Sunday, November 27, 2016

On the importance of kindness in relationships

https://www.theatlantic.com/health/archive/2014/06/happily-ever-after/372573/

Masters of Love

Science says lasting relationships come down to—you guessed it—kindness and generosity.

Every day in June, the most popular wedding month of the year, about 13,000 American couples will say “I do,” committing to a lifelong relationship that will be full of friendship, joy, and love that will carry them forward to their final days on this earth.

Except, of course, it doesn’t work out that way for most people. The majority of marriages fail, either ending in divorce and separation or devolving into bitterness and dysfunction. Of all the people who get married, only three in ten remain in healthy, happy marriages, as psychologist Ty Tashiro points out in his book The Science of Happily Ever After, which was published earlier this year.

Social scientists first started studying marriages by observing them in action in the 1970s in response to a crisis: Married couples were divorcing at unprecedented rates. Worried about the impact these divorces would have on the children of the broken marriages, psychologists decided to cast their scientific net on couples, bringing them into the lab to observe them and determine what the ingredients of a healthy, lasting relationship were. Was each unhappy family unhappy in its own way, as Tolstoy claimed, or did the miserable marriages all share something toxic in common?
Psychologist John Gottman was one of those researchers. For the past four decades, he has studied thousands of couples in a quest to figure out what makes relationships work. I recently had the chance to interview Gottman and his wife Julie, also a psychologist, in New York City. Together, the renowned experts on marital stability run The Gottman Institute, which is devoted to helping couples build and maintain loving, healthy relationships based on scientific studies.

John Gottman began gathering his most critical findings in 1986, when he set up “The Love Lab” with his colleague Robert Levenson at the University of Washington. Gottman and Levenson brought newlyweds into the lab and watched them interact with each other. With a team of researchers, they hooked the couples up to electrodes and asked the couples to speak about their relationship, like how they met, a major conflict they were facing together, and a positive memory they had. As they spoke, the electrodes measured the subjects' blood flow, heart rates, and how much they sweat they produced. Then the researchers sent the couples home and followed up with them six years later to see if they were still together.

From the data they gathered, Gottman separated the couples into two major groups: the masters and the disasters. The masters were still happily together after six years. The disasters had either broken up or were chronically unhappy in their marriages. When the researchers analyzed the data they gathered on the couples, they saw clear differences between the masters and disasters. The disasters looked calm during the interviews, but their physiology, measured by the electrodes, told a different story. Their heart rates were quick, their sweat glands were active, and their blood flow was fast. Following thousands of couples longitudinally, Gottman found that the more physiologically active the couples were in the lab, the quicker their relationships deteriorated over time.
But what does physiology have to do with anything? The problem was that the disasters showed all the signs of arousal—of being in fight-or-flight mode—in their relationships. Having a conversation sitting next to their spouse was, to their bodies, like facing off with a saber-toothed tiger. Even when they were talking about pleasant or mundane facets of their relationships, they were prepared to attack and be attacked. This sent their heart rates soaring and made them more aggressive toward each other. For example, each member of a couple could be talking about how their days had gone, and a highly aroused husband might say to his wife, “Why don’t you start talking about your day. It won’t take you very long.”

The masters, by contrast, showed low physiological arousal. They felt calm and connected together, which translated into warm and affectionate behavior, even when they fought. It’s not that the masters had, by default, a better physiological make-up than the disasters; it’s that masters had created a climate of trust and intimacy that made both of them more emotionally and thus physically comfortable.

Gottman wanted to know more about how the masters created that culture of love and intimacy, and how the disasters squashed it. In a follow-up study in 1990, he designed a lab on the University of Washington campus to look like a beautiful bed and breakfast retreat. He invited 130 newlywed couples to spend the day at this retreat and watched them as they did what couples normally do on vacation: cook, clean, listen to music, eat, chat, and hang out. And Gottman made a critical discovery in this study—one that gets at the heart of why some relationships thrive while others languish.

