My experience of tragedy, disasters and war

Amer Shoaib

Amer Shoaib is a Consultant Trauma and Orthopaedic Surgeon at Manchester Royal Infirmary and Trafford General Hospitals with expertise in conditions affecting the Foot and Ankle. He served with the Royal Army Medical Corps in Bosnia, as well as providing humanitarian support in Haiti after the earthquake and in Syria, treating civilians caught up in the civil war. Amer runs a charity called Orthocycle which runs courses in the UK to train doctors in foot and ankle surgery, and also recycles medical equipment for use in less developed countries.

The view through the windscreen of my vehicle is quite alarming. There are six armed men in the back of a pick-up in front of me, all carrying AK47 automatic weapons.

Fortunately, they are here to protect me. I am returning after a week of operating in Yemen, which is currently enduring a long running civil war. The injuries that I have seen are all related to weapons of war such as bullet injuries and bomb blast injuries. From the moment that we arrived, we could see men and women in the streets with crutches, negotiating their way through an obstacle course that is their daily life on the dusty streets. We are able to offer services not locally available because we have brought a lot of surgical equipment with us, as well as some specialist experience in dealing with complex fractures, deformities and bone infection.

Rebuilding and saving limbs

You may wonder how I got here. Actually, this is exactly what I wanted to do when I went to medical school. Although I wanted to be an orthopaedic surgeon, I also wanted to work in other countries especially in low and middle income countries, treating people who might not otherwise have access to healthcare. I am able to have this alternative life mainly because I am an orthopaedic surgeon, and also because I have been able to take opportunities to gain surgical and non-surgical skills which are necessary to live and work in an austere environment.

I specialise in orthopaedic limb reconstruction surgery and foot and ankle surgery. This surgical background equips me with the skills required to deal with the vast majority of limb trauma, and this is what I do in my day job as a Consultant at the Manchester Royal Infirmary.

Limb reconstruction surgery often involves the use of external fixators rather like a scaffold around an injured limb and I use these on a daily basis in the UK. These are a versatile method for the treatment of trauma, the sequelae of trauma and also ideal for the treatment of acute and chronic war injuries.

Figure 1: Being escorted in the Middle East.

The Ilizarov external fixator was developed after World War II in the then Soviet Union, in order to deal with large numbers of disabling war injuries, that had previously failed to improve with conventionaltreatments. This treatment came to European civilian practice in the 1980s and has come full circle to be used in the treatment of war injuries again.

My work in the UK is also quite satisfying, dealing with complex fractures, bone infection and deformities. It involves a wide spectrum of orthopaedic implants and techniques from internal fixation, external fixation, arthroscopy, osteotomies, joint replacement and soft tissue reconstruction. Most patients have had multiple previous operations, and need psychological and social aspects of their care managed as well as the obvious surgical problems. Working in a major trauma centre puts me at the heart of what I enjoy, dealing with intellectually stimulating tertiary referral elective problems and equally demanding traumatic injuries. I don’t have a dull day, as every day brings fresh trauma and new challenges.

Figure 2: Casualty of war, we frequently used Ilizarov method.

At home and abroad

In 2017, my colleagues and I had to deal with casualties from the Manchester Arena bombing. Those of us with humanitarian experience found ourselves operating on the same horrific injuries we have seen abroad in the UK. Most injuries were orthopaedic, this is often the case with war injuries. The injuries suffered by those injured took several weeks to manage initially, and we still see some of these patients over four years later, still suffering physically and psychologically. It was possible for us to manage the injuries because we had seen and treated a lot of similar injuries before in other countries. In fact, we learned some new surgical tactics from the Syrian civil war, which helped with the emergency management and which we have integrated into our clinical practice.

