Mission chirurgicale conflit Israel Gaza 2014

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 â&#x20AC;Ś 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