key: cord-0771896-z9i399vu
authors: Jabbour, Rima; Harakeh, Miray; Dakessian Sailan, Silva; Nassar, Vicky; Tashjian, Hera; Massouh, Joelle; Massouh, Angela; Puzantian, Houry; Darwish, Hala
title: Nurses’ stories from Beirut: The 2020 explosive disaster on top of a pandemic and economic crises
date: 2021-04-23
journal: Int Nurs Rev
DOI: 10.1111/inr.12675
sha: ccb2bc21d25b625db78cf9a45c07491dde996b2a
doc_id: 771896
cord_uid: z9i399vu

The World Health Organization designated last year as the International Year of the Nurse and the Midwife. And as we know worldwide, 2020 became an unforgettable year as nurses and midwives everywhere confronted the COVID‐19 pandemic. To be a nurse in 2020 was challenging and heroic, but being a nurse in 2020 in Beirut, Lebanon was so extraordinarily charged with adversity. The country witnessed in a one‐year series of tragedies of epic dimensions – laying a heavy toll on front‐line nurses. We present our stories as eight Lebanese nurses, giving voice to our incredible experiences and our ongoing resilience in the face of these adversities. We served in the emergency department of a Beirut city hospital after a catastrophic explosion occurred in the capital on the 4th of August 2020. We reported for duty during a disaster of immense magnitude and are now coping with the aftermath of trauma. As nurses, we have faced many traumas in our country that has experienced through war and terrorism for decades. Arising from this disaster and challenges of the pandemic, we give policy recommendations that deserve urgent attention in Lebanon and underscore the need for disaster preparation, funding, education and importantly mental health care for nurses and other health professionals with help and support of the international community.

The World Health Organization designated last year as the International Year of the Nurse and the Midwife. And as we know worldwide, 2020 became an unforgettable year as nurses and midwives everywhere confronted the COVID-19 pandemic. To be a nurse in 2020 was challenging and heroic, but being a nurse in 2020 in Beirut, Lebanon was so extraordinarily charged with adversity. The country witnessed in a one-year series of tragedies of epic dimensionslaying a heavy toll on front-line nurses. We present our stories as eight Lebanese nurses, giving voice to our incredible experiences and our ongoing resilience in the face of these adversities. We served in the emergency department of a Beirut city hospital after a catastrophic explosion occurred in the capital on the 4th August 2020. We reported for duty during a disaster of immense magnitude and are now coping with the aftermath of trauma. As nurses, we have faced many traumas in our country that has experienced through war... and terrorism for decades. Arising from this disaster and challenges of the pandemic, we give policy recommendations that deserve urgent attention in Lebanon and underscore the need for disaster preparation, funding, education and importantly mental health care for nurses and other health professionals with help and support of the international community.

In Lebanon, the last 18 months have been a period no one would ever want to go through again. Since October 2019, the country has suffered political instability coupled with revolts and violent protests, an economic crisis, followed by financial collapse, all placing a significant burden on the livelihoods and well-being of its population of around 6.8 million people (World Population Review, 2021) . This negatively affected the resources and performance of the healthcare sectorthen along came the COVID-19 pandemic in the winter of 2020 to add to the immense strain. The climax to all this upheaval was a devastating chemical explosion that destroyed much of Beirut, including three hospitals and stores of medical equipment (International Council of Nurses 2020).

On the 4th of August 2020, the world's 3rd most massive ammonium nitrate explosion (~2750 tons) was recorded at 6:08 pm in the seaport of Beirut, a small city of 19.8 km 2 on the Mediterranean Sea (World Population Review, 2021). The explosion was so powerful; it was heard and felt more than 200 km away in Cyprus. Over 200 people died, more than 5000 were injured and 300 000 were left homeless (Edgington, 2020; Perier, 2020) .

Most nurses report for duty without hesitancy during challenging times. But nurses seldomly reflect on their personal experiences, more so in Lebanon, a country with a lingering history of conflict, violence and explosive blasts. We collected the reflections of eight nurses who responded to the questions: Where were you on August 4? What was your main duty? How did it make you feel? What is the one story, or patient, one thing you cannot forget? And how are you coping now? The end result was profound stories that get to the heart of nursing and the emergent concepts illustrating their experiences and the risks they took to their physical and mental well-being. The exposure to such traumatic events may predispose for mental health disorders with possible impact on productivity. Our stories highlight the critical need for nursing and health resources after such a devastation.