Throughout the day, partners would make requests for connection, what Gottman calls “bids.” For example, say that the husband is a bird enthusiast and notices a goldfinch fly across the yard. He might say to his wife, “Look at that beautiful bird outside!” He’s not just commenting on the bird here: he’s requesting a response from his wife—a sign of interest or support—hoping they’ll connect, however momentarily, over the bird.

The wife now has a choice. She can respond by either “turning toward” or “turning away” from her husband, as Gottman puts it. Though the bird-bid might seem minor and silly, it can actually reveal a lot about the health of the relationship. The husband thought the bird was important enough to bring it up in conversation and the question is whether his wife recognizes and respects that.
People who turned toward their partners in the study responded by engaging the bidder, showing interest and support in the bid. Those who didn’t—those who turned away—would not respond or respond minimally and continue doing whatever they were doing, like watching TV or reading the paper. Sometimes they would respond with overt hostility, saying something like, “Stop interrupting me, I’m reading.”

These bidding interactions had profound effects on marital well-being. Couples who had divorced after a six-year follow up had “turn-toward bids” 33 percent of the time. Only three in ten of their bids for emotional connection were met with intimacy. The couples who were still together after six years had “turn-toward bids” 87 percent of the time. Nine times out of ten, they were meeting their partner’s emotional needs.
* * *
By observing these types of interactions, Gottman can predict with up to 94 percent certainty whether couples—straight or gay, rich or poor, childless or not—will be broken up, together and unhappy, or together and happy several years later. Much of it comes down to the spirit couples bring to the relationship. Do they bring kindness and generosity; or contempt, criticism, and hostility?

“There’s a habit of mind that the masters have,” Gottman explained in an interview, “which is this: they are scanning social environment for things they can appreciate and say thank you for. They are building this culture of respect and appreciation very purposefully. Disasters are scanning the social environment for partners’ mistakes.”
“It’s not just scanning environment,” chimed in Julie Gottman. “It’s scanning the partner for what the partner is doing right or scanning him for what he’s doing wrong and criticizing versus respecting him and expressing appreciation.”
Contempt, they have found, is the number one factor that tears couples apart. People who are focused on criticizing their partners miss a whopping 50 percent of positive things their partners are doing and they see negativity when it’s not there. People who give their partner the cold shoulder—deliberately ignoring the partner or responding minimally—damage the relationship by making their partner feel worthless and invisible, as if they’re not there, not valued. And people who treat their partners with contempt and criticize them not only kill the love in the relationship, but they also kill their partner's ability to fight off viruses and cancers. Being mean is the death knell of relationships.

Kindness, on the other hand, glues couples together. Research independent from theirs has shown that kindness (along with emotional stability) is the most important predictor of satisfaction and stability in a marriage. Kindness makes each partner feel cared for, understood, and validated—feel loved. “My bounty is as boundless as the sea,” says Shakespeare’s Juliet. “My love as deep; the more I give to thee, / The more I have, for both are infinite.” That’s how kindness works too: there’s a great deal of evidence showing the more someone receives or witnesses kindness, the more they will be kind themselves, which leads to upward spirals of love and generosity in a relationship.

There are two ways to think about kindness. You can think about it as a fixed trait: either you have it or you don’t. Or you could think of kindness as a muscle. In some people, that muscle is naturally stronger than in others, but it can grow stronger in everyone with exercise. Masters tend to think about kindness as a muscle. They know that they have to exercise it to keep it in shape. They know, in other words, that a good relationship requires sustained hard work.

“If your partner expresses a need,” explained Julie Gottman, “and you are tired, stressed, or distracted, then the generous spirit comes in when a partner makes a bid, and you still turn toward your partner.”

In that moment, the easy response may be to turn away from your partner and focus on your iPad or your book or the television, to mumble “Uh huh” and move on with your life, but neglecting small moments of emotional connection will slowly wear away at your relationship. Neglect creates distance between partners and breeds resentment in the one who is being ignored.

