It’s early March. Two patients with severe gunshot wounds are being treated inside the canvas walls of a tent hospital just erected not far from the Afghanistan border. One is a 35-year-old man who arrived fully conscious but with blood pressure ominously low (60/40) and two chest drains already crudely inserted,1.5 litres of blood contained within. The nurse attempts to use her finger to keep the chest drains airtight, but every time someone asks her about it and she lets go for a second, blood gushes out. By the time the patient is taken for an X-ray, he’s unconscious. He makes it to the operating room, but then there’s a mad rush for adrenalin. “I don’t think he will make it, and I will be surprised if he is alive in the morning,” the attending nurse sums up later in her journal when she’s finally home for the evening.
The other patient is more stable though his injuries are severe. He’s already had surgery to his abdomen at another hospital, arriving with chest drain and catheter in place.” He will make it; however, he had no sensation or control of his limbs. I think he has major damage to his spine. Cannot believe everyone thought it was OK to sit him up for his chest X-ray,” the nurse writes later.
Sometimes, when it’s all so overwhelming and intense that she feels compelled to find an outlet, the nurse, Denise Moyle, writes in her journal; that is, if she can find a spare moment in her 70-hour work week.
Moyle, 35, had just begun a six-month stint as head nurse at the tent hospital — officially known as the International Committee of the Red Cross Surgical Hospital for Weapon Wounded  — in the dusty city of Peshawar in northwest Pakistan. A team of about 20 foreign and 70 local staff provide emergency relief for anyone who’s been wounded by weapons in the present conflict, militant or civilian, no matter with which side they’re aligned.
More than 650 patients have been treated so far and the hospital averages about seven to 14 operations a day. It has seven wards with 90 beds, as well as an outpatient tent, along with tents for X-rays and pathology. At other facilities staff fit amputees with prosthetics and teach them how to use their new limbs.
Moyle’s role was decidedly diverse. In her first two weeks as head nurse she found herself swamped with staff appraisals and duty rosters, chairing meetings, redesigning the mass casualty plan, developing staff health guidelines, treating staff, and entertaining Red Cross bigwigs.
She’d already spent more than nine months as a teaching nurse at the hospital this year, helping to open the facility in February. Much of her work then centred on ensuring staff were up to date with best practice techniques and procedures to avoid scenarios such as the 35-year-old patient with gushing blood and a probable spinal injury who was bent during his X-ray.
According to Moyle, local staff have a degree and formal training but no opportunity for clinical practice: “So if you put them with a patient with a fracture they can tell you everything that’s going on at the cellular level but they might not be able to get the patient’s leg in traction.” That’s why she spent time teaching critical basics about topics such as hygiene, dressing wounds and other protocols.
Moyle grew up near Geelong, Victoria, and attended Ballarat University College. But even in the early stages of nursing, she says, she envisioned her career heading this way: “I don’t think I was ever really cut out for mainstream nursing. I did some work in Alice Springs for nine months and it was clear to me then that I would find settling back into hospital life difficult.”
In 2003, at age 28, she was deployed on her first Red Cross mission to northern Kenya. She’s now on her fifth international mission in the past seven years, including a post in Darfur, Sudan. But experience hasn’t eased the exhaustion and stress that working in a conflict zone such as Pakistan brings. There are several contributing factors, among them long hours and tight restrictions, including being covered from head to toe every time she leaves the house, often in temperatures ranging from 40C to 60C.
As well, there’s minimal opportunity to exercise. The only real option is the little gym, and with 60 delegates sharing two running machines and two stationary bikes that’s not so appealing. Then there are safety concerns: eight bomb blasts in 12 days, one so close the windows shook on her house.
Finally, there’s the challenge of trying to fit in again when you do go back home and people’s concerns and worries seem so trivial. Meanwhile, the work itself can be extremely draining. That’s so as the extent of damage and trauma tends to be greater from war injuries than what’s typically seen in emergency rooms in Australia. War injuries usually occur at close range so the impact damage and fragments often extend deep into the body.
Injuries are worsened by patients having to travel three or four days to reach the hospital, sometimes on the back of a donkey cart. By the time they arrive their wounds are festering and contaminated from the dusty, dirty environment.
There are heartbreaking tales. According to Moyle, patients are sometimes young children or teenagers who’ve had the misfortune of being in the wrong place at the wrong time. Sometimes they’re just too inquisitive, such as the 13-year-old boy who found an interesting object outside his home and brought it in to play.
The “toy” exploded, blowing off part of his arms and injuring his sister as well. In an instant the lives of his entire family permanently changed. Everyone knew it, including the boy. Moyle says he had a haunting, ever-present “vacant look on his face, at the realisation of the enormity of what he caused his family”.
Still, there’s hope for the boy, who received prosthetic limbs and a second chance, she adds. Moyle recalls other cases, such as the man who suffered burns over 100 per cent of his body but lived more than two days, still conscious, still able to talk and communicate.
She talks of complicated success stories such as that of the. 25-year-old woman who was four months pregnant when a bomb blasted off both her legs and killed her unborn child. The woman’s mother-in-law stayed to help with her recovery, but the husband was no longer interested in her.
In fact, in conversations, emails and journal entries Moyle recounts dozens of sobering stories. So what keeps her motivated amid so much suffering? Moyle says it’s partly the belief she really can help that one person. It’s also the realisation that if she and her colleagues don’t help, no one else will.
But it goes further. Moyle tells a simple story. In the evenings when the killer heat fades into the summer night, patients and staff leave the airconditioned tents and sit outside together, sharing a communal meal of nan bread and one giant pot of meat soaked in oil. Everyone eats with their hands, dipping into the same dish. Staff pull out the beds of patients who can’t walk so they can join the group. Somehow, even with her limited language skills in Urdu and Pashto, Moyle feels a sense of connection and togetherness.
She says one patient even told another nurse that if he’d seen her a month earlier he would have killed her, but now he could not. Moyle says she’s often heartened by the courage patients display, as well as their ability to rise above tragedy to show kindness and generosity.
“People go above and beyond to help in these crisis situations and it often brings out the best in people,” she says. “I see people suffering and I could not imagine such pain, but from that I get to meet some of the most beautiful people.”

The Australian, 2010, copyright Lynnette Hoffman