Primary Trauma Care, From Pakistan to Palestine: An Interview with Sir Terence English
Sir Terence English, KBE, DL, MA, BSc, FRCP, FRCS
‘All my life, I’ve taken the view that I was trained as a cardio-thoracic surgeon, and my interests lay in treating my cardiac patients in front of me. I recognized the value of Public Health, but mine was very much a clinician’s attitude’. And yet today, you will find Sir Terence English – past President of the Royal College of Surgeons, past President of the BMA, and Master of a Cambridge college – in Pakistan, helping educate women in midwifery, to address the shocking levels of infant and maternal mortality – inexorably drawn into public health and development work.
Despite his track record, Sir Terence does not seem a man obsessed with ambition. As an engineer-turned-surgeon, he once quit medical school to go prospecting in Canada – but in spite of his best efforts to break away, nine months later he found himself back in England, continuing with his medical studies.
Even his personality seems to shy away from his impressive stature, towering over the room – he sinks into the sofa, perhaps trying to hide his height, legs stuck under the coffee table in front of him. He is quiet and reserved, softly spoken, taking time with every sentence to make sure he does justice to the question asked. Almost invariably he will try to highlight the achievements of others, as though he is always a by-stander – although this is the man who carried out the first successful heart-transplant in the UK. Sir Terence is not someone who has chosen his place in history; fate has chosen him.
Since 2003, Sir Terence has been the patron of the Primary Trauma Care (PTC) Foundation, a small charity dedicated to training doctors in resource-poor settings how to cope with serious traumatic injuries. Recently returned from Iraq, he invited me into his home to talk further about PTC, and the potential for transference of knowledge and skills from the developed to the developing world.
‘In 2003, I went with a colleague, John Beavis, to North West Frontier Province in Pakistan, because he wanted to bring better trauma care there. I knew the country from my son, who had cycled through Pakistan when he was a medical student. He’d cycled up the Karakoram highway, and he’d told me that it was a fabulous country – so, when I’d finished my three years as President of the RCS, I joined a trek largely on the basis of what William had told me. It was wonderful – I love that part of the world: very remote but wonderfully grand. We walked up the Baltoro glacier all the way to the base camp of K2. This was in August 1992.
‘I had actually been to Peshawar [the capital of North West Frontier Province] two years earlier, when the RCS took a visit to Pakistan; we had a meeting first in Karachi and then some of us went to Peshawar, which is where I met the professor of surgery, Mohammad Kabir, and where he and I became good friends. So when John Beavis, in 2002-2003, said he wanted to bring better trauma care to the North West Frontier Province, I wasn’t in any way intending to get involved other than to act as a facilitator through my friendship with Kabir!
‘He proved a great help in getting us to meet the right people in Peshawar – like the governor of the Province and the Minister of Health – and put together the right people to come to the first courses which we held. And then, inevitably, I got involved, because John is a wonderful guy to work with, and we became wonderful friends. He’s got his own charity, IDEALS, and it was his idea to go to Gaza, as well.
‘The need was trauma: there are huge numbers of deaths due to trauma in developing countries. It differs from country to country – for example, in Pakistan, I think John originally wanted to go there (and particularly to the tribal areas) because a lot of children were stepping on land mines left by the Russians. So there were children losing their legs, and there were a lot of road traffic accidents – and gunshot wounds: they all carry rifles up in that part of the world, and when they get excited they fire them off and, sometimes, the bullets come back and go through people.
‘In Gaza the trauma there is largely due to the repetitive invasion by Israel into Gaza. They’ve suffered from bombs, from shelling, from tanks, from rifles, from phosphorous bombs dropped on schools.
‘So where there’s a lot of trauma, how do you deal with these people? There’s a sort of golden hour, if you like, immediately after injury. Often the local doctors may have the knowledge – because they come across trauma in surgery – but they don’t always know how to apply that knowledge in the correct order or form; and so just teaching them this can bring a lot of benefit. I’m absolutely convinced that it can be hugely useful.
‘At that time we didn’t know about PTC. Before we went to Pakistan, John and I both took the Advanced Trauma Life Support (ATLS) course at University College Hospital. There was an interesting experience: there was I, past President of the Royal College of Surgeons, John a retired orthopaedic surgeon, and both of us very frightened at the concept of failing the ATLS exam – and the faculty who were taking the course equally scared about failing us! However, we passed – and we recognized that, having done so, ATLS wasn’t going to be suitable for Pakistan.
‘And then, quite fortuitously, I met Douglas Wilkinson, who’s a consultant anesthetist and intensive care doctor in Oxford, who hails from South Africa. He considered that the ATLS, which was organized by the American College of Surgeons, was not appropriate for delivery to developing countries, because it relied too heavily on sophisticated imaging. But, he also recognized that the principles espoused by ATLS were absolutely the correct ones – the ABCDE of airways, breathing, circulation, and so on.