The hardest time to practice kindness is, of course, during a fight—but this is also the most important time to be kind. Letting contempt and aggression spiral out of control during a conflict can inflict irrevocable damage on a relationship.

“Kindness doesn’t mean that we don’t express our anger,” Julie Gottman explained, “but the kindness informs how we choose to express the anger. You can throw spears at your partner. Or you can explain why you’re hurt and angry, and that’s the kinder path.”
John Gottman elaborated on those spears: “Disasters will say things differently in a fight. Disasters will say ‘You’re late. What’s wrong with you? You’re just like your mom.’ Masters will say ‘I feel bad for picking on you about your lateness, and I know it’s not your fault, but it’s really annoying that you’re late again.’”
* * *
For the hundreds of thousands of couples getting married this month—and for the millions of couples currently together, married or not—the lesson from the research is clear: If you want to have a stable, healthy relationship, exercise kindness early and often.
When people think about practicing kindness, they often think about small acts of generosity, like buying each other little gifts or giving one another back rubs every now and then. While those are great examples of generosity, kindness can also be built into the very backbone of a relationship through the way partners interact with each other on a day-to-day basis, whether or not there are back rubs and chocolates involved.

One way to practice kindness is by being generous about your partner’s intentions. From the research of the Gottmans, we know that disasters see negativity in their relationship even when it is not there. An angry wife may assume, for example, that when her husband left the toilet seat up, he was deliberately trying to annoy her. But he may have just absent-mindedly forgotten to put the seat down.

Or say a wife is running late to dinner (again), and the husband assumes that she doesn’t value him enough to show up to their date on time after he took the trouble to make a reservation and leave work early so that they could spend a romantic evening together. But it turns out that the wife was running late because she stopped by a store to pick him up a gift for their special night out. Imagine her joining him for dinner, excited to deliver her gift, only to realize that he’s in a sour mood because he misinterpreted what was motivating her behavior. The ability to interpret your partner’s actions and intentions charitably can soften the sharp edge of conflict.

“Even in relationships where people are frustrated, it’s almost always the case that there are positive things going on and people trying to do the right thing,” psychologist Ty Tashiro told me. “A lot of times, a partner is trying to do the right thing even if it’s executed poorly. So appreciate the intent.”

Another powerful kindness strategy revolves around shared joy. One of the telltale signs of the disaster couples Gottman studied was their inability to connect over each other’s good news. When one person in the relationship shared the good news of, say, a promotion at work with excitement, the other would respond with wooden disinterest by checking his watch or shutting the conversation down with a comment like, “That’s nice.”

We’ve all heard that partners should be there for each other when the going gets rough. But research shows that being there for each other when things go right is actually more important for relationship quality. How someone responds to a partner’s good news can have dramatic consequences for the relationship.

In one study from 2006, psychological researcher Shelly Gable and her colleagues brought young adult couples into the lab to discuss recent positive events from their lives. They psychologists wanted to know how partners would respond to each other’s good news. They found that, in general, couples responded to each other’s good news in four different ways that they called: passive destructiveactive destructivepassive constructive, and active constructive.
Let’s say that one partner had recently received the excellent news that she got into medical school. She would say something like “I got into my top choice med school!”
If her partner responded in a passive destructive manner, he would ignore the event. For example, he might say something like: “You wouldn’t believe the great news I got yesterday! I won a free t-shirt!”
If her partner responded in a passive constructive way, he would acknowledge the good news, but in a half-hearted, understated way. A typical passive constructive response is saying “That’s great, babe” as he texts his buddy on his phone.

In the third kind of response, active destructive, the partner would diminish the good news his partner just got: “Are you sure you can handle all the studying? And what about the cost? Med school is so expensive!”
Finally, there’s active constructive responding. If her partner responded in this way, he stopped what he was doing and engaged wholeheartedly with her: “That’s great! Congratulations! When did you find out? Did they call you? What classes will you take first semester?”