Hala Darwish: My only solace was in the emergency department (ED) I am a professor at a nursing school. I started my career as an ED nurse working in both Lebanon and the USA. But I had been away from ED nursing for the past 15 years, dedicated to my academic responsibilities. Early in 2020, I feared the pandemic scenes of European hospitals flooded with patients with COVID-19 would replicate in our smaller and under-prepared hospitals. I also feared our hospital resources would be exhausted one day, and I would be called to duty in response to staff shortage. Little did I know; instead, I would volunteer to serve during the pandemic in one of the deadliest traumatic events of the 21 st century known to humankind.

On that day, for some reason, I came back home from work earlier than usual. Shortly after, what felt like an earthquake shook the building where I live and the whole country to the core. It felt like an earthquake to many; however, it turned out to be a human-made catastrophe. After a moment of freeze and some time to process what happened, news about the blast spread, and the medical centre activated the disaster code. Without hesitancy, rushing to the ED to help was the only sensical act that could give me solace at that moment. The ED already reached its full capacity and I heard from colleagues an ancillary ED was opened in the main hospital's 5 th floor waiting area.

Messages from family and friends flooded my phone, checking on my safety. All that mattered was getting to the hospital. On my way to the ED on August 4, I wondered how many historical events one could survive in one year! And on the way, I mentally rehearsed the ABCs of trauma management and flashes of my ED years, and my previous experiences of trauma management in Beirut and the United States came back all at once. I walked down the hospital basement with tears struck by the destruction to walls and heavy metal doors. I knew how to handle what awaited me on the 5 th floor, I reminded myself, and took the elevator up. I took care of the first young man I stumbled upon across the elevator doorshe had multiple injuries. Without a hitch, I started to give directives, assessing and providing acute nursing care to the patient.

Then, I realized we needed to upgrade our surgical masks to N95 respirators; after all, we served during a pandemic. After donning proper personal protective equipment on my colleagues and myself, I collected my courage and took the elevator down to the main ED. No reference book or training could prepare anyone for such an apocalyptic scene. I was not ready for this chaos and the number of casualties piled in the ED rooms and hallways. The ED received a total of around 500 patients of various severity levels within a few hours. I am an ED nurse trained to save lives and provide nursing care with perfection. I carry my nursing interventions by protocol. But I learned the hard way that there is no room for strict protocols during a disaster. I agonized about this fact for many days onward, trying to get to terms with the fact that it is acceptable to suture patients with little lidocaine under such conditions. Back on the 5 th floor, a patient with a fractured ankle required a closed reduction under conscious sedation prior to surgery. I had to improvise to accommodate his needs. So, we transferred him from the waiting area to a room in the cardiac imaging laboratory with available monitor and life support equipment and supplies. The patient had two children who were safe. I learned that while distracting him during the procedure. I walked a patient, one of many with orbital injuries, to a stretcher (more comfortable than the waiting room chair) while waiting for the plastic surgeon to repair her eyebrows' severe and deep lacerations. The greatest relief came from seeing my colleagues safe and working side by side.

I am not sure how the six or more hours passed, and I returned home to sleepless nights. At least three weeks of insomnia followed, expected after such a traumatic event. I kept thinking I could have been one of those many who lost their lives or loved ones, got injured or lost their home. Yet, one must rationalize and take self-care measures to recover emotionally and cognitively. I asked myself several times How much self-awareness one should have to self-heal and remain productive, sane, and sensitive after such an experience? This experience left me grateful for every breath I take daily.

Rima Jabbour: 'Not again, please, not again' I am the nurse manager of the ED and manage its operation. On August 4, I had just reached home from work when the explosion occurred. I rushed back to work and resumed my charge of directing the operations and secondary triage. Decongesting the ED remained the main impediment for several hours. Decongesting meant the patients' proper disposition, according to acuity and medical needs, to the following areas: the operating room, intensive care unit, inpatient unit or radiology. I prepared the ED cubicles to receive new patients waiting in line in the hallways while trying to ensure the availability of medical supplies and coordinating with all nursing units and administration.

Not again, please, not again, I silently screamed, not another blast of a series I have witnessed over the years.

I vividly remember a father performing cardiopulmonary resuscitation on his dead son; he begged us to help save him. A tearful mother found her son severely injured but alive. A fianc e was looking for his lost fianc ee; sadly, later, we found out she was dead upon arrival and had been sent to the morgue. A brother searched for his sister for hours; she had presented in a conscious state to the ED. She had been admitted to the hospital as 'unknown' because we hadn't had the time to register her under her real name.

