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In an Iraqi ER, doctors attend to disaster

Figures on civilians killed in the relentless violence in Baghdad and other restive regions are hard to come by, but a visit to one hospital emergency room in the capital gives a window into the plight of doctors who are trying to save lives.
/ Source: a href="" linktype="External" resizable="true" status="true" scrollbars="true">The Washington Post</a

It was morning, the skies tinted gray by a winter storm, when the station wagon careered toward Yarmouk Hospital. Crowds scurried from its path before it screeched to a halt at the emergency room. Desperately, the driver pulled the bloodied body of Firas Abdel-Hassan from the back seat, which was littered with broken glass. Then he crumpled to the ground.

For a few minutes, the driver, Mohammed Abdel-Jabbar, sat in the parking lot, embracing his friend's body and weeping as blood collected in a pool on the pavement. His wails drew stares from some in the lot. Others gazed at the car — four bullet holes in the windshield, three side windows shattered by gunfire, blood smeared across the dashboard.

"Help me! Help me!" he shouted finally. "Can someone help me put him in a stretcher?"

A bullet had burrowed a gash across Abdel-Hassan's scalp. His left arm was twisted at an angle impossible in life. Blood soaked his gray shirt; his dark blue pants were still a shade darker. With practiced routine, and barely a word, nurses rolled his corpse into the emergency room, where his name was recorded as the day's first entry in the tattered register of patients.

"Arrived deceased," it read.

"This is the grimmest shift," Luai Rubaie, a physician at the hospital, said as he settled into work. "You haven't seen anything. It's just the beginning."

He shook his head, as if uttering what was self-evident. "Day and night," he said.

Rubaie, a stocky man with a gentle face, displayed both the detachment of a physician and the anguish of a man whose country seems cursed by far too frequent deaths. Figures on civilians killed in the relentless violence in Baghdad and other restive regions are hard to come by, however. A report last month in the Lancet medical journal said that at least 100,000 Iraqis may have been killed since the U.S. invasion in March 2003. A research group called Iraq Body Count put the number at a fraction of that — probably 14,600 to 16,800.

The numbers vary widely for a reason: lack of information. The Lancet study based its numbers on a survey of 33 neighborhoods in Iraq; Iraq Body Count relies on media reports. For months, an authoritative account was provided by the Iraqi Health Ministry, but it quit publicizing the toll in the fall. It reported 3,853 civilians killed from April 5 to Oct. 5.

Rubaie knows the numbers only at Yarmouk, one of Baghdad's largest hospitals, located in a neighborhood with its own share of kidnappings, shootings, car bombings and armed clashes. He sees maybe 100 cases a day, twice as many as before the invasion in March 2003. Back then, he estimated, one in 1,000 was a victim of gunfire. Now half the cases are the consequence of the city's strife.

"It's a museeba," Rubaie said — a disaster.

'It was just banditry'
Abdel-Hassan was the doctor's first case, in a six-hour shift that began at 8 a.m., and there was nothing he could do. Blood from the dead man's scalp dripped from the black leather stretcher to the grimy tile floor. A green sheet was draped over the body, then pulled over the head. Abdel-Jabbar tried vainly to pull a ring off one finger. Another friend splashed a cup of water over the dead man's right hand, loosening the ring. A nurse then tucked the limp arm under the sheet, blood already seeping across it.

"It was just banditry, right out in the open," Abdel-Jabbar said angrily, lighting a Viceroy cigarette in the emergency room.

"I swear, next week I'm going to leave the country," muttered Uday Nsayyif, another friend of the deceased man.

That morning, Abdel-Jabbar had been driving a truck piled with lumber for a construction company. A second truck followed, and Nsayyif and Abdel-Hassan were riding in a car providing an unarmed escort. In an episode that has become unexceptional along Iraq's treacherous roads, they were fired on by two assailants riding on a tractor as they headed from Abu Ghraib, a turbulent town west of Baghdad, to Musayyib, a seething city to the south in a region Iraqis have dubbed the Triangle of Death.

Inside the hospital, other friends of the victim speculated on what was behind the attack. All insisted on anonymity.

"We're a construction company trying to build a new Iraq," one said. "That makes us infidels."

To the side, another friend whispered a more likely scenario, saying the men had worked for a contractor at a U.S. military base. "They were working with Americans and they can't tell the truth," he said.

Minutes later, the conversation was interrupted by more shouts. Kadhim Ali, the second truck driver, was wheeled into the emergency room. His truck had overturned in the cascade of gunfire, shattering his left leg, and a bullet had grazed his right cheek.

"Is this jihad?" shouted a friend pushing his wheelchair into the emergency room. "Firas has already died!"

Ali's screams brought Rubaie and another doctor, along with four nurses, to his bed. One nurse cut off his blood-soaked jeans; another tried to put an IV in his arm. "My leg!" Ali shouted. "Oh, uncle, my leg's broken!"

A nurse pleaded for him to stop yelling, and friends held down his arms.

"Say, 'God,' " the nurse commanded.

"Oh, God," Ali answered, then started writhing again.

"I'm dying! I swear to God, I'm dying," he screamed. "Doctor, I'm dying!"

Doctors who know war
Rubaie and the other doctors in Yarmouk's emergency room worked methodically, nearly all of them drawing on long experience with war: the Iran-Iraq war that lasted from 1980 to 1988, the Persian Gulf War in 1991, the U.S. invasion and the far dirtier fight that has ensued. Rubaie boasted of their experience, proud of what they could do — even as he expressed remorse that they had to do it.