‘So he adapted this course for use as Primary Trauma Care; and it had been going for some years by 2003, when we went to Peshawar, and so that is what we took with the first team.
‘And it proved to be very successful. There are four medical schools in Peshawar, and through the good offices of my friend Professor Kabir, he had managed to get six of the senior people from each medical school to attend the first course; and following that we selected instructors from those 24 people. They then went back to their medical schools accompanied by a member of our team and held a course, so by the time we left there were 80 doctors trained. Then one group took a PTC course to Delhi in India, which really pleased me because this was the first example of medical collaboration between Pakistan and India for a long time.
‘So I became the Patron at the time. And since then the Pakistanis have taken the course to Iran, and PTC has now been delivered in over 40 countries worldwide. It’s still a small charity – all the instructors are volunteers. When I spoke on a Radio 4 appeal of the week on a Sunday morning I was able to point that, on average, to train a doctor in a developing country in PTC, it costs us about £50. I was hoping that this would act as a stimulus to those who might inclined to give to the charity – and indeed, we got £15,000 from the broadcast, which was a huge surprise and satisfaction.
‘Basically the course itself is designed to help doctors look after seriously injured patients in a very rather rigid way so that they don’t miss out on what really is the priority in each individual. This is delivered not just by lectures, but also demonstrations. In Gaza we had the carcass of a goat on which we could practice insertion of intercostal tubes into the chest, and we were able to remove the larynx and have a very close look at the airway.
‘Usually we have 24 to a course and about five or six instructors – initially from this country, all volunteers – so it breaks up into four groups. There are the so-called scenarios, where one of the members of that group of 6 will pretend to have been injured in a very particular way, whether he’s got a fractured femur or a tension pneumothorax or whatever. One of the members will have been excluded while this has been set up; then that member comes back, he’s told the history, and he has to get on and treat that individual – and does he do the right thing first? Does he put the oxygen mask on first straight away? Does he stabilize the neck appropriately? And the rest of the team are watching his performance all the time – he’s put under quite a lot of pressure to do things in the right way, in the right order. And after a while they love this, because they recognize how fast they’re learning; but initially they can be a bit embarrassed if they get things wrong.
‘Not all of the courses have been successful – for some in Africa, it just hasn’t been taken forward by the locals. It’s very important to get the members of the first course carefully selected, and then form a local committee that will be responsible for picking the instructors to deliver further courses. Sometimes there’s friction between different parts of the country – in Iraq, where I’ve just come back from, we’ve been making an assessment to start the courses there. When we had our preliminary meeting with doctors it was held in Baghdad, but there was strong pressure to try and deliver the first courses in different parts of the country rather than in Baghdad. We felt that what was important was to get a really well trained corps of instructors first and then let them go to the different parts of the country.
‘But the opposition can come from all sorts of different quarters. In Gaza it’s been much more difficult because there have been a lot of different players locally who want to get involved, and how do you bring them all in? You’re not aware of that at the beginning, hence the need for these assessment visits.
‘We approached Medical Aid for Palestine: they were keen, as an NGO, to be seen to be using their money and their influence properly, and for us to go out and do this. But they just wanted us to go in and run a course – they said they’d be able to select the people for the first course, and we said no, we’ve got to go first – John and I had to go, we talked as doctors to the local doctors, and got some sort of feel as to who were going to the main players and who was going to try and resist it.
‘I think that we were lucky in Pakistan because we had the right guy, Kabir. He just took us straight to the Minister of Health, whom he knew intimately. Then he took us to the Governor, who lives in a magnificent palace – he’s an army man, who controls North West Frontier Province. It’s different from the rest of the provinces in Pakistan, and with that sort of authority behind us, everything just happened very smoothly.
‘So it varies from country to country. I have only been to Pakistan, India, Gaza, and Iraq. But there have been 43 countries now, altogether – South-East Asia, Indonesia, Central America, South America, and Africa – the main developing countries which are, in particular, poor nations.
‘It’s also in South Africa. There was a little resistance there first, because I think the white doctors felt that ATLS was the gold standard, but of course it is for the sort of first-world medicine that is practiced in white South Africa – but it ain’t for a lot of rural South Africa.
‘It’s very difficult to actually track the impact in any sort of academic way. We get feedback from the different groups – in Pakistan, for example, there was a bomb attack in the Sind Province last year. Shariq Ali, who was one of the guys who’s been very interested in taking PTC forward was involved in this, and he wrote back to say how effective it had been, in that they were all working from the same hymn sheet. But in terms of actually being able to say so many lives have been saved – it’s nearly impossible.
