adviser Julie Blackburn said: ‘ADAPT members continue to improve the quality of rehabilitation in resource poor settings. 

‘They demonstrate the valuable role physiotherapy has to play in supporting those most vulnerable with health research needs across the globe.

‘We are proud to support members such as Pete Skelton, who combines both compassion and excellence in managing the mass mobilisation of international emergency medical teams with WHO.’ 

Find out more about ADAPT or Twitter: @ADAPT_CSP