Delayed access to surgery is one of the main reasons leading to complications and possibly death when working as a surgeon in conflict areas. The story below is from Yemen in 2012:
It was late afternoon and I was standing on the roof of the brand-new MSF hospital in the outskirts of Aden, the main city in the south of Yemen. It was the beginning of May and already around 30 °C while the muezzin called to prayer in a nearby mosque. Due to the tense security situation we were not allowed to leave the hospital at any time and the entire team was installed in rooms on the 2nd floor. If you needed a breath of fresh air you had to go to the roof. Only brief roof visits were allowed though, due to the risk of shelling.
The medical team leader came up and told me he had received a call from another hospital 4-5 hours away, a smaller facility where surgery was not available: They had received an 11-year old girl who had fallen down from a 1 meter high rock while playing outside. She was not doing well, they said, there was nothing to see on her body, but she had severe stomach pain and could not move. Could we receive her? Yes of course.
5 hours later the girl arrived and upon examining her it was immediately apparent that she had peritonitis as she presented with a classic peritoneal reaction upon palpation of the abdomen. Blood tests, apart from hemoglobin, were not available, no imaging was possible, but none was really needed: She required immediate surgery. 15 minutes after she arrived, she was prepared and intubated and the surgery began. I had talked to her father via an interpreter and explained the situation, told him that I did not know what was wrong but adviced that she may need a stoma.
Immediately after opening the abdomen I noticed the 2*2 mm perforation on the surface of the small intestine approximately 40 cm from the ligament of Treitz. I remember telling the anesthetist that this was good news, the surgery would be completed in less than 30 minutes. I hope so, she said. Accordingly, I sutured the perforation and closed the abdomen. The anesthetist, trained in pediatric anesthesia and intensive care was responsible for the management in the recovery room. When I woke up the next morning I went downstairs to the recovery room, where the girl was sleeping. She was lucky, it went well, I remember saying. The anesthetist looked at me with an odd expression on her face: She is dying. She has acute renal failure. And there is no access to advance therapeutics such as dialysis, the only possibility to save her life.
The almost 24 hours it took for her to gain access a hospital with surgical facilities turned out to be too long. She died later that afternoon. Had she been operated earlier her life would almost certainly have been saved.