As an orthopaedic specialist, I have been able to work in austere environments, several wars and also natural disasters such as the earthquake in Haiti. There is a real paucity of orthopaedic surgeons in many countries, for example, there are more in Manchester than in four countries in East Africa. I have found that orthopaedic surgeons in many less developed countries have been glad to have someone to work with, discuss cases with and become true friends. It is a privilege for me to meet those with real professional difficulties. I know I will be going home whereas they are faced with an infinite amount of difficult clinical work with limited resources.

However, there are other surgical and nonsurgical skills required to allow safe working in warzones and low/middle income countries. There is always a security risk to me, my patients and my team, whenever we work abroad, and there is a responsibility to mitigate security and health risks when deploying. It is necessary to have the correct training to allow us to be able to manage problems such as basic personal safety to health risks. The knowledge required may be how best to hide if you are in a vehicle that comes under fire, how to avoid being a target for robbery in any environment, and how to take relevant health precautions to avoid getting ill while deployed which would render you a burden rather than an asset.

Figure 3: Making friends in Tanzania.

I help to run a charity called Orthocycle (www.orthocycle.org). This charity collects the single use items that are usually consigned to landfill after one patient use. This includes Aircast boots, knee braces, orthotics and some surgical equipment. These are not used again in the UK due to infection control risks, but in less privileged countries, the risks of infection control are dwarfed by the risks of not having an orthotic at all. These orthotic devices are often used repeatedly, until they fall apart, and so many patients benefit from their use. Surgical equipment such as out of date implants, out of date sutures and gloves can be used quite safely. Often implants are not re-sterilised because in the UK it is not cost effective. Donated surgical equipment allows us to work in partnership with other countries, to deliver surgical training to fellow surgeons abroad, who may not have had the opportunity to have worked with external fixation in the same way. We also offer training in the UK on external fixation techniques and cadaveric training in foot and ankle surgery. This raises funds for the charity and also delivers quality training to UK graduates – another of the charities objectives.

How to get involved

I am sure that there are many others who harbour similar ambitions as I did as a medical student and junior doctor. I didn’t find it straightforward to gain the right experience. I believe that there are more opportunities now for junior doctors to develop relevant skills to pursue this type of work.

Figure 4: Funding of charitable work through educational courses.

The routes to open these opportunities involve attending courses, working with relevant organisations and applying for out of programme training opportunities.

There are many courses available to gain the relevant knowledge, skills and attitudes to be able to work outside the UK. I have attended the Medical Care of Catastrophes course at the Society of Apothecaries in London, but there are also specific surgical skills courses like the David Nott Foundation Hostile Environment Surgical Training (HEST) course and the RCS Surgical Training for Austere Environments (STAE). These courses emphasise safe treatment and also thinking outside the box.

Working with appropriate organisations can allow the development of skills that are required to work and lead in austere environments. In the UK, there is a government funded group, the UK Emergency Medical Team (UK EMT), that is trained to form part of a coordinated response to an international disaster either natural or man-made. They offer training to certify competence to work in these types of situations. UK-Med are a Manchester based charity that work with other similar groups to provide the manpower and training for such UK EMT missions.

Working for Médecins Sans Frontières (MSF) or the International Committee of the Red Cross (ICRC) is another way to gain experience, but I found that during my training, it didn’t fit in with my life to work in a surgical capacity. These organisations want fully qualified consultants rather than trainees. The training environment has changed in recent years, and out of training programme experience is fortunately much more valued now. There are opportunities to work in less developed countries, which tie into existing projects.

Another option is to join the reserve or regular forces. This allows the development of some of the skills required, and the opportunity to deploy in a relatively protected manner. There is also an emphasis on teamwork. However, this may not suit everyone’s personal lives, ethical stances or motivation. Ethical dilemmas may exist, if there are future conflicts, perhaps involving deploying to countries like Afghanistan or Iraq.

Nothing can compare to the learning curve from deployment on a mission – there are always new challenges to learn to overcome.

I couldn’t see myself doing anything else apart from orthopaedic surgery. I have the privilege of witnessing improvements in the quality of life of my patients, both in the UK and abroad, something that I find is immensely satisfying.