Among the four response styles, active constructive responding is the kindest. While the other response styles are joy-killers, active constructive responding allows the partner to savor her joy and gives the couple an opportunity to bond over the good news. In the parlance of the Gottmans, active constructive responding is a way of “turning toward” your partners bid (sharing the good news) rather than “turning away” from it.

Active constructive responding is critical for healthy relationships. In the 2006 study, Gable and her colleagues followed up with the couples two months later to see if they were still together. The psychologists found that the only difference between the couples who were together and those who broke up was active constructive responding. Those who showed genuine interest in their partner’s joys were more likely to be together. In an earlier study, Gable found that active constructive responding was also associated with higher relationship quality and more intimacy between partners.

There are many reasons why relationships fail, but if you look at what drives the deterioration of many relationships, it’s often a breakdown of kindness. As the normal stresses of a life together pile up—with children, career, friend, in-laws, and other distractions crowding out the time for romance and intimacy—couples may put less effort into their relationship and let the petty grievances they hold against one another tear them apart. In most marriages, levels of satisfaction drop dramatically within the first few years together. But among couples who not only endure, but live happily together for years and years, the spirit of kindness and generosity guides them forward.

Friday, November 25, 2016

"Much medical training is about information and knowledge and less about traveling the more difficult path of feeling…it’s crucial for doctors to stay with the feeling, listen feelingly, and not turn away from the pain and suffering in patients and themselves. There is one shining difference between knowledge and understanding: We doctors may forget knowledge, but we never forget what we understand. We understand through feeling."
- Samuel Shem, “Fiction as Resistance”

Tuesday, November 15, 2016

'A biologist's Mother's Day Song'

Poems: 'Today I do not want to be a doctor' and 'Today I want to be a doctor'

TODAY I DO NOT WANT TO BE A DOCTOR - Glenn Colquhoun.

Today I do not want to be a doctor.
Nobody is getting any better.
Those who were well are sick again
and those who were sick are sicker.
The dying think they will live.
The healthy think they are dying.
Someone has taken too many pills.
Someone has not taken enough.
A woman is losing her husband.
A husband is losing his wife.
The lame want to walk.
The blind want to drive.
The deaf are making too much noise.
The depressed are not making enough.
The asthmatics are smoking.
The alcoholics are drinking.
The diabetics are eating chocolate.
The mad are beginning to make sense.
Everyone’s cholesterol is high.
Disease will not listen to me
Even when I shake my fist.


TODAY I WANT TO BE A DOCTOR - Glenn Colquhoun.

Today I am happy to be a doctor.
Everyone seems to be getting better.
Those who were sick are not so sick
and those who were well are thriving.
The healthy are grateful to be alive.
And the dying are at peace with their dying.
No one has taken too many pills.
No one has taken too few.
A woman is returning to her husband.
A husband is returning to his wife.
The lame accept chairs.
The blind ask for dogs.
The deaf are listening to music.
The depressed are tapping their feet.
The asthmatics have stopped smoking.
The alcoholics have stopped drinking.
The diabetics are eating apples.
The mad are beginning to make sense.
Nobody’s cholesterol is high.
Disease has gone weak at the knees
I expect him to make an appointment.


http://lifeinthefastlane.com/today-i-do-not-want-to-be-a-doctor/

DeepMind, Google and the NHS - article from the Guardian newspaper

Google's DeepMind shouldn't suck up our NHS records in secret


https://www.theguardian.com/commentisfree/2016/may/04/googles-deepmind-shouldnt-be-sucking-up-our-nhs-records-in-secret

