MSF doctor's casebook: Treating patients in MSF's makeshift facilities in Monrovia

Dr Andrew Schechtman treating a patient in one of the MSF makeshift facilities in Monrovia, Liberia. "I don't understand how lobbing artillery shells into a densely populated area can be considered a legitimate tactic in war. Ã? Is it overly simplistic for me to say that, unequivocally, this is just plain wrong?" - Dr Schechtman
Yesterday was much quieter than the heavy artillery attacks of Monday. Ã? One 18 year old boy was hit by shrapnel from a mortar shell and had a deep wound in the side of his neck. Ã?  "Do you feel this?" I asked as I pricked him with a needle, marching from his stomach, up his chest, towards his head. Ã?  The answer was no until I reached his upper chest. Ã? He could move one of his arms a bit but was otherwise paralyzed from the neck down. Ã? The hole in his neck contained bits of bone from his shattered vertebrae. Ã? The fragments had also collapsed his left lung. Ã? I put in a chest tube to re-expand the lung. Ã?  His father asked me if he'd be OK. Ã?  "He has a very serious injury," I told him. Ã? "I don't think he'll be able to walk again." There wasn't much we could do for him. Ã?  I don't understand how lobbing artillery shells into a densely populated area can be considered a legitimate tactic in war. Ã? Is it overly simplistic for me to say that, unequivocally, this is just plain wrong? Another patient yesterday was an 18 month old girl who was taking a nap when she woke up screaming. Ã? Her mother didn't know what was wrong. Ã? There was a streak of blood on her left cheek and she wouldn't stop crying. Ã? A vigilant nurse made the diagnosis. Ã? In addition to the tiny bleeding hole in her left cheek, there was a hard lump in the right side of her neck. Ã? She'd been hit by a falling bullet. Ã? The bullet had entered her left cheek and passed through to underneath her right jaw without damaging any of the vital structures in her neck. Ã? Amazing. Ã?  I sedated her, made an incision over the bullet and, with a little manipulation, pulled out the copper-colored AK-47 bullet from her neck. Ã? I explained to the nursing staff that this incredibly lucky little girl was not a typical case. Ã? For every lucky little girl there were probably two who weren't so lucky, dying at home from their injuries. Ã? These patients we will never see. The whole family I was about to say "the whole family" before I remembered that their family was far from whole. Ã? Two days before, their mother had also been wounded in the same attack.
I discharged two children today, a twelve year old boy and his nine year old sister. Ã? They'd both been injured in the artillery attacks that landed on an encampment of displaced people on Monday. Ã? The girl had only minor cuts and scrapes from the mortar shell that landed near her. Ã? They were easily cleaned and dressed. Ã? She could have gone home right away but I kept her in the hospital so she could stay with her brother. Ã? His injuries were a little worse. Ã?  I dug a small fragment of shrapnel out of his knee. Ã? He also had a deep two centimeter hole in his flank that was briskly bleeding. Ã? After I got the bleeding stopped, I decided to keep him for observation. Ã? But today, two days later, both kids were definitely ready to go home. Ã?  Their father came to pick them up. Ã? He'd also been injured by the exploding shell. Ã? His injuries had been mild - just a cut on the foot and a small scratch on the face. Ã? I passed the three of them standing all together in the doorway as I was heading out to the front yard of the hospital. Ã? I was happy they were doing well and that they were ready to leave. Ã? It was nice to see them all standing together. Ã?  Smiling, I touched the man on the shoulder and said, "The whole . . .". Ã? I caught myself and stopped mid-sentence. Ã? I was about to say "the whole family" before I remembered that their family was far from whole. Ã? Two days before, their mother had also been wounded in the same attack. Ã? She'd been brought into our emergency room on a bright orange stretcher and lifted onto the bed. Ã? Each of her four limbs had been mangled by the blast. Ã? Both arms hung on her body attached only by thin pieces of flesh. Ã? One leg was missing half way past the knee. Ã? The other leg was shattered, fragments of bone protruding from the foot which laid at an unnatural angle in relation to her leg. Ã?  I had never seen anyone so severely torn apart. Ã? I hesitated before I approached her. Ã?  