"The war with Iran was on the borders," said the world-weary Rubaie, who graduated from medical school at Baghdad's Mustansariya University as that conflict ended. "Now it's inside Baghdad. The war has now come to the city."

About 20 physicians work in Yarmouk's emergency room, divided among three shifts. It is an egalitarian system: Doctors make about twice what nurses do, their salaries ranging from $230 a month to $470. There are no days off — Rubaie, with a smile, said he works "eight days a week." They struggle with shortages of antibiotics, drugs and bandages. Only the paint is new, he complained.

"Look at the equipment," he said. "It's all contaminated."

He pointed to a tray splotched with iodine solution. On it was a jumble of scissors, gauze and gloves smeared with blood. Flies gathered on plastic bags, perched next to coils of suture thread and used IV tubes. A lone, portable radiator warmed the room. Drips of blood across the floor led to the rickety metal beds where patients were propped on thin mattresses sheathed in plastic. On the reception desk, next to the patients register, was a rotary telephone that never rang.

An endless procession of patients and their friends and relatives approached Rubaie with questions: Is he going to be all right? Can we take him home? When will the pain stop? To each, Rubaie answered politely, usually with a reassuring "Don't worry."

"Everybody does what they can do," he said. "If I get depressed, I can't work. If I don't, who will? They're our people."

He turned to Hadi Abdel-Karim, a 32-year-old nurse, and grabbed his hand.

"The nurses are the heroes," he said.

Abdel-Karim has worked as a nurse for 12 years, two of them at Yarmouk, where he has seen perhaps 60 friends, relatives and neighbors enter the emergency room's doors as corpses or injured. Today was tolerable, he said — nothing like the attack in October that still haunts him, when dozens of children were killed by twin car bombs. That attack unleashed hysteria and chaos at the hospital. The staff received the dead just past the barbed wire at the building's entrance: By Abdel-Karim's count, there were 43 killed, along with 132 wounded.

He said he worked 32 hours straight.

"I couldn't believe it," he recalled. "When we finished with one patient, three more would come. I can't forget it."

Gaunt and soft-spoken, Abdel-Karim fell silent for a moment. "God is generous," he said. "God willing, things will get better, but I don't see how. Day after day, it gets worse. I see the reality every day

People without a choice
The shift wore on, and phrases became familiar. "God forbid" was uttered often. In one bed was 18-year-old Ramzi Mohammed, shot in the foot while riding a bicycle when a clash erupted between U.S. troops and insurgents. Two beds down was Mishaan Fadhil, a 62-year-old bus driver with a bullet lodged in his neck. He said it was fired by U.S. troops.

Across the room was Shaalan Tarish, 40, wounded by a mine that targeted an American military convoy in the neighborhood of Dora. No U.S. troops were killed, and the attack merited no more than a paragraph in the day's newspaper coverage.

Tarish's chest was bruised and his face bandaged, concealing a gash on the left side. A friend, an Egyptian named Khalil Mohammed who has lived in Iraq for 24 years, stood next to him.

"In this situation, I'd like to go home. Today would be better than tomorrow," the friend said. "Even the Iraqis want to leave. If anyone had the money, he wouldn't stay longer than an hour. Everyone in here is poor."

The patients register was filling, entries handwritten in blue ink, in Arabic and English: RTA, road traffic accident; bullet; shelling; FFH, fall from height; burns; trauma.

Rubaie stood with colleague Haider Mulla Khadir, 33. A former military doctor, Khadir had served in a barracks on the Iranian border, without a toilet, and then in a tent in Nasiriyah during the U.S. invasion. He possesses a resilience that, along with toughness, may be the country's most enduring trait.

"At least I live under a roof now," Khadir said, smiling. Then, turning somber, he added: "The situation has to change. It can't stay the way it is. How much worse can it get?"

There is a sentiment often voiced in Iraq: the idea of a people left without a choice. Some Iraqis remark that, before the war, they were trapped between an America they mistrusted and a leader they despised. During the war, their fate was out of their hands. Now, they often say they feel powerless as U.S. forces and the insurgents battle for an uncertain future.

"We're scared for our lives. I'm not even sure each day I'll make it back to my house," Khadir said. "The people are caught in the middle. The Americans, the terrorists and the Iraqi forces all shoot in every direction, 360 degrees."

Rubaie interrupted. "In any country that's occupied, there must be resistance," he said. "Resistance is legitimate."

Khadir shook his head. "If they were an honorable resistance, I would join them," he said. "All they're doing is giving the Americans a justification to stay here. If they weren't here, the country would settle down and the Americans would leave."

He smiled. "Even if Israel came and provided stability in the country, I would accept it," he said.

"I wouldn't," Rubaie shot back.

They talked on — about being afraid to send their children to school, about crime in their neighborhood, about how old the patients' blankets were. The most grievously wounded shouted at times, "Oh mother!" Rubaie urged a patient with bandaged arms and legs to stop pacing around the room. "Quit moving, my friend," he called out. Nurses washed the drying blood off the arms and legs of a now-subdued Ali, the truck driver whose X-rays rested on his blanket, displaying his broken tibia.

"It's always the same," Rubaie said. "It was the same thing yesterday, it will be the same tomorrow and the day after."

At 2 p.m., Osama Abdel-Wahhab, the senior doctor of the next shift, arrived.

"Can we go?" Rubaie asked him.

"We're ready," Abdel-Wahhab said, smiling. "Go with God's blessings."