Trauma Care in the Arab Spring

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Dr. Adam Levine, an assistant professor at Brown University Medical School, traveled to Libya with International Medical Corps (IMC) during August, just as rebels were beginning to overthrow the Gaddafi regime. The following are excerpts from his travel blog, which first appeared on .



Dr. Adam Levine, an assistant professor at Brown University Medical School, traveled to Libya with International Medical Corps (IMC) during August, just as rebels were beginning to overthrow the Gaddafi regime. The following are excerpts from his travel blog, which first appeared on Emergency Physicians International (

August 15, 2011
My first day at the field hospital was largely spent packing it up for a move to a new location. The field hospital, located on a small farm about 20-30 kilometers west of Misurata was intended to be contained in a series of inflatable tents, which included an emergency room, a basic operating theatre, a post-op observation unit, a laboratory, and a pharmacy. For security reasons, though, instead of being set up in a field, the tents were all placed inside a large warehouse-style barn located on the property. Though the barn would offer only minimal protection from a direct mortar hit, it would protect staff and patients from any shrapnel from a stray mortar landing elsewhere on the farm, which might otherwise rip right through the flimsy walls of the tents. The field hospital had been set up several weeks prior when the front line was closer to Misurata. Now, with rebel advances, the front line had moved farther west, and so the field hospital was to be moved to a new location about 10 kilometers from the fighting – close enough for injured patients to be able to arrive within the “golden hour” of trauma care but far enough away to be generally outside the range of stray mortars.

Luckily, it was now Ramadan, which meant that little fighting happened between sunrise and early afternoon, when everyone on both sides of the conflict were fasting and most were sleeping. Fighting, and injuries, would pick up in the late afternoon and early evening, before stopping again for the night. We took advantage of the relative quiet during the early part of the day to pack up the hospital, loading boxes of gauze, splints, IV fluids, the portable ultrasound and X-ray machine, a large generator, boxes of antibiotics and pain killers onto several trucks and a few of the makeshift ambulances. In between packing, we still saw a handful of random soldiers coming in from the front lines, mostly with shrapnel wounds – small bits of twisted metal from exploding mortars buried in arms, legs, chest, back, head, neck. Practically any part of the body not protected by body armor was open to shrapnel injuries, which meant all parts of the body for most of the rebel fighters.  In general, this was a self-financed war. Those willing and able with the money to purchase a gun headed out to the front line to fight. Those too poor to purchase a gun helped out in other ways, but few also had the money to also purchase body armor, and those that did felt guilty wearing it around their fellow, unprotected soldiers.


Fifteen or so kilometers down the road, past a series of freedom fighter checkpoints, was the location for the new field hospital where we began unloading supplies from the trucks and ambulances. The new site was an Italian-style villa abandoned during the recent fighting, with ornately carved doors, stained glass windows (now mostly shattered), and a few pieces of beautiful, handcrafted furniture. A large stone wall, riddled with bullet holes surrounded the villa. Beyond it lay a small orchard of fig trees. Broken glass crunched underfoot as we walked through the large house, and small piles of accumulated rubble and debris had to be cleared out before turning the house into a hospital. The rest of the day was spent sweeping: we cleaned up the large ballroom to be used as the new ER, the sitting room that would become the new operating theatre, and the bedroom destined to be our post-op observation unit, as well as a few smaller rooms that would become offices and storage rooms. Then we moved in supplies and equipment. After a bit of discussion between the ex-pat staff and the local Libyan volunteer doctors, who provided much of the staffing for the field hospital during the day and nearly all the staffing overnight, we were finally able to decide on a layout for the new ER and an organizational system for the drugs and supplies in the new hospital. All that was left was to put up a new sign directing patients to our new location.


August 19, 2011
After several relatively quiet days at the new field hospital where we saw no more than a handful of patients, mostly with minor shrapnel wounds and lacerations, we walked in this morning to find a scene of complete chaos. We knew something was amiss on the drive in from Misurata when we saw several ambulances speeding past us in the direction from which we came. Apparently the Libyan rebels had finally invaded Zlitan, one of the last main cities on the road west from Misurata to Tripoli, at dawn that morning, and the casualties were now starting to show up at the field hospital.

We arrived at the Italian villa-turned-hospital to find dozens of ambulances and trucks carrying patients to us from the front line, and carrying patients from us to the referral hospital in Misurata. They were all jammed into the relatively small patio between the house and the stone walls surrounding it. Our ER was filled to the brim with patients, as were two overflow tents set up outside the villa, and another tent apparently designated as a morgue. The Libyan doctors covering the field hospital overnight were busy running several trauma resuscitations, splinting fractures and dressing wounds. Local volunteers, mostly men too young or too old to fight on the front lines, were scurrying about, carrying patients on stretchers, fetching blood or supplies. Everywhere people were screaming, crying, shouting. The deep, dull boom of outgoing mortar rounds could be heard in the distance (which are relatively easy to distinguish from the high pitched whine of incoming mortars). For a moment, I stood in place, paralyzed by the scene around me. So many patients, without any clear system of triage in place – where to begin?