The severity of her injuries looked incompatible with life, so much so, that I was startled when I first saw her move. Ã? She was alive! Ã?  Our team worked on her aggressively. Ã? We tried to stabilize her by pumping Ringer's lactate into her veins, a poor substitute for all the blood she'd lost but the only option we had available. Ã? We compressed her mangled limbs and stumps to stop her from losing more blood. Ã? The nurses continued to apply pressure dressings to her wounds as I moved on to attend to another patient. Ã?  There were many patients to be seen that day, more than 70 flooded into our emergency room in the 30 minutes after the mortar barrage. Ã? I was busy with someone else when I heard that she'd died about 15 minutes later. Ã? We couldn't save her. Ã?  Her son laid on a bed across the room from his mother, watching everything. Ã?  "My mother's dead! Ã? My mother's dead!" he wailed. Ã? Today, I watched him leave the hospital with his father and his sister, all three of them limping out together through the hospital's front gate. Ã? Their family is far from whole. Going home Yesterday morning, the morning after the heavy artillery attacks, I walked through the hospital ward where we'd put our wounded. Ã? The room - which was our dining and living room before we'd converted our residence into a hospital - was far too small to accommodate the 25 patients who were there. Ã? They lay on the floor on woven straw mats, shoulder to shoulder. Ã? I walked through the room discharging patients, sending them home. "Sending them home" is a bit of a euphemism since most of them left their homes days or weeks ago. Ã?  Most of our patients are IDP's - internally displaced persons - people who were forced to leave their homes because of fighting, shelling or the threat of violence from the lawless armed men who roam the streets beating, raping and looting. Ã?  Having left their homes, most of our patients found themselves living in terrible conditions. Ã? Thousands of people would take shelter in a school building, piled in sleeping 60 people to a classroom. Ã? No clean drinking water. Ã? One or two bathrooms for thousands of people. Ã? No food. I need to discharge these patients from the hospital to make space for the inevitable influx of wounded that we'll get following the next big artillery attack. Ã? None of the patients want to go home. Ã? Here in the hospital they have food, water, and a dry place to sleep. Ã? The home awaiting them has none of this. Even the limited accommodations they had before might now be shattered and burnt, no longer suitable for living. Ã?  "If you can walk, you need to go home," I announce to the room. "We need to make space. We'll give you tablets to take home." Meanwhile, every 10 or 15 minutes, a mortar explodes in the distance or we hear a burst of gunshots. "Pack your things and move downstairs," I tell them. Ã? "Of course, you can wait until it is quiet. Until the bombs stop," I add. Ã?  We have limited space, limited food, and limited water (the water is brought by trucks that cannot travel when there is fighting). Ã? I feel like a jerk for kicking them out but, if I didn't, the hospital would soon be overfilled, our stores depleted. Luck Today, a stray bullet broke through the window of our emergency room and skidded to a stop on the floor. Ã? No one was hurt. Ã? It is all so random. Ã? People hit by falling bullets. Ã? Artillery shells falling from the sky. Ã?  When I think about it, it could so easily be one of us. Out-of-control armed men, more intent on looting valuables from civilians than in fighting, shoot into the air to cause panic. Ã? People flee the gunshots; the armed men take what they can carry. Ã? The bullets fall, usually clinking on the zinc-plated roof or landing with a thud in the dirt, sometimes hitting someone walking on the street, forced to come out of doors in search of clean drinking water or food. I stand in the front doorway of the hospital looking out into our front yard. Ã? Our team has been sleeping in the hospital. Ã? I haven't left the hospital grounds in the past five days. Ã? I can't help but think, "What's stopping the next artillery shell from landing right here in our front yard?" Ã? I could be the wounded one. Ã?  I picture myself in the place of any one of my injured patients and then I quickly try to put it out of my mind. Ã? So far our team has been very lucky. Ã? The work is so important that it is worth taking some risks.