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Catherine Mullaly MD, FRCPC, MPH is an MGH anesthesiologist working as a Durant Fellow with support from the Massachusetts General Hospital Center for Global Health. For more news and information, follow @MassGeneralNews on Twitter.
Wednesday, October 26, 2011

 

Thursday, October 20th, begins as “just another day” for MSF (Médecins Sans Frontières) staff and volunteer national staff at Qasr Ahmed Hospital in Misrata, Libya. The day begins with morning rounds on the 18-bed, second floor IPD (In Patient Department). Patients newly admitted from the night before are interviewed and examined. Civilian and military patients (both rebels and loyalists), with the traumatic, post-explosive and infective sequelae of war, lay before us. Hard copy x-rays are pulled from the brown envelopes stationed at the foot of each bed and are passed to the physicians of the rounding team. One by one, each physician holds the films to the available light and then returns their visual focus to the waiting patient to reconcile the completed injury. Is this injury open or closed? There is the entry – where is the exit? How is your breathing? What are the vitals? What is the hemoglobin? Do you have pain? The patient in bed 2 is a prisoner with a partially amputated left lower extremity whom we resuscitated hours before. His hemoglobin is now 9 and he is stable for surgery. Previously admitted and postoperative patients are also reviewed and management plans are updated accordingly. Who can be discharged? Who will be evacuated today? Who will go to the OT (Operating Theater)? Is there blood available for this patient? Does the ICRC know about this unaccompanied minor? Dressings are changed, new and postoperative wounds are inspected, antibiotic plans are updated and a priority list for surgery is made.

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With the bulk of rounds complete, I make my way to the OT suite – a differentiated space on the first floor of Qasr Ahmed Hospital. It consists of two operating rooms (OT1 and OT2), a recovery room, a pharmacy/ workroom and a sterilization room all put in place by MSF France for this emergency, humanitarian surgical program at Misrata, Libya. I prepare OT1 for the first patient of the day – a prisoner – keeping in mind the needs of the patients who might follow. Would they have extremity injuries? Could regional anesthesia techniques be used? Would general anesthesia be needed: GA+ or GA- (with or without intubation)? Do I have what I need, or might need, to safely implement the anesthesia plan?

The first patient arrives in the holding area. Gada helps me obtain anesthesia consent – as she has done with almost every patient coming for surgery here since September. He is 23 years old and is a prisoner. He has extensive second and third degree burns to both hands, both feet and his left leg. There is healing eschar on his face with his eyes and mouth spared. He is thin and in pain. He was sleeping by the side of his car in Bani Walid when the bombing started and he was burned. The national volunteer staff at Qasr Ahmed handle him with the greatest of care – they move slowly and secure eye contact with him that communicates complex concern and impartiality. We bring him to OT1, alleviate his pain, induce general anesthesia and secure his airway. The national OT staff have seen this before. Ibrahim and Mufta meticulously unwrap the wounds – one by one. Abdulrahman is scrubbed and waits to assist them. The debridement and fascial releases proceed. I am grateful for the isoflurane that supplanted the halothane just days before. Outside, I hear the sound of truck and car horns coming from the local streets. This is unusual. The checkpoint just outside the hospital is usually quiet. Dr. Ali M. pokes his masked face past the, now open, door of OT1 – “Sirte is finished!”, he exclaims. The young 23 year-old patient is extubated and stable. Mohammed and Kubair navigate the stretcher to the recovery area as I walk behind. Ruby connects the facemask tubing to the oxygen concentrator, applies a pulse-oximeter, as best she can, to his ear, quickly places an axillary thermometer and reaches for the manual blood pressure cuff hanging on the wall. There is a known and well-traveled peri-operative routine here. The proud players of this team know well their roles and duties.

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I now hear a loud noise coming from outside the operating rooms. It is coming from the main hospital entrance. It is not the sound of one person but of many – it is a collective sound. As I walk from the recovery area and past the small office off to the right, the sound increases and becomes more organized. Through the OT entrance, the X-ray room is at my left and the hospital radio room is at my right. The door to that latter room is usually closed – but, today, the door to the hospital radio room is flung wide open.

Inside this small space, I discover 5 or 6 female hospital staff whose eyes are all focused in one direction – toward a small television screen now featured prominently in the corner of the room. The screen bursts with the proud national colors of Libya – red, black and green – and shows those present in Sirte dancing in the streets. The ticker tape of Arabic script at the bottom of the screen communicates the latest events. Nisry, a fifth year medical student, rushes to translate the news to me: the battle for Sirte is over. Libya is free. The hospital entrance, foyer and stairwell fill with jubilant, chanting staff. These volunteer staff worked for months at Qasr Ahmed – some from the very beginning, 8 months ago. Many volunteers had lost family, friends and colleagues in the rolling battles from Benghazi to Misrata to Tripoli to Ban Walid and now Sirte. Now, it is over. The NTC (National Transitional Council) had declared that when Sirte was “finished”, the nation state of Libya would be declared “free”. In the accumulated noise of the television broadcast, the shrill ululations of the joyous women, the unrestrained, ubiquitous greetings of “Allahu Akbar” and the hurried exchanges of cell phone videos and photos, they all know it is “finished” – the war is over.

As I walk just outside the hospital entrance, I make contact with the head of the hospital. “They have him,” he starts. “Perhaps he will come here.” By now, Gada is again at my side and interprets the developing news. Colonel Qaddafi is captured in Sirte. Back in the radio room, new television footage from Al Jazeera shows him disheveled, but alive, near Sirte. We learn that he is on his way to Misrata. I know the usual triage mechanism for Misrata – front line patients are initially evaluated at the field hospital west of the front line and then flight evacuated to Misrata for definitive care at one of only a handful of locations. MSF’s reputation at Qasr Ahmed is clearly known: an impartial, independent and neutral humanitarian organization – providing care to all patients, including prisoners. I begin to think about possible resuscitation scenarios – about the unexpected. I study the, now English, television screen more closely. Is he injured? What are his injuries? Would he make it here to Misrata? Hospital staff now pour back into the small radio room and motion that I should quickly channel to the Arabic language reports. The images are close up. Qaddafi is dead. His body is now enroute to Misrata.

Back in the OT, the burn patient is recovered well and is prepared for immediate return to the prison. Security is tightened. There will be no further patients from either the civilian or military prison today. Contingency admission plans are made for those who cannot be discharged. Operative care of the waiting in-patients continues. The previously reviewed, resuscitated patient from bed 2 of morning rounds arrives. He will need an above knee amputation. We proceed.

By day’s end, the exhilaration of the events of the previous 72 hours are consciously itemized: the unannounced visit by Secretary of State Hilary Clinton to Tripoli on Tuesday, the unexpected fall of Bani Walid on Wednesday, the collapse of Sirte on Thursday – culminating in the unexpected capture and death of Colonel Qaddafi. None of the events of that Thursday were predicted twenty-four hours in advance. One day can change everything. The journey’s goal that began as Libya’s “Arab Spring” on 17 February, 2011, became realized on that extraordinary day – Thursday, 20 October, 2011. The singular spoil of war is now present – victory. After 42 years, Libyans experienced the first uncensored joy of a, now victoriously, free nation state.

Catherine Mullaly MD, FRCPC, MPH is an MGH anesthesiologist working as a Durant Fellow with support from the Massachusetts General Hospital Center for Global Health. For more news and information, follow @MassGeneralNews on Twitter.

Published online at MassGeneral News, October 26, 2011

http://www.massgeneral.org/about/newsarticle.aspx?id=3052

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