A Nurse's Letter from Libya
12th May 2011 is International Nurses Day. But do we really need another world day?
This letter is from Alison Criado-Perez a nurse on both MSF boat evacuations last month, which brought over 100 wounded patients out of Misrata, Libya to safety and further treatment in Tunisia.
We had just returned from MSF’s second evacuation of war-wounded from the besieged city of Misrata to the safety of hospitals in Tunisia. I walked out onto the balcony and saw a small, blonde girl, dancing alone in the sunshine on the terrace below. The contrast was too much; I found myself bursting into tears.
A few days later, there were more tears, as Ibrahim, still in intensive care and hooked up to monitors, drains and intravenous solutions, took Kate’s hand and kissed it; she had cared for him throughout the long night of MSF’s first sea-crossing. If he had been left in Misrata, he would probably have died. But now he would live – even if with an above-knee amputation to one leg.
Bringing 71 patients successfully out of the devastation of Misrata at the beginning of April, and knowing that the city continued to be bombed on a daily basis, causing unimaginable casualties and overflowing hospitals, prompted the MSF team to make the second evacuation boat trip just ten days later. It was a successful mission, bringing back about 70 severely-wounded patients; but it was a mission that nearly didn’t happen.
With a bad weather forecast for the end of the week, and wanting to avoid the resulting rough seas, we’d put the trip forward by a couple of days. But fate, in the form of hundreds of Tunisian fishermen protesting against high fuel taxes, stopped us leaving the port of Sfax: we were met that evening by a solid line of red: – the lights of the boats that blocked the exit of the harbour.
Negotiations by the authorities drew a blank; the fishermen were not budging. Andrei, our emergency coordinator, decided to try his own hand. Taking to the water in a rubber dinghy with the young Tunisian psychologist on our team as translator, he headed off towards the blockade. Dirty fuel and a broken paddle slowed them down, but eventually our young psychologist’s charm, combined with Andrei’s impassioned portrayal of the humanitarian nature of our trip convinced the fishermen to open the way.
With big cheers on the top deck from the combined team, we were finally en route to Misrata, 24 hrs behind schedule. After a few more hours preparing the boat to receive the patients – a small ICU unit with monitors, oxygen and ventilators secured into position in case of rough water, and all the remaining equipment and medications organized for rapid access – we laid out mattresses wherever we could find a space and tried to get some sleep, to be prepared for the day and night ahead.
But more delays faced us: as we waited in international waters, 20 nautical miles outside Misrata, we received the news that the port was being shelled at that moment. “I can hear the shelling over the sat phone,” Andrei told us. “It’s not safe to enter now.” With heavy hearts, thinking of the tragic situation at the port, of the dead, of the wounded lying there needing our assistance, and with not enough fuel to remain on stand-by for longer, we took the decision to leave for Malta to refuel, and to return the following morning.
A window of opportunity greeted us: a temporary cessation of shelling enabled us to dock in Misrata and start the evacuation. As the ambulances started to trickle in and the difficult process of triage was carried out – who to take, who to leave behind – two of our team, a doctor and a logistician, went ashore and into the town of Misrata itself, to assess the situation in the health structures. “The main hospital has been shelled, but they are still using it, as well as other clinics”, Dr Morten Rostrup told us. “There’s a shortage of senior doctors, of nurses, and very few reserves of medical equipment and drugs. They rely completely on outside help for those.” Water was scarce and unclean, electricity sporadic.
“The other crisis facing Misrata is that of the migrants, who are flocking here in the hope of finding a way out of Libya. They are camped out, under plastic sheeting, with little food, little assistance, just beside the road. About 5-8000, and numbers growing all the time.”
Meanwhile, on the dock, ambulances continued to arrive with patients chosen by the hospitals as the most in need of evacuation. We had already agreed to a limit of three patients on life-support machines: we had a limited amount of oxygen, and each patient on a ventilator needed literally one-to-one care. To provide this to more would mean limiting the number of other patients we could safely bring on board for the 12-hour crossing to Sfax, Tunisia. With a team of three MSF medical staff and about eight Tunisian medical volunteers, we had to be realistic about the number of severely-wounded we could take care of. On top of this, when the sea was rough, almost half of the medical staff was sick… and out of duty.
I wept with a mother as she kissed goodbye her son, who was in a critical condition – why wasn’t she coming with him? But finally we were away, and the task of taking care of our patients, ten of whom were severely ill and all of whom needed medical attention, began.
We struggled through the narrow spaces between the mattresses, often on our hands and knees as the seas became rougher, to put in intravenous lines, change soaked dressings, inject antibiotics, administer analgesia; with so many severe injuries - fractures, amputations, abdominal and chest wounds, multiple wounds from shrapnel or bullets, head injuries, burns – we needed a lot. The ventilated patients needed constant attention; a young man with a tracheotomy due to breathing difficulties needed suction. It was hard to keep up with all the needs. Were we managing? I worried constantly
Trying to catch a couple of hours’ sleep around 3 a.m., I could hear the waves splashing against the windows on the upper deck where we had our lounge area. The sea was getting rougher, the waves about 2.5 metres high. “The captain has said it’s too dangerous to continue to Sfax,” Andrei, the emergency coordinator, told me. “We’ll have to turn on to a different course, which will make for a smoother crossing. We can’t reach Sfax.” The storm lasted three hours and a bigger storm was expected on the way to Sfax. It was decided to dock in Zarzis to save the lives of patients, as many of them were moving during the storm, experiencing pain. We were lying down taking care of them, especially the ones who were on ventilation, trying to keep them connected to the equipment.
Bad news. 24 ambulances were waiting in Sfax, ready to take the patients to the large hospital there, while no one was expecting us in Zarzis. Now we would have to land, unprepared, in the smaller port of Zarzis.
Authorities from the Ministry of Health and the WHO were on the dock to help us organize the chaos, and stretcher bearers from the Red Crescent; but Sfax was a good four-hour drive away and it seemed like the special ambulances for the most critical would never arrive. We thought about getting helicopters, but it was too windy, too dangerous. We just had to wait.
Finally the most critically ill were on their way. Now we had to find hospitals for the 60 or so remaining, finding the most suitable hospital for each patient. “Identify ten patients who are in a suitable condition to sit in a mini-bus for three hours,” Alice, the WHO doctor asked me. “Identify two of the more severely-wounded who need to lie in an ambulance. And two who can sit, who don’t need caretakers.” It was an all-day task; on top of a day and a night already on the go, we were at the limits of our endurance.
As I accompanied one young man, Adbelmajid, into the ambulance, his face drawn with pain and anxiety, and by now appearing severely ill, he made a gesture, pointing beneath his eyes. “What’s he saying?” I asked the paramedic accompanying him in the ambulance. “He says he will see you again,” she told me. I hoped that would be right.
A few days later Kate and I visited the hospitals in the various towns the patients had been taken to, to check on their condition. We were greeted with cheers and smiles, with repeated thanks. Nearly everyone seemed on their way to recovery; just one young man was still in a critical condition in intensive care. But where was Abdelmajid? We were in the last hospital, and had just visited the last ward. “There is just one more patient, in intensive care,” the helpful Tunisian surgeon told us. I held my breath as we entered the unit. And there he was. Still sick, but alive, and improving. He smiled at us as we came in.
That evening we stood on the terrace outside our house in Zarzis, and watched the reflection of the moon shimmering across the sea, framed by the silhouettes of palm trees. It was very peaceful.
“Paradise can be very close to Hell,” said Andrei.