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The BMJ appeal 2021-22: “Without this team there would have been many more deaths”—the MSF workers dealing with mass casualty incidents in Afghanistan

BMJ 2022; 376 doi: (Published 05 January 2022) Cite this as: BMJ 2022;376:n3101
  1. Jane Feinmann, freelance journalist
  1. London, UK
  1. jane{at}

The BMJ’s annual appeal is this year supporting the work of MSF in Afghanistan. Jane Feinmann looks at how MSF helps care teams boost survival after a major influx of injured patients

“If you do a good triage, you ensure that limited hospital resources are focused on the most urgent cases,” says Yves Wailly, an emergency department nurse and medical adviser to Médecins Sans Frontières in Afghanistan. “If you don’t, you’ll overburden the emergency room and put lives at risk.”

Triage clinicians work against the clock, with around 30 seconds to assess each patient and decide who receives priority. “You do a clinical examination often with projectiles sticking out of the patient and suffering considerable blood loss,” James Lee, a UK trained emergency care doctor and adviser to MSF on emergency care and intensive care, tells The BMJ.

“There’s no time for an x ray or even getting the patient’s name,” he says. “Those with internal bleeding need to be stabilised—and that means the doctor making a lightning decision on what needs doing, using a stethoscope and an examination of the belly, and then moving on to next patient.”

When a suicide bomb killed and injured hundreds of worshippers inside a packed mosque in Kunduz, northern Afghanistan, in October, there was media speculation worldwide about the fragile security of the new Taliban government.

For the MSF team based at its newly opened trauma centre, the blast triggered a well rehearsed response to the management of multiple serious casualties best described as reverse triage. Dealing with mass casualty incidents means healthcare teams need to organise themselves in the best possible way to increase survival rates after a major influx of injured patients.

“We had more than 100 major casualties arrive at the hospital within two hours,” recalls Lee, who had been in Kunduz to train the team there in dealing with mass casualties and was on duty that day. Within two hours of the blast the hospital had admitted 74 patients and received 20 people who were dead on arrival.

“Almost all the patients had severe shrapnel injuries similar to a high velocity gunshot wound,” says Lee. In such cases “rapid intervention to stop internal bleeding is critical.” It means turning triage on its head and prioritising those patients who are most likely to survive, ahead of those who are more seriously injured.

MSF has refined the standard protocol for a mass casualty incident over years of experience. Wailly tells The BMJ that it’s always specific to each individual hospital, “matching its capacity, the health context in which it is embedded, the volatility of the situation, and the risk of being confronted with further disasters.”

MSF’s work in Afghanistan is supported entirely by private donations, and the charity operates alongside a depleted government healthcare system to offer healthcare in Afghanistan to anyone in need. MSF built its hospital in Kunduz through private donations, and it is this support from individuals that also finances the salaries of MSF’s largely Afghan healthcare team, which includes surgeons, anaesthetists, nurses, and others.

In developed countries pre-hospital triage often aims to ensure that cases are spread across several hospitals. But the MSF hospital is one of just two facilities in Kunduz able to offer trauma surgery. This makes hospital triage ever more crucial.

In Kunduz in October it went well: 19 lifesaving operations were carried out the same day, a further 60 over the next 36 hours, and just five patients died. A debrief followed two weeks later, and Lee spoke to The BMJ in mid-November, just a couple of days after a simulation exercise to take on the lessons learnt from the incident in October.

The review is perhaps more timely than ever, this being the first multiple casualty incident in a hospital that had only recently opened. It replaced the original MSF hospital in Kunduz, which was destroyed, with 42 people killed, by US airstrikes in 2015.1

Lee and his team focus on the details. The hospital’s response to multiple casualty incidents needs to become “less ER-focused,” the debrief concluded—so staff need to resist their tendency to move towards the emergency room in response to the arrival of large numbers of patients. “We all now understand that doctors and nurses need to stay in the ward, that blood bank staff remain in place, and pharmacists continue to do their routine job,” he says.

With bystanders bringing patients to the hospital in a “scoop and run” way, there’s also a need for more non-medical staff, including stretcher bearers. And getting patients’ names as quickly as possible, so that family members at the hospital gates can be given news about their relatives, is both humane and a contribution to crowd control. “People need certainty, whatever it is,” Lee says.

Overall, however, the team has developed confidence in its ability to manage this worst case scenario. “Without this hospital, and a team of clinicians able to make such difficult decisions, there would have been many more deaths that day,” says Lee. “It’s individual donors who keep MSF going, so that when there’s a need we can be as well prepared for scores of casualties as it’s possible to be.”

How to donate

Please give generously to The BMJ’s appeal for 2021-22. Donations can be made at

The 2021-22 appeal is being supported by the Green Room Charitable Trust. Up to £50 000 in funding has been made available to match donations received before 31 January 2022. This means that your support will go even further.

The Afghan Crisis Appeal will fund MSF’s work in Afghanistan, as well as supporting its work in neighbouring countries.


  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Competing interests: None declared.


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