The daily threat of the pandemic and the dire economic situation in Lebanon have prevented me from reflecting properly on the dreadful experience of August 4. At times, as ED nurses, we discuss our experiences; those conversations bring tears to our eyes and sadness to our hearts. At other times, our shared experience brings pride and joy as we could serve and save people.

Miray Harakeh: 'I could not breathe' I have been an ED nurse for more than six years. Nursing remains my passion. I love helping and taking care of others. Throughout the years, this feeling never changed; I hope it never will.

I was off duty and at home on August 4 when the blast occurred. I thought it was an earthquake at first, then I heard the blast sound and rushed to my mother, thinking it was a bomb or worse yet, a missile attack. Living in Beirut makes one, unfortunately, habituated to these events. Thinking a bomb exploded in our neighbourhood in the suburbs, my first thought was to thank God my sister was at work. Then, I learned the actual news, and the grip of fear took over me again since my sister worked downtown, an area near the blast site.

I knew I could not stay home and watch the disaster unfold while my colleagues and other people fought for their lives on the front lines. So, I rushed to work. Before arriving at the ED, my family and friends' safety preoccupied me; fear and worry were the primary emotions. The second I arrived at the ED, a switch flipped in my head, and nothing mattered anymore but caring for the injured. Nothing mattered, especially myself and my feelings. Like a robot, emotions on hold, I swept from side to side, delivering the disaster management care we had been trained for. I triaged casualties, assisted in procedures, comforted families and the injured, and worked for four hours without batting an eye. I occasionally stopped to check on my friends, just looking from afar to make sure they were alive.

I cannot forget the after-effects of the hours I worked on that day. I left the ED around midnight. I went home to rest since I had to come back in a few hours for the morning shift. I stayed with a colleague who lives closer to the hospital. We sat in the living room and stared at the empty walls for what seemed like hours. Right then, I felt the shock overpower my mind, and suddenly, I could not breathe. I had never felt such strong emotions storming me all at once before; sadness, anger, gratitude, disbelief, and much more I could not describe.

That night, I thought I experienced the cruelest shift of my nursing career and of all the previous disasters I had witnessed. But the next morning was worse. We came back to an ED painted with streaks of blood. The foul smell of blood seemed to seep out of the walls and the ground. It took a few days to clean and erase the stains off the walls and ceiling.

My friends and family supported me throughout this phase, but August 4 will never be forgotten. I am still haunted by the fear I felt on that day. Every abrupt sound elicits back all those negative emotions. Someday, we will overcome the emotional sequelae of this disaster entirely and heal. For now, I am thankful for the support system I have and know I can fall back on when life gets too heavy.

Vicky Nassar: 'I avoid driving by the seaport' I used to be an ED nurse. Now I hold an administrative position at one of the outpatient clinical centres. I have been away from the ED for many years. I had just finished work a bit early because I needed to pick my car from repair and pass by the hairdresser. While my hair was being styled, I heard the explosion and saw the aftershock destruction. I went directly home; I put on more comfortable clothes and reported for duty. I called the ED first to check for their needs. I was told they were coping, yet I heard from colleagues that the hospital's 5 th floor was opened as an extension to the ED. It was around 6:50 pm when I was heading there. I was numb all the time, maybe not grasping what happened. I needed to focus on helping patients. On my way there, I tried to remind myself of the clinical skills necessary in trauma management, the ABCs of trauma, assessment, triage and what should happen in the aftermath. I remembered having the same thoughts when I was an ED nurse during the 2005 blast in Beirut. Yet this time, it was surreal. It was not an assassination, not war, not a major car accident, not a protest fight. The scene seemed like an atomic bomb disaster. The hospital was also damaged. This situation has no reference in disaster preparedness. I took care of a military personnel who kept asking me about what happened until he felt safe and secure.

Till now, I avoid driving by the seaport. I have a continuous fear something catastrophic will happen again. I suppress the feeling by finding ways to distract myself. Self-calming and repeating the mantra that everything will be okay are now my go-to strategies.

Silva Dakessian Sailan: 'I had to rescue my brother'

I have been a clinical nursing instructor for the past ten years. On August 4, I was in the parking lot of my building with my youngest daughter and husband when what felt like a massive pressure hit the building. The shock wave threw my daughter around two metres, and then, we heard a blast, followed by the sound of shattered glass from the surrounding buildings. I frantically held my daughter and rushed indoors.