Just then, another ambulance raced in through the gates and screeched to a halt just a few feet in front of us, shaking me awake and providing a clear answer to my question. Several volunteers rushed up to help the ambulance driver unload the patient, a young man with blood soaking through the back of his shirt and his right pant leg who looking pale and diaphoretic. This was where I would begin.

I followed him into the ER we had set up inside the villa and helped load him onto a recently vacated bed. We quickly stripped off his clothes, rolled him, identified three bullet wounds to his right back, two to his right thigh, and one to his left leg. His heart rate was high with a weak radial but strong carotid pulse, no breath sounds on the right but good breath sounds on the left.  As two of the Jordanian nurses working with International Medical Corps placed IV lines and started drips, I went to our storeroom to grab some supplies. The storeroom looked like it had been ransacked, but I found w
hat I was looking for and within about 15 minutes had a right chest tube placed, lower extremity wounds cleaned and bandaged, antibiotics, analgesics, and tetanus given, and the patient back on another ambulance, headed for the polyclinic in town. My initial fear on arriving melted away as I plunged into patient care and allowed the simple ABCs of the ATLS protocol to take over.

Within the next hour or so, our team from International Medical Corps met with the Libyan doctors and worked out a system of triage. Our small 8-bed ER would become the resuscitation room, while patients with less serious wounds would be sent to the large wedding tent they had set up a couple days before, next to the villa. The tent, which had been erected by the Libyan doctors a few days before as a contingency plan for treating patients, proved to be vitally important in serving the mass casualties in addition to our more secure ER under hard cover within the villa. Incredibly, despite the chaos of the day, and language and cultural barriers, our IMC team and the Libyan volunteer doctors worked in almost perfect harmony to triage, treat, and dispo the many patients.

The day felt like such a blur, and even now, I can barely remember all the patients I saw. I know it was a lot though, and most were pretty sick. There are just a few that stand out in my memory: the man with the bullet entrance wound to his mid-sternum that exited through his right flank, whose trajectory managed to miss his heart completely and leave him with little more than a thin smear of intra-abdominal bleeding on ultrasound. There was a young man, a captured fighter with Kadafi’s army, who had an open tibia fracture that kept bleeding. The mid-part of his lower leg was a mess of macerated muscle and bone, and I couldn’t locate a specific source of bleeding to tie off. In the end I pumped about three syringes of Celox hemostatic powder into the wound, put on a pressure bandage, elastic wrap, reduced the fracture as best I could and splinted the leg, which seemed to do the trick. There were several patients who came in dead, with severe cardiac or abdominal injuries. One patient had the distinct smell of feces coming out of a baseball-sized hole in his right lower quadrant. Another patient had second and third degree burns to his entire left leg, all overlying an open femur fracture. Dressing, packing, traction splint and as much pain medicine as we could get (we had plenty of IV ketorolac and IV tramadol, though narcotics were understandably hard to come by in this setting). There was a six-year-old girl with minor injuries and several teenage boys with fractures and burns.

Overall, we saw somewhere between 110 and 130 trauma patients between dawn and dusk today in our small field hospital and may have had about 20-30 deaths (though many of these were likely DOA). Given our location on the eastern side of the front line, most of the casualties were rebel fighters, but we also saw some civilians caught in the fighting as they attempted to flee the city, as well as a handful of Gaddafi soldiers captured after being injured. The Libyan doctors and IMC team worked to ensure that the Gaddafi fighters were protected during treatment and designated someone to accompany them when they needed to be transferred to Misurata to ensure that they received proper care.

As the day wore on, I could see many of the Libyan doctors and nurses, most of whom were still fasting for Ramadan, begin to fade. There were several emotional scenes outside of the tent we had set up as our morgue, with friends and family walking out of the tent crying or screaming after identifying the body of their loved one. A television crew arrived at the hospital, and they were asked respectfully to allow space for the doctors to work without cameras and disturbance. Many of the Libyan doctors and nurses, as well as many of the rebels we were treating, still had family in Tripoli, which they felt would be put in danger if images of them appeared on international television.

By evening, the patients had slowed to a trickle, and our team piled into the van to drive back to our apartment in Misurata. We quickly found ourselves in gridlock, caught in the traffic of refugees fleeing the city of Zlitan due to the fighting. Some had mattresses piled on top of their cars, one had six goats in the back of his truck along with boxes of other possessions. The farm where our old field hospital had been had actually turned into an overnight displaced person’s camp, housing several hundred people and supported by many local residents who came with food and water. Hopefully they will not have to be here for long. The word is that the rebels have almost secured Zlitan, so hopefully the displaced families will be able to return home soon. Personally, I cannot wait to get through this traffic, where I am now typing my recollections of today, and back to my soft bed in Misurata.

To read the rest of Dr. Levine’s blog, go to Emergency Physicians International.



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