During my time in Iraq I was working in an emergency COVID-19 response project, supporting the ICU in a limited resource setting and managing activities where the focus is management of critically ill adults.
As a paediatrician and infectious diseases doctor, this could not be further from my comfort zone.
But I was there as medical activities manager, so I worked to find my balance, put on my critical care hat and uphold myself to meet all needs.
IV lines and ventilators
I was part of the Médecins Sans Frontières / Doctors Without Borders (MSF) team working at Al-Kindy hospital to offer case management, training and advice. Initially, the actual clinical care was being done by the hospital’s regular staff, employed by the Iraqi Ministry of Health.
However. Sometimes the MSF team would be the only doctors present in the ICU when a patient collapsed!
So while a nurse rushed to inform the Ministry of Health specialists they were needed, I’d be kneeling on the floor by the patient, putting in an IV line, while Pedro the MSF ICU specialist re-set the ventilator or started CPR.
However there was no typical day. That meant that on other days the MSF ICU team would reconfigure or connect a ventilator circuit; I often demonstrated to patients’ carers how to do chest physiotherapy.
Taking on clinical care
The Ministry of Health staff, patients and carers had confidence in the MSF ICU team, as our clinical interventions and staff training helped to improved patient outcomes. But the Ministry of Health residents and specialists covered 240 beds in the hospital, making it challenging for them to get timely care to the most critically ill patients.
That need for support, resources and staffing was the common feature of government health facilities in Baghdad. So, with the agreement of the Ministry of Health, MSF made the decision to take on COVID care and organisation in Ibn Al-Kindy hospital: it was the most crowded and not yet equiped for the COVID-19 pandemic.
As the medical activities manager, I didn’t work exclusively at the bedside in the ICU, but the days I joined the clinical ward round always reminded me of the difference we were making, even if they didn’t all have happy endings. My role reminded that I enjoy caring for all vulnerable people, not only children.
Trouble-shooting, brain-storming and demonstrating clinical competencies got me through my hours inside the PPE, but the key to my positive outlook on things was the sense of appreciation and the welcoming manner from my Iraqi colleagues, despite their being an overworked and understaffed team of clinicians.
Trouble-shooting, brain-storming and demonstrating clinical competencies got me through my hours inside the PPE
MSF trained anaesthetic assistants and ICU nurses on the principles of oxygenation, ventilation setting and nursing COVID patients. We also focused on infection prevention and control measures. This meant not just designing the measures, but sharing relevant training and educating staff and community members hospital-wide.
MSF’s team of Iraqi doctors and nurses were key to building the skills and knowledge of the local staff. For example they would demonstrate how stable COVID patients could be nursed in a face-down position known as “proning”, which helps the lungs and leads to better recovery rates.
An urgent situation
One day in the COVID ICU, we entered the first bay to see a man in his late thirties, half-sitting up in the bed. He was wearing a mask and receiving CPAP (continuous positive airway pressure): a treatment that makes it easier to breathe.
The lady next to him waved and raised a welcoming voice as soon as the MSF team came closer. As she started to say thanks (in Arabic) I suddenly recalled that this COVID patient with the smiley eyes had been unconscious last week, having had a stroke.
The fact that he was awake and better was a miracle for the family
When we reviewed him then, the family were struggling to get a diagnostic CT brain scan, which is vital to ensuring stroke patients get the right treatment quickly.
So I spoke to the Ministry of Health ICU specialist to advocate for an urgent CT scan, and Pedro, the MSF ICU specialist, reassured staff on how a ventilated patient could be safely transported to the CT, explaining how they could use the available equipment.
The right result
After he’d been for the CT scan, the team were able to put him on appropriate treatment, and the man improved dramatically. The scan confirmed that the stroke was due to a blood clot, so the team was able to start him on vital medicines immediately.
Talking to his wife, I learned that he had residual left-side weakness, but the fact that he was awake and better was a miracle for the family who had witnessed many deaths around them since he’d been in the ICU.
I listened to his chest and back and gave the thumbs up. The patient silently gestured a hand shake, bringing his right hand to his weaker left hand on his lap. The wife yelled happily “Dear doctor, thank you all”.
Then as I was wiping my stethoscope she added a phrase I hadn’t heard before: “Aachatt Eedich!”
This is the exact pronunciation. At the time, I thought it just sounded nice.
I later came to realise this phrase means (literally) “May your hand live/thrive”, which is a charming Iraqi phrase for gratitude and thanks!
Such a heartfelt expression, and to me the reward I felt was well worth it. The kindness I sensed and witnessed in Iraq are my “small victories”.
Top image shows the COVID-19 ICU at Al-Kindy hospital. Patients in the photograph are not those described in this blog post.