August 4, 2020, at 6:07 pm, I was sitting down, unwinding with my family, when the floor of our apartment began to shake. I knew the drill. As an emergency physician who had relocated to Beirut a decade ago, I had been through it countless times. I leapt up, but before I could yell at my daughters to get away from the windows, I heard a loud rumble, followed by a deafening explosion that blasted through our windowpanes, sparing only the one behind us. For a moment, we stood, frozen, in awe at having escaped injury and absorbing the damage around us. Glass was everywhere. Dagger-shaped shards lay across the floor, on the tables and countertops, covering every surface. Beyond the hollowed windows, I saw a mushroom cloud of smoke. I had overseen many mass casualty responses in my tenure as chairperson of one of the largest emergency departments in Lebanon, but I knew this one would be unprecedented.
I left my family to deal with the debris of our shattered home and sprinted the 500 metres uphill to the hospital while mentally rehearsing the disaster plan our team had refined over the years. “Code D Alert” appeared on my phone. I reached the one open entrance that was guarded by security men and a steel gate. It slid open and I entered, noting the bars that were recently installed after a crowd, in the throes of grief, had stampeded through our glass entrance, injuring nurses and residents.
I scanned the emergency department. The electricity was out, except for a few dim emergency lights powered by a generator. Shattered glass lay on the floor. A door had been blown out of its frame. Parts of the ceiling dangled above a staff member who was helping bandage a patient’s wounds, oblivious to the blood soaking through the back of his own shirt. Patients, blood-drenched from the glass that had weaponized across the city, were everywhere: in the trauma bay, in the waiting areas, in hallways. And through the entrance, they continued to pour in.
Teams of responders from across the hospital had already formed in all areas, gowned and masked, barely recognizable through the COVID-19 armour that had become our reality during the pandemic. In the high-acuity zone, a physician was intubating a 5-year-old child. Another section was bursting with patients sitting shoulder-to-shoulder, physical distancing now a distant concern. I ran back toward the entrance, past the desperate pleas of wounded patients lining up along the way. We had done this before, but had never witnessed this scale of tragedy. Where would we care for all these patients? How many more would be coming? How many still lay under the rubble? My mind raced as I made my way to the triage area. Just inside the door stood one of our most experienced nurses. My anxiety settled as I saw him take control of triage and start diverting patients to one of the three designated surge areas that would be opened by the end of the night.
My phone buzzed. I recognized the number. A close friend, injured and already in the emergency department. A 20-kg chandelier had fallen on her head, leaving her with multiple lacerations and a pounding headache. A resident was placing her last stitch when I walked into her room. “Do I need a CT scan?” she asked. Under normal circumstances, yes, I thought. Then, visualizing the trail of stretchers with unresponsive patients that had started to pile up for imaging, I reassured her, ignoring my own doubts, “No, you’ll be okay.” I promised to call her the next day and walked out heavy with the decision I had just made, a sickening sense of betrayed trust welling up inside.
A medical student grabbed my arm, pulling me to the side of a body in the area where deceased casualties were lined up, waiting for the morgue. The body was of a man around my age, in his mid-forties, with no clear sign of trauma, just a coat of ashy dust from head to toe. Three leads on his chest marked the resuscitation that had been attempted and called off. The patient’s elderly father was holding his hand. “He’s warm … please do something!” he pushed on his chest mimicking compressions. I checked for a femoral pulse, remembering stories of bodies prematurely pronounced dead during the civil war, only to be found later alive, chests rising. No femoral pulse was palpable. I felt for carotid pulses. Nothing.
“I am sorry sir, Allah yirhamoh.” May God have mercy on him.
“He has two children,” the father implored.
I stood paralyzed for a moment in a turmoil of indecision. Resources in mass casualty situations needed to be saved for salvageable patients. One cycle, I thought. One cycle of compressions would allow this father to mourn in peace, knowing that we, and he, had tried everything. But before I could make the call, a nurse pulled me to the stretcher-congested hallway, away from the father whose face and aching plea would visit my dreams for months to come.
By now the problem was no longer finding places to see patients, it was the gridlock of patients who clearly needed admission. There were 87 patients piling up in our 40-bed department by the end of the night. We needed beds. We had no time for electronically entered admission requests. I ran through the list of open hospital beds with the admitting team. Some were unusable, damaged by the blast. We sent patients to the remaining beds, foregoing the usual safety checks that mark transitions of care; no handover, no patient names, no medication lists. Instead, we dispatched an army of residents led by attending physicians to start receiving the patients.
I was now drenched in sweat from running back and forth under the impermeable gown. The metallic smell of mopped up blood that still managed to get through my N95 mask had become overpowering. I stepped into the safety of the women’s locker room and dry-heaved in solitude. How much more can we take? I thought. Collecting myself, I headed back to triage.
The crowd was now trying to get through the barred gate, looking for their loved ones. They had become loud with anger, strong with resolve. The steel bars were rocking back and forth, hinges coming undone. They wanted names we had not had the time to collect. My eyes locked with those of our medical director. We recognized the gravity of this shortcoming. He took off with our case manager in search of patient identities. Twenty minutes later, he stood before the crowd and announced one name after the other, allaying the fears of many and leaving others, whose loved ones were still missing, in even deeper despair.
By midnight, the activity had shifted out of the emergency department, into the operating rooms and onto the inpatient floors. At our hospital alone, we had seen around 360 casualties, a count that would increase to 700 by the end of the week. I left at 5:30 am, walking back through the silent streets of a city in mourning. Nearly 3 tons of ammonium nitrate had detonated in the harbour, less than 4 km from where I stood, causing the largest non-nuclear explosion in history. Lives were lost, many were still missing. Neighbourhoods were shattered, leaving thousands displaced. Demolished hospitals were evacuated. Flooded emergency departments were emptied. A pandemic, once nearly contained, was now unleashed. Physical wounds were closed, but for medical teams who had responded across the city that night facing impossible decisions, moral ones were opened.
Today, almost 6 months after the blast, as we face a raging pandemic that is again forcing us to make decisions under unimaginable constraints, I often think about the father who wanted us, me, to do more. Remembering his pleading eyes as his hands pushed desperately at his son’s chest, I realize now that maybe we needed that last cycle as much as he did. Pausing amidst the calamity to ease the suffering of one is perhaps what we all need to sustain us through the tragedies of the many.
Acknowledgements
The author would like to thank her husband and daughter, Jad and Emesa Melki, for encouraging her to reflect on this experience through writing and for their feedback along the way.
Footnotes
This article has been peer reviewed.
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