MSF surgical team 2014 Israel-Gaza conflict Kelly Dilworth MAR OCP
JournĂŠe chirMSF MSF2014 Paris Surgical Day 2014 Paris
Background
Life in Gaza before war
Population 1.8 million = 4500 inhab/m2 Israeli enforced blockade (land-air-sea) since 2007 Importation restrictions 45% unemployment 70% earn < 2 USD/d 70% receive aid 57% households food insecurity Pb water quality Fuel, power, housing crises
Background
Healthcare in Gaza before war
32 hospitals 97 primary health centres 10 000 MOH staff Blockade >> availability, quality, access ALL compromised RESULTS - chronic shortage drugs/material - progressive deterioration infrastructure - limited specialist services - restriction patient and staff movement in/out
Background
MSF in Gaza before war
Coordo Jerusalem Combined house/office Gaza City Existing projects
Plastic day-case surgery 4-5x/year since 2009 Post-op dressing/physio clinic ICU support
Background
Events leading up to war March
Collapse 2013 US-brokered peace talks
2nd June
Formation National Unity govt. b/w Fatah and Hamas Suspension peace talks by Israel
12th June
Abduction and murder 3 Israeli teenagers
14th June
Launch Israeli military operation “Brother's Keeper” Mass arrests/searches in West Bank, 10 civilians killed
2nd July
Abduction and murder Palestinian teenager
7th July 8th July
Escalation tit-for-tat rocket + airstrike fire b/w GS and Israel Launch Israeli military operation “Protective Edge”
26th August
End of war
5 751 air strikes 16 302 tank shells 3 344 naval shells
5 844 rockets 1 708 mortars
Emergency Medical Team
Day10:Arrival1 contingent (Med An, ER doctor, OT nurse) st
Night 10 : Ground invasion commences Day 13/18 : Arrival 2 surgeons, 2nd Med An, ICU-RR nurse
Hanoun Jabaliya Beit
Shuja'iyya
Shuja'iyya
Khuza'a
Hanoun Jabaliya Beit
Shuja'iyya
Shuja'iyya
Khuza'a
Al-Shifa Hospital Al-Shifa hosp.
Choice of Al-Shifa
MSF
N°1 teaching hospital 3° referral centre in war 5 min from MSF base And they asked us to ...
The job
SUPPORT ROLE Resuscitation bay ER OT Recovery room CLINICAL LEAD BURNS ICU
Gaza City
Al-Shifa Hospital
Getting started
Introduction to Shifa medical teams Individual « embedding » Logistics
Organisation
Night shift 16H-7H: An / 2 Su / ER doc / Nurse / Trad Day shift 7H-16H: An / Trad MTL Rendezvous point (cafeteria)
Initial impressions
Massive n° severely-injured patients 95%+ injuries due to explosions Unpredictable work rhythm Massive n° hospital personnel Noise/crowd factor Equipment high's and low's Hospital mutation
Level of fatigue and stress on our Palestinian colleagues and their courage, compassion, humour and competence
Emergency Room
OT
OT activity 500 ITV in 1st 35 days 168 laparotomy 102 external fixator 50 debridement 45 amputation 42 craniotomy 20 thoracotomy/VATS 18 vasculaire 8 tracheostomy - maxillofacial 6 laminectomy - sternotomy 4 opthalmic - neck - skin graft 15 other
STAFFING Rotation 24h ON / 24h OFF Per shift : - 1 senior MD An - 4 junior MD An - 6 An Tech - multiples surg teams
THEATRE CASES
Explosive injuries 3 factors
Environment: closed v. open space Explosive charge Distance of victim from epicentre
Amputate d Burnt
Burnt
Blasted
Blasted
Blasted
Projected
Projected
Projected
Projected
Shrapnel
Shrapnel
Shrapnel
Shrapnel
Shrapnel
Distance from explosion
AMPUTATIONS Blast +/- Projectiles +/- 3° injuries I m p o ssib le d ’a ffic h er l’im a g e.
Blast wave-induced bone weakening and auto-pulverisation
Adult male Bilateral LL injuries
Adult male Polytrauma
BLAST-RELATED LESIONS
6 yo boy Post-thoracotomy Blast 48 h ago - closed thoracic trauma - ruptured L axillary a. Postop - respiratory failure - anaemia - persistant air-leak
Pulmonary blast injury
Mechanism
Risk factors
alveolar-capillary disruption haemorrhage, oedema systemic air embolism
closed space, proximity, HED paediatric thorax
Complications
death at scene air-leak respiratory distress >> ARDS pneumonia
PROJECTILES
Adult male Tiny shrapnel injury chest wall Rupture and primary repair L subclavian a.
9 yo girl Cranio-cerebral shrapnel injury
The longest day … the
th 30
July
Followed a murderous 29th July
Shelling crowded market-place + UNWRA school at noon
45 polytrauma cases/12h (4pm – 4am)
Launch hospital emergency contingency plan
2 simultaneous op/OR x 6 + 1 op in corridor + 1 op in RR
Medical IPD + obstetric ward converted into surgical IPDs
Transfer stabile(-ish) cases from RR >> out
OT 2
OT 3
OT 4
Recovery ‌ inchAllah
2 am
Burns ICU
Rationale for involvement
Receiving major burn injuries from war Complications
Inhalation burns Associated trauma Crush syndrome Unsurvivable TBSA (80%+)
3/27 ICU beds MSF 24h medical cover MSF ICU nurse
BURN ACTIVITIES Resuscitation Intensive Care Surgery (later on)
General ICU
350 admissions 10 transfers out of Gaza 50 deaths
Final impressions
Challenges for surgeon
Multiplication and hierarchy of surgical teams
Difficulty of implementing change
Chaotic noisy OT
Lack of some specialist surgical material
Final impressions
Challenges for anaesthetist
Lack of some basic material cf. sophisticated kit Impressive set-up and technical skills but gaps in fundamental standards and modern practice
Using RR as RR
Pain management
Anaesthetic specialties
Final impressions
Challenges for all
How to be useful
How to gain respect
Environment: detonating flying objects, drones, shaking buildings, shouting surgeons, politics, diplomacy, linguistics, Ramadan...
Horrific injuries, orphans, death
Alternating action/inaction
Not knowing when it would end
Take-home messages
Anticipation Rapid identification HR needs
Rapid identification key missing equipment
Donation (ex. capno monitor, filters)
Flexibility, diplomacy
Sending specialist senior HR
Accepting lots but working towards better standards
Interpreters
ﺷﻜًﺮاThanks