The revelation that 1.6 million patients’ records are being used by the company’s artificial intelligence arm rings alarm bells
TV screens show live broadcast of Google DeepMind’s Go match against world champion Lee Sedol
 A live broadcast of Google DeepMind’s Go match against the world champion Lee Sedol. DeepMind won. Photograph: Ahn Young-joon/AP
When it was revealed that Google’s London-based company DeepMind would be able to access the NHS records of 1.6 million patients who use three London hospitals run by the Royal Free NHS trust – Barnet, Chase Farm and the Royal Free – it rang alarm bells.
Not just because the British fiercely guard their intimate medical histories. Not just because Google, a sprawling octopus of a company with tentacles in all our lives, wishes to “organise the world’s information”. Not just because patients are unlikely to have consented to Google having this information.
The issue for many is the intertwining of these concerns with the idea of artificial intelligence (AI). DeepMind is no ordinary company. It specialises in AI, developing technology to exhibit something like intelligent reasoning.
Last year its engineers produced a research paper showing it had created a program that could replicate the work of a “professional human video games tester”. In March, Google’s DeepMind made history by creating a program that mastered the 3,000-year-old Chinese board game Go, thought to be beyond current technology because of the number of possible moves. In what was considered a computing milestone, the company’s AlphaGo program beat the world Go champion 4-1.
Now such a company has a database containing detailed, private, albeit anonymised, records of all these people’s medical history, including HIV status, past drug overdoses and abortions. DeepMind says it needs the data to produce medical alerts for hospitals attempting to prevent acute kidney injuries.
The fear for some is that DeepMind’s database could allow for much more than the original stated purpose. The public is no stranger to the fact that NHS patient privacy has not been safeguarded – in 2014 the government was forced to halt and then scale back its proposals to produce a single English medical database over concerns that medical confidentiality could be put at risk.

DeepMind has not hidden its work with the NHS, announcing in February it was working with the health service to build an app called Streams to help doctors and nurses monitor kidney patients. What it did not reveal was the extent of its data haul, which encompasses historical patient records. Instead of the few thousand patients with kidney injuries, DeepMind got all the patient records of all three hospitals. That’s millions of confidential documents.
It says it needs the entire patient database to make Streams work. Backers of such databases claim that with such data powerful software packages can be created to diagnose diseases sooner.
The New Scientist magazine obtained the data-sharing agreement between DeepMind and the NHS, which revealed just how much information was being made available. The Google company’s skill is to discern complex patterns in huge quantities of data – and the NHS is a goldmine for such “deep learning”.
In this treasure trove of data are logs of day-to-day hospital activity, such as records of the location and status of patients – as well as who visits them and when. DeepMind will also obtain pathology and radiology test patient records.
As well as real-time data, DeepMind has access to the historical records from critical care and accident and emergency departments. Crunching this information, so the theory goes, allows DeepMind to develop predictions based on data that is too broad in scope for any one person to assimilate and analyse.
By comparing patient data, DeepMind might be able to predict that someone is in the early stages of a disease that has not yet become apparent. This is the medical holy grail: not treating a patient when they are ill, but treating them before they become ill. 
Utopian? Perhaps. Behind the promise of these technologies lies the crux of the dilemma in the age we live. Google, Facebook and others feed on the fact we suspend our privacy rights in return for new technology built with our data.

Like Apple, Google is building a reputation in medical apps. It is also true that the use of machine learning in medicine by academics is nothing new. However this data is being passed to and controlled by one of the world’s biggest and most powerful companies. It raises questions over whether it might quickly become the biggest player, a de facto monopoly, over NHS health analytics.
AI also represents something new, a promise that a program could improve itself – and very quickly surpass human intellect. This is the so-called “intelligence explosion” – a point where humanity courts its own destruction. We are some way off this. No one has built a machine that respects social and ethical norms, even at the expense of its goals. It’s difficult enough to get humans to do that.
Some may say such extrapolation is ridiculous. After all Tay – the “intelligent” Twitter chatbot from Microsoft – lasted a few hours until she “learned” to become a racist, genocidal tweeter and was killed off. However as Elon Musk, the inventor who originally invested in DeepMind, said, it was worries over “Terminator” technology that drove him to warn about its dangers.
For perhaps sound commercial reasons, DeepMind operates under the radar. But this often raises more questions than answers. Google’s AI ethics board, established when Google acquired DeepMind in 2014 for £400m, remains one of the biggest mysteries in technology, with both companies refusing to reveal who sits on it.
Artificial intelligence needs data to learn. Hence the sucking up of all those patient records by Google’s DeepMind. So why the secrecy? If patients had been told what was going on and why, they could make informed choices. If they think the potential risks of Google dominance over a new critical technology for the NHS are outweighed by the benefits, then let’s have that debate. But if the company does not explain and carries on in secret, the public will rightly not go along with such plans.