Something massive happened was all I knew. Once I realized the blast's location was near my father's shop, I worried about my brother's safety as he handles the work. He was not answering his phone and so my husband and I went to look for him. We stopped by St. George Hospital first, a major university hospital in Beirut, closest to the blast location, which endured severe destruction from the blast. The hospital ED entrance scene was devastating; people were lying on the ground and the nearby street. Everyone was either crying, shouting or panicking. Two healthcare professionals intubated an unresponsive young girl on the parking lot floor. A mother standing with her child was screaming for help.

The emergency crash cart was on the street. Healthcare providers were handing over medications such as epinephrine ampoules across the area to their colleagues. The women and men surrounding the place were all bleeding. I desperately searched for my brother among the casualties. He was not around. Then, I realized some people were covered with blankets on the sidewalk. I needed to check those bodies to be sure my brother was not among the dead. I fearfully assessed the faces under the covers. I saw swollen faces covered with dust losing their original features. This was an excruciating experience. After checking two bodies, I decided to leave the area since I did not find him.

Around 8.30 pm, we finally made it to Hotel-Dieu de France Hospital ED, another major hospital in Beirut. After circumventing the angry crowd and the police swarming the ED entrance, I made it inside. There I looked for my brother. Finally, his friend led me to him. He was lying on the floor. His face was swollen, covered with blood mixed with brown dust. He was in his underwear as he was assessed for injuries. He was shouting in pain and crying. Seeing my brother cry was inconceivable. He had always been a self-controlled, proud man. He always coped with problems with humor, but not on that day. Seeing him in pain and so vulnerable broke my heart. I immediately asked the staff to place him on a stretcher. We finally transferred him to a ward corridor, which was a significant achievement on that night.

My brother had multiple wounds/ lacerations sutured in the ward's kitchenette with only one small ampule of lidocaine. His cries of pain were roaring in my head and ears. It was a daunting endless night. His wounds covered his ears, eyes, back, abdomen and lower extremities.

The incident still haunts me and hangs over my shoulders like a ghost. Not losing my brother was my only consolation.

I consider myself lucky. The August 4 event was an unforgivable tragedy; it has filled my heart with scepticism and disgust. I try to keep myself busy with work, and family, and feeling grateful for my blessings. I remember the blood; I was begging the housekeepers to keep cleaning so that the awful scene would not get stuck in people's memories. I remember a surgeon on his knees suturing a young girl's face in the waiting room. A confused middle-aged man was making small talk with me as I transferred him to a clean area where we could remove the glass from his wounds before suturing. There was another man with a blood-soaked shirt; we cut his shirt to manage his moderately severe wounds. After wound care, I gave him a doctor's scrub suit top I randomly snatched from a random office. I sent him off, carrying some doctor's name stamped on his chest.

Then, I went to the ED area with the most critical cases, the main ED. I remember the look on the doctors' and nurses' eyes, which was glassy, unrecognizable and lost. I saw tubes going in the throats, chests being pumped, heard yells for Propofol and sensed the fear hanging heavy in the trauma rooms. I did what I could do to help, along with my friends who were there.

Wearing the protective gear weighed heavy, so I went out for a breath. A terrifying moment awaited me outside: I was stormed by a crowd of families searching for their loved ones, asking if I had seen any of them. Just after midnight, as I walked home, I asked myself repeatedly What had just happened?

I took a sleeping pill. The next day there would be more to do. I woke up two hours later, confused and frantically crying Elie. A woman outside the ER asked me if I saw Elie. But I had not seen him. Propped up in my bed, my partner looked up the list of missing people online and found Elie. We called the number listed next to his name and asked the lady who answered the phone if they found Elie. She said no.

How we pulled off wound care and management in the next few days and weeks after this tragedy is beyond me. I do not know how we continued taking care of the wounded. I do not see how we could repeatedly listen to stories of horror, fear, disappointment and sadness.

This memory will stay with me forever. I do not want to talk about it, hear about it or write about it any longer. This is it. I am burying this memory deep inside, somewhere unreachable.