‘There have been spin-offs: John, as soon as the Pakistani earthquake happened, went out and worked with PTC teams at the site of the earthquake. And he saw that there was this village that had been completed shattered, and so through his charity he bought tents and he put the 200-odd villagers into tents. Initially they were going to rebuild locally, but the landowner, who was getting all the money, wasn’t pushing it down to the villagers. So John decided that the best thing to do was to buy ground about 10 miles away, and build a new village there! There are 36 houses that have been built now, at about two and a half thousand pounds each. So the whole village has moved – they’ve now got the freehold on that ground. And that just came through having got to know Pakistan and love the people.
‘In Pakistan we became aware that there was a very high incidence of maternal and infant mortality – particularly in the tribal areas. There are seven tribal areas, and they’re all self-contained and jealous of each other. There’s a very high illiteracy rate amongst the women, and they have birth attendants but no access to proper maternity care. And so what John did, in conjunction with a local Pakistani NGO in Peshawar, was to identify 15 young women to come out of the Khyber Agency (which is one of the tribal areas), and they’re in Peshawar now on an 18 month course in midwifery. And that’s fantastic because not only will they go back and be midwives, but they’ll be role models for the girls in that tribal area, because they will have come out and seen the world and then, going back, they’re empowered.
‘The future for PTC is in China – and that’s a colossal problem, and I’m not sure that we’re equipped to deal with it. Douglas Wilkinson – who is a medic in the TA; he’s just come back from Afghanistan – found me two days ago to say that it had finally looked as if he had got permission to develop PTC in China. Now, this has taken seven years. He’s had immense difficulties because of the politics of the whole thing. He’s got a large amount of money from somewhere to try and bring this forward, but dealing with the Chinese hierarchy has been extraordinarily hard. He wants me to go out with him in June to sign a ‘memorandum of understanding’ from each country when we’ve done the initial assessment, as to what we’re going to provide and what we expect from them. And that might work – but it will work, as in other places, by going to particular areas and hospitals, getting a core of people really interested in it and sufficiently interested to take it forward in their own country. That’s the strength of it, you see – ATLS is not like that. All ATLS instructors have to be trained by ATLS and only they are allowed to deliver the course; this is the strength of PTC, the way it can be propagated and adapted. It’s flexible.
‘I think it is a model – it illustrates the value of collaboration between communities and countries. In Baghdad, the first course will have two Pakistani instructors, and that’s great. It’s grown using people from one country who are really enthusiastic, to go to a neighbouring country, as in Pakistan and India. It’s the value of people moving into different countries that they’re not familiar with, getting to understand the problems. I had no knowledge about the injustices which the Palestinians deal with until I got involved.
‘We were horrified by what we saw in August. From the moment we left Jerusalem for the border – we had flown into Tel Aviv – there was a demonstration, and we asked our driver to pull over so we could see what it was about. There were two Palestinian homes, and at 6 AM the Israeli eviction police had gone into them, and the women were still in bed. And they had thrown them out, and two hours later, Israeli settlers were in their homes. This sort of behaviour by the Israeli police is appalling.
‘At the border, it was like a bloody great prison. You go through one door, and you have to stop and wait for a green light, and then you go through the next. Then you get to the other side, and the world is totally different, because it’s been totally bombed out – the buildings, the schools, the mosques, the hospitals. You can see it was once a beautiful place, but very little reconstruction has occurred.
‘I used to have the figures – you know, number of hospitals bombed and so on. There were around 1,500 Gazans were killed in the last conflict – it wasn’t a war, just an invasion – at the end of 2008, of which 40% were women and children. When you talk to Gazans, they tell you that the stories of human shields are absolutely untrue.
‘The health consequences are well illustrated by a special Lancet report – but it’s when you go there and you meet normal, decent people trying with families who are trying to make something of their lives and they tell you what they’re up against – these sort of humanitarian, human rights – call them what you will – abuses are going on all the time. Israelis regard Palestinians as just being dirt, they just want them to go away. And this is their whole policy towards Gaza – to drive it into total submission so they don’t want to live there any more. And they won’t win, eventually – they can’t. Twenty, thirty, forty years time, I hope the Palestinians will prevail.
‘I don’t know that there’s a duty for healthcare workers to learn more about these things. I think that they should certainly be encouraged. I think that some will be as I was – very focused on delivering a particular service to a particular group of patients in your area.
‘But I think that particularly young doctors should be encouraged, both during their medical school and during their early post-graduate time, to go to different countries, to go to poorer countries to see what they’re doing. And then some of them will, perhaps, get seized with the idea of what you can learn from them.
‘They’d be better doctors if they do.’
For more information about PTC’s work, go to their website
PTC is a registered charity (UK Charity No. 1116071).
Ben Warner is a third year medical student at Dundee University in the UK
benedict.warner(at)googlemail.com