Monday, November 14, 2016

Kunduz - attack of medical facility in Afghanistan in October 2015

https://www.bma.org.uk/connecting-doctors/doctors-as-volunteers-forum/b/blog/posts/remembering-kunduz-the-aftermath-and-the-future

Remembering Kunduz: The aftermath and the future

The attack on a Médecins Sans Frontières (MSF) hospital in Kunduz Afghanistan last year led to the deaths of 42 patients and staff.
In the run up to a memorial event commemorating one year since the attack, the BMA is reproducing an account of the bombing written by Australian intensive care specialist Dr Kathleen Thomas, who witnessed the attack.
Click here to read Parts one and two.
Part three: The aftermath of Kunduz & attacks on the medical mission
The repercussions of the attack in Kunduz were to reach far beyond the lives lost and those injured.
As a result, all of northern Afghanistan was left without any trauma facility. The injured now had to make their way all the way to Kabul, way too far for many trauma victims.
In 2015 alone, 75 MSF hospitals, predominately in Syria and Yemen, but also in Ukraine and Sudan, were attacked. 
Only some of these attacks attracted media attention because of their international profile and NGO status.
The reality is that medical care is under fire, our colleagues around the world are under fire. We are under fire.
Where once a red cross would ensure protection in warzones, now hospitals in both Syria and Yemen are built underground, staff disguise themselves to hide their occupation, and their GPS coordinates are kept secret.
International humanitarian law clearly protects hospitals and medical personnel in any armed conflict.
Despite calls from NGOs such as MSF and even a UN Security Council resolution, hospitals continue to be bombed with impunity.
Why is this the case?
In regards to Kunduz – accountability for the attack is complicated. But enforcement of International Humanitarian Law is inherently problematic and when four of the five permanent UN security council members are involved to varying degrees in these attacks, it is easy to imagine the barriers to enforceability.
Just before being evacuated to safety after the bombing, leaving behind my surviving colleagues in the ruins of the hospital in a city still in the midst of war, the last thing that was said to me was: ‘Please, please tell the world our story.’
As I have watched hospital after hospital bombed in Syria and Yemen, I realise that it is not just the story of the Kunduz hospital attack that I must tell.
It is the story of countless patients and medical staff attacked in hospitals around the world.

https://www.bma.org.uk/connecting-doctors/doctors-as-volunteers-forum/b/blog/posts/remembering-kunduz-the-week-leading-to-the-attack

Remembering Kunduz: The week leading to the attack

For the past 45 years, Médecins Sans Frontières (MSF) aka ‘Doctors without Borders’ have seen doctors and medical staff from around the world volunteer to care for patients in war zones around the world.
Under article 18 of the Geneva Convention, hospitals are designated protected status meaning that ‘in no circumstances’ can they be targeted by any parties involved in a conflict.
Despite this, in the early hours of 3 October 2015, a MSF hospital in Kunduz, Afghanistan came under repeated attack by the United States Air Force.
The attack, which went on for more than an hour, resulted in 42 patients, care givers and staff being killed.
Tragically, almost a year on from the attack at Kunduz, hospitals and medical facilities in conflict zones around the world have continued to come under attack, including the bombing of an MSF hospital in Yemen on 15 August this year.
The BMA and MSF will be holding a special memorial evening at BMA House on 3 October to mark the first anniversary of the attack, as well as explore the efforts being taken to prevent future such tragedies.
As part of this memorial, the BMA is reproducing an account of the Kunduz hospital bombing, including the lead up and aftermath by Dr Kathleen Thomas, an Australian intensive care specialist present on the night of the attack.
The names of patients and some staff have been changed to protect their privacy.
Part one: The week leading to the attack
It was about two in the morning when I was woken from sleep by the sounds of intense fighting.