There was life before August 4, and then, there was life after August 4. It was a life-defining moment for me and many othersa life-altering moment for the injured and a life-ending for those who were killed. More than 200 souls were lost. It was overkill. We already felt dead, barely surviving after a year dominated by a pandemic and an economic crisis, the culmination of over 30 years of a failing state, and a Ponzi scheme orchestrated by corrupt and criminal politicians.

August 4 started like any other day; I was walking back home from work at the Multiple Sclerosis Center. I typically put on my AirPods and listen to music to unwind after a long day. After the blast, it took me around three months to listen to music again. That haven, the sacred refuge for my thoughts, was no more.

At 6:08 pm, I was 2-3 minutes away from home when the blast rippled through my neighbourhood. I escaped the collapse of a building's glass fac ßade by seconds; I ducked down and ran into the foyer of another building. The blast sounded like nothing I have heard before. I collected myself, but my body's fight or flight response was activated, the tachycardia now rampant. I looked up to the sky and saw a vast, swelling and pink cloud. In what world do deathly things have beautiful colours? The direction was towards downtown. I knew because I remember watching another cloud, a grey one though, forming above the same location after the explosion of 2005. I ran home to check on my parents; they were in shock yet physically unharmed. With trembling hands, I called my sister.

After the initial shock and after checking on friends, my sister, her partner and I found ourselves walking towards the ED. As we approached, the magnitude of the blast unveiled. Our footsteps became more purposeful. Upon arrival at the ED, I found myself making another comparison between the 2005 explosion and this one. As an undergrad sophomore taking a microbiology class located above the ED in 2005, they sent us home soon after victims from the Hariri assassination started arriving in the ED. It was pandemonium. I remember opening the staircase door and being flooded with the smell of burning flesh from bodies spread on stretchers in the ED hallways. This time, the stench was different; blood, sweat and tears. We had to squeeze through injured bodies to get inside; I feared slipping over the blood-stained floor. Nothing prepared me for this.

We went up to the floors to check on our colleagues. I know this hospital like the back of my hand. On that night, I struggled to recognize its dark corridors, damaged ceilings and walls.

My sister received the call that a mobile, makeshift emergency room will open in the waiting area on the 5 th floor. Seamlessly, we assembled a group of volunteers. Many of them were injured but powered through. Nurses, doctors, pharmacists, housekeeping staff and many others volunteered immediately. I had always dreamt of working alongside my sister, but never would I have fathomed it would be in such a devastating event.

We prepared for the onslaught of victims, gathering supplies. I was not trained in emergency nursing. I am a certified MS nurse. So, I used my experience and visual memory to triage patients, assign cases to colleagues and set priorities. Fractured arms and legs of stable patients had to wait, as the orthopaedic surgeon told me the radiology department was swamped with life-threatening injuries. On the phone, I received preliminary CT brain results, set treatment plans for the patients and determined patients' dispositions.

At one point, I held up my phone light for a friend who sutured the head wound of a patient next to the elevator. We later learned she did all that with a broken foot. I logged all patients we received in the waiting room and documented their assessment findings, medications and procedures. It looked like organized chaos. Hours passed, we sent some patients home and admitted many others for further treatment and management. We stayed till the last patient left, way past midnight. An eerie silence filled the area as my sister, and I stood there looking at each other, trying to grasp what happened.

I barely slept that night and woke up for work the next day. For healthcare workers, there are no breaks. Looking back now, I see nothing has changed, yet everything has. Every 4 th of each month, I count how many months passed. I had researched resilience for my master's degree, but how can I even bring up the word at a time like this? Lebanese tend to be obsessed with the rising from the ashes phenomenon drawn from our Phoenician ancestors' myth of the Phoenix.

But, how do we rise from something like this? The 3 rd biggest blast known to humankind in one of the smallest cities in the world.

People beautifully came together to help each other, but where is the accountability? Who pays the price? We are all broken-hearted. I stayed up nights watching the news of 'Flash', the Chilean rescue dog, who felt a heartbeat under the ruins (international rescue teams helped on damaged sites). There was nothing. So for now, I have lost hope. I decided to get a one-way ticket out of Lebanon. I choose to leave because I owe it to my mental health to thrive and not just survive. I started journaling again after many years. Writing and reading about what we collectively went through can be retraumatizing, or it can be cathartic; either way, it should be done.

