Yemen: “The weight of suffering will stay with me for a long time”
As COVID-19 continues to spread around the world, the danger of patients waiting too long to seek treatment is all too clear to MSF staff responding to the crisis.
Dr Rachel Lister, an intensive care doctor from New Zealand, spent six weeks working in MSF’s COVID-19 treatment centre in Aden. She highlights three patients' stories that had a profound impact on her during her field placement in Yemen.
Médecins Sans Frontières opened the COVID-19 treatment centre in Aden in May this year as the pandemic surged. We saw new patients every day, struggling for breath, their lungs damaged by the virus. It was overwhelming, with numbers initially well beyond our capacity to treat, from young and healthy patients to those older and frail.
The novel coronavirus alone caused suffering and death on a scale that really shocked us. However, the problem in Aden wasn’t just COVID-19, but the downstream impacts of the virus on the healthcare system. The fear of the virus was so strong that some hospitals closed outright. Those that remained open would not admit patients showing any symptoms remotely resembling COVID-19. That included fever, shortness of breath, changes seen on chest X-rays or CT scans, and generally anyone low on oxygen. They were all being turned away, refused care for fear of spreading the virus.
Patients with various medical conditions came to MSF’s clinic because no other hospital would accept them, and we could not turn them away. But I felt powerless to help – we had no surgeon to operate on them, nor the right drugs to treat their heart attacks. We had no CT scan to diagnose their strokes, and worse, regardless of their underlying health problems, they risked quickly being exposed to COVID-19 at the clinic.
“On the day he came into the clinic, he was having a heart attack”
Emir*, a patient in his 60s, had been to his regular hospital seeking help for chest pain and shortness of breath but they turned him away fearing he might have COVID-19. In fact, that was not his problem. On the day he came into the clinic, he was having a heart attack. The bad kind. The kind that if left untreated could quickly lead to death. The kind that could be treated with clot-busting medication or a relatively simple cardiology procedure. Both the drug and the procedure were available in other hospitals in Yemen. But not for someone who had low oxygen levels and a hazy chest X-ray. It wasn’t available because of the fear of COVID-19. And unfortunately, treatment was not available in our facility which was only set up to treat COVID-19.
We tried to help him, but over the course of the next few hours he became more breathless. I gave him oxygen, aspirin to thin his blood, and pain relief. His blood pressure started to drop; his heart already failing. I got on the phone trying to figure out how else we could help him, where else he could go to get the treatment he needed, but just as he reported more chest pain his heart suddenly stopped. My colleagues tried to resuscitate him. They did not succeed.
His main problem wasn’t COVID-19, but he paid the price for a healthcare system collapsing under the weight of this disease.
“Surviving ICU is a complex process”
The fear of COVID-19 also meant that people were coming to us too late. This included Amara*, who had been sick with the disease for a while, enduring antibiotics and oxygen at home before arriving at our facility.
Like many others trying to get treatment at home, she avoided hospital until she had no other choice. She was getting 30 litres of oxygen a minute – a huge amount – but her oxygen saturations were unrecordably low when I slipped the probe onto her finger. Her heart rate was fast, trying to compensate for the lack of oxygen, her skin tinged blue. Amara was working hard, using every muscle from her neck to her abdomen to try to get more oxygen. Her entire body shook with every breath.
It was obvious she needed to be intubated and on a ventilator. We prepared the drugs and explained to her what we wanted to do. It was a conversation that was becoming increasingly hard for me in Aden. I told her we wanted to put her under anaesthetic to try to save her life. To do the breathing for her since her lungs were so damaged by COVID-19. Explaining that part was easy, but how could I explain that there was a high chance that she might never wake up? Or that she might not speak to her family again? How could I explain that she might spend her last days hooked up to machines, with the team trying desperately to improve her breathing, knowing that it probably wouldn’t work?
Normally, working in an intensive care unit (ICU), I initiate interventions like this all the time, knowing that some patients will not survive but most will live. I do it with a reasonable expectation of a good outcome. Every day in Aden, however, it became increasingly apparent that our intubated COVID-19 patients struggled. The novel coronavirus is an aggressive disease, killing thousands of people in modern, well-resourced ICUs all over the world and here we were seeing the most severe cases.
On top of that, surviving ICU is a complex process with huge demand on staff, resources, equipment and drugs that we simply did not have access to in Aden. Yemen is a war zone, with limited resources and limited ability to provide the investigations and treatments we needed for these critically ill patients. I was rapidly confronted with the statistics. Few of the critical COVID-19 patients in Aden survived.
“Her family begged us to do whatever we could to save her”
It was an impossible decision to make. For Amara, for us.
Doing nothing meant she would likely not survive the day as her body was already struggling from the lack of oxygen. To intervene gave her a chance. It was a distressingly small chance, but that’s all we could offer. Her family begged us to do whatever we could to save her.
It was hard to look this beautiful young woman in the eyes, hers glazed with both fever and fear. She was scared and alone. I held her hand. I told her we would talk again once her lungs were better. I told her we would look after her. The words were heavy in my mouth. The whispered hope felt more like a prayer.
Unfortunately, we could not change the outcome for her. She managed seven long days in the ICU trying to coax her lungs back to function. Seven days of laying hands on her fever-wracked body trying to change the outcome, watching her blood tests get worse, her chest X-ray get worse. By day seven, she had developed a secondary infection that did not respond to antibiotics, leading to multi-organ failure. There was nothing else we could do within the limits of what we had access to. We made sure she was not in pain. That she did not suffer.
Amara joined the list of patients whose outcomes I could not change and whose names I will not forget.
Yemen is beautiful – a place of white sand beaches and spectacular jagged hills, of generous and resilient people who are quick to smile despite the years of war and poverty. It is a beautiful place, but the weight of suffering will stay with me for a long time.
*names have been changed