Having been in Kunduz for five months of the “fighting season” I had grown accustomed to the sounds of war, but this was different. It was close, heavy, and coming from all directions.
So, as had also become a habit when fighting became audible, I waited for the phone call from the ER announcing the onslaught of patients and the request for help.
It took hours for that phone call to arrive – the fighting was too heavy for anyone injured to actually get to the hospital… but then, as the sun rose on Monday, 28 September, the fighting slowed momentarily, the call came, and began what would be the longest week of my life.
The Kunduz Trauma Centre was an MSF-run, 92 bed hospital in Northern Afghanistan providing emergency surgical care for victims of accidental and violent trauma, and was staffed mostly by local Afghanis. 
As one of 18 expats, my role was as supervisor of both the hospital’s emergency department which saw about 100 patients per day, and the eight-bed, four-ventilator, intensive care unit (ICU).
My first day was chaos – over 130 patients poured through our doors in only a few hours. Despite the heroic efforts of all the staff, we were completely overwhelmed. Most patients were civilians, but some were wounded combatants from both sides of the conflict. 
Reflecting on that day now, brings back so many memories.
The smell of blood that permeated through the emergency room (ER) and the touch of desperate people pulling at my clothes to get my attention begging me to help their injured loved ones.
The wailing, despair and anguish of parents of yet another child lethally injured by a stray bullet whom we could not save.
My own sense of panic as patient after patient was carried in and laid on the floor of the already packed emergency department.
Rising above all this in the background the tut-tut-tut-tut of machine guns and the occasional large boom from explosions that sounded way too close for comfort.
The hospital swelled far beyond our capacity that week.
Dr Osmani was my right hand man in ICU, a bright, young, open-minded doctor full of infectious energy.
He took great interest in his country and the rest of the world. A few weeks earlier he had mentioned the new Australian Prime Minister to me, before I had even heard the news of the changeover.
Having actually resigned from the hospital several months earlier to start Ophthalmology training in Kabul, he had generously agreed to return to Kunduz every weekend to work in ICU, helping us to train the new doctors hired to replace him.
He had told me: ‘MSF has given me so many opportunities and I have learnt so much, now I wish to give back to them.’
The persistent fighting took its toll on all of us. By the end of the week we were physically, mentally, and emotionally exhausted.
There were moments when a sense of hopelessness overwhelmed us.
Dr Osmani expressed these sentiments on the final day, following a tragic incident where a family trying to escape Kunduz was caught in crossfire, killing several children at the scene, with two more dying in our ER and operating theatre (OT).
With the remaining children being treated for severe injuries, he stated: ‘the people are being reduced to blood and dust. They are in pieces. Oh God, is there anybody who can hear their cries?’

https://www.bma.org.uk/connecting-doctors/doctors-as-volunteers-forum/b/blog/posts/remembering-kunduz-the-attack-on-the-hospital