I am a faculty member at the nursing school with critical care nursing experience. I still cannot believe I physically survived the 3 rd largest non-nuclear explosion in the world. It took me weeks to believe it. I was born in wartime, 1983, in Beirut. I played in streets struck by missiles. I survived bombings, assassinations, the 2006 war that tore my country down, but it all seems easier than August 4. Nothing could have prepared me for what I saw that day, not my advanced healthcare training nor my 17 years of critical care experience.

A few hours before the blast, my partner and I hit the road to the mountains after a heavy day at work. I remember I was laughing hard when I received the call from my sister. While crying and screaming, she asked if I was okay. I immediately knew something terrible had happened. I hung up the phone in panic mode, and we rushed back to Beirut. I was lost. My partner and I did not realize the explosion's impact until we reached Beirut and saw people covered with blood running in the streets. When I arrived in my neighbourhood, the shattered glass of buildings covered the asphalt. The sound of empty roads and the void was deafening. I checked on my family and immediately headed to the ED.

As soon as we entered, I knew I could not leave. We squeezed through the blood-drenched corridors, damaged ceiling and broken glass. I am not an ED nurse by training, but I am strong-headed and detail-oriented, and at that moment, I knew this would help. I received a call from the hospital nursing director about a makeshift emergency room to be opened in the waiting area on the 5 th floor. I immediately informed my colleagues and asked for volunteers. We assembled a team of nurses and doctors; some were injured by the blast but showed up to help despite their injuries. Everyone was in full gear. I do not know when I was assigned the lead. The moment I felt overwhelmed, I would look over my shoulder, search for my sister and friends. We would share a quick look; then, each went their way. This helped me gather my strength to keep going. It seemed chaotic but goal-directed.

Assigning numbers to the casualties to identify them bothered me the most. Usually, I know my patients' names and life stories by heart. I am not accustomed to serving numbers. Most of the casualties were dead silent, looking around with empty stares. Their silence startled me. Everyone was shocked and silently shed tears. I want to forget the scenes of that day, all the blood, broken limbs and crushed souls. I know I will never be the same person again.

When the adrenaline rush of that day ended, I returned home exhausted, empty and emotionless. I felt guilty as I cried in the shower. I should not cry when other people have lost their lives, loved ones, homes, or were severely injured. Was I the only one who didn't hear the blast, not lost a loved one, did not get injured? Is it fair I survived while others lost everything? Survivor's guilt is real! These unresolvable questions reflect our natural inclination to give meaning to nonsensical experiences. The guilt of being lucky is heavy.

Like many grieving survivors, I asked existential questions. I became consumed with philosophical questions about the fairness of life, randomness and equity. I find it hard to forget the story of a mother I saw on TV, outside our hospital's ED, searching frantically for her missing son. When asked by the reporter to describe him and what he was wearing so people could help identify him, she answered, her son 'is a kind, beautiful boy with chestnut hair and brown eyes'. She probably didn't notice what he was wearing the morning when he left for work. Why would she when it is only a regular day like any other? Why would she remember those details when it was expected he would be back home soon? He was killed.

For nights, I would lie in my bed and reflect on what happened. None of it felt real; none of it was fair. The government response was irrelevant if present at all; this fact added anger to the pain. This was when I decided to volunteer in the humanitarian efforts that followed the blast. The only way to endure survivors' guilt is to live a life of purpose. To do more and give back. We know the guilt will come and go, but it would not last forever unless we let it.

Reflecting on August 4 makes me wonder, can the Lebanese survive more mass massacres? If they can, do they have to? Don't we owe it to ourselves and loved ones to leave this country? I do not have answers to these questions yet.

The realization that those who live and those who die in battles, wars and mass massacres like August 4 has a chillingly random aspect that is scary. This diminishes the values of the lost lives and fuels survivor guilt. Undeniably, some people lost their lives, some families lost their loved ones, some lost their houses, some were severely injured, but everyone was affected.

We hope that reading carefully through these powerful nursing stories gives the readers an insight into this series of health disasters that tested the people and the healthcare system. With the onset of COVID-19 pandemic and quarantine, health professionals, including nurses 'started showing symptoms such as severe stress, frustration, confliction, and anger, as a result of separation, stigmatization, fear of contracting the coronavirus, the clash between the obligation to family and profession' (Fawaz & Samaha 2020, p.560) . The massive explosion in Beirut undoubtedly compounded these symptoms for many in the healthcare system. When our stories are examined closely, various concepts emerge that get to the existential heart of the nurses' experiences. Policymakers and healthcare leaders can learn from these stories to help understand better what needs to be done to make a very difficult, entrenched situation better.

