Yemen: How can I not?

There’s an echo inextricably linked to an end of mission that seems to reverberate harder each time.  

“How?  How can you?”  

How can you cope?  How can you continue?  How can you deal with what you see? How can you function back at home?    

How?  How?  How?   

How can I cope?   

In Yemen, there is no buffer between the Emergency Department and the outside world.  With no retrieval services and no public-use ambulances, patients are bundled into unregulated vehicles set to careen along windy, pockmarked roads to the closest skeleton of a health service available.    

They’re not lovingly tended by functional retrieval services the way we’re used to in Australia. With no pre-hospital care, often the bodies that arrive are a mess – acute trauma, acute abdomens, acute respiratory compromise – seemingly minutes from death.    

Playing a game of Russian Roulette with ‘too late’, patient care begins the moment they’re carried in the door. 

Even the most seasoned medical practitioner in a city centre will be faced with goosebump-inducing scenarios, in the face of which they’ll muster the expansive knowledge they possess, call in every resource available to them, and just deal with the emergency before them.    

In the face of a patient, gunshot penetrating his chest, fighting to breathe, I do just that. I’m no cardiothoracic surgeon, but I know the basics to save his life.    

A young girl seizing, with limited insight as to why, and resistant to almost all our medication to stop it.  Again, I’m not a paediatrician, but step-by-step with my colleagues we walk through the immediate management to save her life and then investigations to differentiate the cause.    

Just like I did when I joined MSF, I choose to act.  Adhering to universal medical principles to do no harm, I choose to act and in doing so I can manage.  Medically, physically, and ultimately emotionally, action is how I cope.  

How can I continue?    

A woman is rushed in, 32 weeks pregnant, seizures wracking her body as she delivers a stillborn boy.  The emergency room doesn’t stop. The patient in the next bed with a gunshot wound in his back still needs a chest tube.  The man in triage having a stroke deserves no less attention.    

Immediately, we work to save the life of the woman, the life remaining.  In parallel, we stabilise the man shot in the back for evading a checkpoint and care for his friend with a mildly less morbid gunshot wound to the shoulder.  We work systematically, we persevere.    

The following day it could be quiet, with an ever-present chance of spontaneous and resource-saturating calamity.  Prospective patients don’t deserve less, so we continue.  

Each day we trade emotional and physical fatigue for job satisfaction. The balance is not always equal and sometimes overwhelmingly lopsided, but always countered by the alternative option: inaction.    

My active involvement is time-limited, after which the long-closed airport (2016) will open to facilitate my safe return from the conflict, a luxury stripped from millions of Yemenis.    

As for them, they continue to be innocent victims of countless human rights violations. They continue to lose family members prematurely to diseases that should have been eradicated; continue struggling to live, although the support structures allowing that to happen serenely crumble around them.   

I continue because that could be me, my family.  I continue because we’re part of the same global community.  I continue because for me, it’s still a choice. 

How can I deal with what I see?  

How can I deal with what I see and still care about patients back home in Australia?  We’re all the same, physically, fundamentally, but in Yemen people break differently.  Deregulation of all society’s safety measures, in addition to prolonged and active conflict, bring shattered humans united only by a thready heartbeat.    

The confrontation dulls somewhat with repetition, but soon enough it’s replaced by a sense of responsibility – to bear witness and to speak out. To lend another decibel to a vocal global minority screaming out for those broken by a fractured system.     

I care no less for the stable child of a panicky parent presenting in an Australian emergency department than a man dying of neglected cardiac disease in Yemen. 

My empathy is equal between women on separate continents experiencing the devastating loss of their newborn.    

My care continues with the same dedication for an Australian child who broke her arm falling from a tree, and an eight-year-old Yemeni with his thigh gruesomely fractured in two by a car. 

Experience changes us. I’ve seen things that will be etched in my memory and inform my medical practice for years to come.  How do I deal with it?  I let it change me: my practice, and my person.    

In a world that’s doing all it can to make us hard, I stay soft.  I continue to care for patients, acknowledging their personal sense of vulnerability pays no attention to their geographical location.    

I have lost no empathy for patients I see back home, but I’ve gained endless amounts of gratitude for a system that, more often than not, has our back.    

Standing in an operating theatre in Tasmania with more than a century’s worth of combined professional experience, watching my colleagues cry over the stillborn freshly delivered brought this home.  So many professionals so unaccustomed to premature mortality that each new confrontation brings them to tears.  Our system is OK.  

In my post-assignment haze, those questions continue to ring.    

Needing less to justify my choices and understanding just what this work – flawed as it can be – means as an idealist with grand dreams for a global humanity, I’ve found my answer.  

To the question “How can you?”, I can comfortably pose the simplified rhetoric:  

“How can I not?”