Remembering Kunduz: The attack on the hospital

The attack on a Médecins Sans Frontières (MSF) hospital in Kunduz Afghanistan last year led to the deaths of 42 patients and staff.
In the run up to a memorial event commemorating one year since the attack, the BMA is reproducing an account of the bombing written by Australian intensive care specialist Dr Kathleen Thomas, who witnessed the attack.
The names of patients and some staff have been changed to protect their privacy.
Click here to read Part one
Part two: The attack on Kunduz Trauma Centre
During the week leading up to the attack, the expats had set up camp in the hospital meeting room. This room was located in the office complex about 50 metres from the main building which housed the ICU, ER, OT and outpatient departments (OPD).
This is where I was when, as I slept, on 3 October at 2.08am, I was ripped awake by the first explosion. I could feel the vibrations in my chest and I instinctively covered my ears to protect my eardrums from rupture.
This was a totally different type of sound to anything previous and much, much closer. I had hardly managed to sit upright before the next explosion. I felt adrenaline pumping through my body – my legs tingled, my mouth was so dry, my hands shook.
I scrambled to put on my jacket and headscarf while looking at the terrified expressions of the three expat nurses with whom I shared the room. ‘It sounds like they’re bombing the hospital.’
More explosions followed in quick succession. We had no idea what was going on. It was dark in the room but we didn’t dare turn on any lights.
One of the nurses tried to look outside on several occasions, but every time he opened the door, heavy debris would hit the walls. I tried phoning everyone that wasn’t in the room with us, unsuccessfully – the ICU and ER staff and all of the other expats.
We scurried around the room like rats in a cage trying to figure out the safest place to be in case we took a direct hit. But we knew by the magnitude of the sounds - in a direct hit, there was no safe place. We were overwhelmed with this gripping fear.
The explosions continued, one after the other, separated every now and again with a short pause, presumably while the AC130 Gunship circled around. Every now and then we also heard heavy machine gun fire.
The message, as to what was going on, was delivered with our first patient.  We heard a voice outside calling for help. Jecs, one of my colleagues with me in the room, opened the door to the sight of one of our ER nurses. All four of us froze as we absorbed a scene from a horror film.
He looked like a zombie; backlit, his left arm hanging by a small piece of skin and coated in thick grey dust. His bloody clothes were shredded. Several large wounds gaped and a piece of metal stuck out of his back. His right eye streamed blood. Then he collapsed.
We pulled him inside by his feet. Panic welled up inside me as I leant over to ask: ‘Where were you when you were hit?’
‘I was in ER.’
I was struck with disbelief. Did he misunderstand my question? He couldn’t have been inside the ER.  ‘No, no, no. You must have been outside ER!’
‘No. I was inside the ER. Inside.’
This was the moment reality hit. It really was the worst case scenario. They really are bombing the hospital.
Soon after, our meeting room and the three surrounding rooms filled with injured people bringing absolute chaos. Most of them colleagues, friends and some patients, all covered in the same thick dust.
The injuries were the same as what we had been treating in patients all week – penetrating chest wounds, open fractures with extensive soft tissue wounds, traumatic amputations.
At first there was just me, three nurses, and a basic first aid kit. It’s hard to describe being surrounded by friends and colleagues, with life threatening injuries, calling out your name begging for help that you have no capacity to give them. It was horrendous.
Dr Osmani, Dr Ramakee, a training ICU Doctor, and two cleaners, were all in the ICU isolation room. Dr Osmani and one of the cleaners, Nasir, suffered devastating injuries and were killed.
Dr Ramakee, suffering blast injuries to the eyes and ears, managed to run out of the room literally dodging shells that rained down through the ceiling. One of those shells landed right in the middle of the ICU hitting and killing two of our nurses instantly. 
He then hid in the laboratory until it caught on fire then escaped through a window. He recalls hearing Dr Osmani's cries for help fade into silence over about 20 mins, but was unable to get back to him. 
We had seven patients in ICU at the time of the attack. Three were on ventilators. One was our injured Head ER nurse Lal Mohammed, the other two were chest and spinal cord injured patients.
I hope with all my might that Lal Mohammed was sedated enough to be unaware of the situation, but I know the other two were awake. Even if they’d been able to rip themselves off the ventilators, their paralysis would have prevented escape. 
When the shells ripped through the ceiling in ICU, and the whole unit went up in flames, all those patients were killed, witnessed burning in their beds. 
Our final intubated ICU patient was in theatre at the time of the attack, found dead on the operating table.
The only surviving patient in ICU was a three-year-old girl named Shaesta who had suffered horrific blast injuries yet was recovering in ICU.
The rest of the main building suffered the same fate including the ER, theatres, OPD where many staff were sleeping that night.
People fleeing the main building, like Tahseel, were picked off by machine gun fire. Forty-two people were killed, 14 of them were our staff. Countless others were injured, many suffering injuries making them unemployable in Afghanistan.