Professional altruism was at the forefront in this disaster. The actions of the nurses depicted remarkable selflessness across all the narratives, placing others' lives and well-being ahead of self-comfort. The pride nurses take in saving lives and caring for others is a value of this profession, but it comes often at a cost.

Another concept that is common among these nurses is gratitude. We have expressed overwhelming gratitude for simply being alive and having our loved ones safe. All of us have depicted humanness in a range of emotions, including fear, sadness, insomnia and guilt. An array of intense emotional responses is a significant theme in our accounts and these still occur today months after the event. Trauma is a part of our nurses' lives, and for most, the August 4 blast was not our first traumatic experience. It is clear that in these accounts there is a strong sense that nurses may be at risk for mental health consequences such as post-traumatic stress disorder. And there is profound realization that this is the reality for many living in Beirut.

Another concept prevalent in the accounts is our relationship with the work environment. When nurses care for a patient, they interact with them, as well as building relationships with the physical and psychological environment, colleagues and families. The human and the physical damage, including walls covered with blood, moved the nurses who reported for duty on August 4. Irregular pain management for those they cared for was also a concept of shared experience. This violates an essential ethical aspect of nursing care, which is providing comfort to patients and relieving their pain but being unable to do this in a situation of a disaster was so distressing. The ethical values of us as nurses were further stressed as we focused on caring for patients while concerned for our family members.

The different coping strategies highlighted in the previous narratives like seeking support, humor, venting, self-blame, suppression, journaling, relaxation, helping others or avoidance, some of which are undoubtedly helpful, like seeking support. However, others may be imperfect strategies, like avoidance of places and do not necessarily lead to healing. Such nurses need psychological support and the support of others.

It is imperative that the government, working in collaboration with the health system, develops a mental health care policy addressing the trauma effects on healthcare workers in general including nurses. This policy should also include the community members who suffered trauma in this disaster. There is also urgency to develop and implement a national disaster plan that includes guidance for pre-hospital and hospital management, given that Lebanon is a country with such a repeated and haunting history of traumatic events. Some of the nurses' narratives highlighted that no disaster plan prepares any healthcare worker for what happened on August 4, but this does not negate the fact that the lack of an effective national disaster plan made this experience harder for most front-line healthcare workers. Clearly, the media needs to be involved in this, to ensure that adequate attention is paid by politicians to the urgent health needs of the country and the resourcing of health, hopefully with international assistance in these desperate times.

All the above observations, thoughts and feelings remain carved in the memories of the nurses who served in the ED on August 4. Of note, Lebanese nurses' involvement in patient care extended into the aftermath of the blast, with their engagement at makeshift wound care clinics and in resident healthcare support at the disaster site. Unfortunately, in all the harsh reality of the moment, some nurse colleagues at sister hospitals (like St Georges hospital) lost their lives due to the explosion, and others died due to COVID-19. We honour their memory.

Finally, Lebanese nurses experienced unprecedented hardship during 2020 that continues today due to the pandemic. We have no doubt that the physical and mental health of nurses and other healthcare workers are jeopardized. Most hospitals have now reached their full capacity, and the vaccination programme to of writing this paper has not started yet. The Order of Nurses in Lebanon has reported that around 600 nurses have emigrated seeking better opportunities in other countries (M. Doumit, President of the Order of Nurses in Lebanon, personal communication 4 February 2021). Many more are contemplating or actively planning to leave the country, which cannot afford this nurse attrition. During an unfolding pandemic, the nurses' exodus is adding strain on the healthcare sector. Practicing nurses have reached burnout. The current nursing workforce is depleted physically and psychologically. Mental health support for the health sector workers is critical, a matter that policymakers need to urgently address. Nursing shortages are also critical as is a range of health resources, and the help of the international community is warranted. Some say only a miracle can save the Lebanese nurses from this never-ending disaster.

Beirut explosion: What is ammonium nitrate, and how dangerous is it? BBC News

The psychosocial effects of being quarantined following exposure to COVID-19: A qualitative study of Lebanese health care workers

Nurses: Heroes of the Beirut disaster. 13 August

Lebanon: Chronicle of a tragedy foretold

Available at: https:// worldpopulationreview.com/world-cities/beirut-population accessed 8

We dedicate this paper to all the nurses of Beirut and Lebanon who experienced a historic 2020 and gave, and continue to give, their all to withstand the crises of the country.