Training in Somaliland with 'A Woman of Firsts'
In March 2022, we were honoured to train 34 healthcare workers in Hargeisa, Somaliland. Here, our CEO Elly Nott shares how this HEST course came to fruition and how it marks the beginning of a special relationship with a very special hospital.
Over Christmas, I came across a book. ‘A Woman of Firsts’ is Edna Adan Ismail’s inspiring story of how she became a pioneering political and global health leader and campaigner for women’s rights. The respect and affection in which she is held in her home country, Somaliland, is truly remarkable and witnessed wherever one goes with her.
Building an empire
In 1998, she began building a hospital on an empty patch of land in the capital of Somaliland, Hargeisa. Through her will and determination, the foundations Edna established became a maternity hospital, which has since diversified into a major referral institution.
The Edna Adan Hospital treats obstetric, paediatric, surgical and medical cases from across the Horn of Africa. The Edna Adan University provides skilled healthcare workers to work in the hospital and other institutions in Somaliland, consistently occupying the top of the teaching league tables.
When I contacted Edna and asked if she would be interested in us running a HEST course at her hospital, she welcomed the idea straight away.
From the moment we arrived in Somaliland, we felt the warmth of Edna’s hospitality and all the inspirational healthcare workers who had travelled from across the country to participate in our training. Our outstanding faculty enjoyed sharing knowledge and techniques that would make a real difference to the participants’ management of traumatic injuries.
A need for well-trained surgeons
There is a real need for our partnership. A 2020 paper for the Lancet written by Dr Shukri Dahir et al, concluded that ‘the surgical system in Somaliland did not reach any of the target indicator goals as defined by LCoGS’ [Lancet Commission on Global Surgery]. The greatest need was for protection against catastrophic expenditure for low-income families on medical care and access to well-trained surgeons, anaesthetists and obstetricians.
The HEST course was just the start of our collaboration. In the coming months, we will welcome the doctors we met to the UK for our next Train the Trainers course. This time, they will teach alongside our UK-based faculty. We will also continue to work with the dedicated healthcare workers of Somaliland to support their training and ensure local people have access to safe, skilled surgical care.
By chance, our course coincided with International Women’s Day (IWD). A solid third of the participants in this HEST course were women and we were delighted to have the opportunity to contribute to their surgical careers. To spend IWD 2022 in the company of Edna, and the healthcare workers she has inspired and mentored, was truly an honour.
More on our HEST course in Somaliland
A lasting legacy in hospitals across Somaliland
Michael Odesoji, Surgical Nurse at St Mary’s Hospital, attended his first HEST course as Nurse Lead in Hargeisa, Somaliland. Here, Michael shares the importance of surgical nursing for improving patient safety, and how his training will make an impact right across the country.
Hargeisa was my first mission with the Foundation as Nurse Lead – and it was amazing. We trained 34 healthcare workers at the Edna Adan Hospital in Hargeisa, Somaliland.
Following David Nott’s ethos, it’s important to ask healthcare workers what they need, rather than deciding for them. Imposing knowledge without insight isn’t useful. Some of the topics the participants wanted to cover included how to form a safety checklist for surgery, emotional preparation of patients for operations, and maintaining good antiseptic techniques in the operating theatre.
With Mubarak, the Nurse Anaesthetist at Edna Adan Hospital, I led an interactive session on the importance of the surgical safety checklist for both the multidisciplinary surgical team and the patients. It resonated really well with the participants and the hospital’s surgical theatre staff.
Making a big impact
I then helped to design a bespoke surgical safety checklist for the hospital, which suited the cultural environment of Somaliland, using the WHO surgical safety checklist template. The checklist was implemented and put into use in the operating theatre before the end of the course, which was incredible to see.
Mubarak took it upon himself to champion its continued use, as well as ensuring it is implemented in every hospital in Somaliland. This was fantastic to hear, as it will further enhance patients' safety and reduce avoidable mistakes in operating theatres across the region.
I also organised a neonatal resuscitation session with the midwives and ward nurses, alongside Faculty Member, Dr Jeanne Frossard. The whole team were awesome and worked tirelessly to deliver the best possible experience for every trainee.
It was so exciting to see that the course was making a big impact in such a short period.
Moments to remember
Edna Adan Ismail, a passionate advocate for women’s health and Founder of the Edna Adan Hospital 20 years ago, was a force of nature and very welcoming. One of my best memories of the trip was when Edna and the hospital team organised a surprise birthday party for me, which was very thoughtful.
My first David Nott Foundation mission as Nurse Lead was an incredible one – and gave me a real favour for the real impact of the charity's mission. This trip was hopefully one of many.
A mission to reach every healthcare professional in Ukraine
In response to the Ukrainian crisis, our Co-Founder David Nott and Former Consultant Surgeon at St George’s Hospital Henry Marsh delivered a 12-hour online war surgery course to hundreds of doctors in Ukraine on Saturday 5th March.
Taking our action one step further, we’ve turned our life-saving course into a condensed recording and are translating it into Ukrainian. Now, we are on a mission to share it with every healthcare professional in Ukraine.
To reach as many doctors as possible, David has further condensed the Foundation’s surgical training into a 6-hour recording, divided into 15 chapters and packed full of surgical experience from the frontline. Chapters include triage, neurosurgery, damage control, burns, cardiothoracic, orthopaedics, paediatrics, plastic surgery and anaesthesiology.
The resource has already been shared with many doctors within Ukraine. One shared with us: “Perhaps hundreds of lives and destinies will be saved, thanks to your work. Thank you!”
Another healthcare professional within Ukraine, said: “David has gone through almost all the wars of the past 20 years and arguably has the most conflict medical experience in the world. He did this course for us.”
David Nott, our Co-Founder, said: “The emotions that healthcare professionals in Ukraine are feeling and the circumstances within which they are working – I’ve been there. I’ve worked in hospitals that have been hit by bombs. I’ve performed surgeries in the dark. I’ve been terrified for the lives of my patients. I can’t stop this war, but I can arm them with knowledge.
Condensing my war surgery experience into a recording that can be streamed from any device means any doctor within Ukraine can gain life-saving skills. All of us at the Foundation will continue to do all we can to help.”
War doctors should consider controlling blood loss with surgery and limiting blood transfusion
Trauma surgeons should consider surgically-controlling severe blood loss and limiting the amount of blood transfusion, according to a Lancet research letter by our Co-Founder David Nott and others. These findings are the results of preliminary research carried out by David in Syria in 2013, under austere conditions with limited blood stocks.
In 2013, the Syrian regime targeted hospitals and healthcare workers in Aleppo. David recorded the clinical outcomes of 57 war-injured patients undergoing surgery. Of 55 severely injured civilians, median age was 25 years and 17 (31%) were children.
Triage identified the people most in need of surgery, and immediate surgical control of the bleeding followed. All patients received whole blood after bleeding was surgically controlled. Every patient selected for surgery survived.
Although an extensive study in regulated hospital conditions is needed to validate the findings, this analysis suggests children and young adults with blast and penetrating war wounds, who are rushed to hospital and receive rapid surgical control of bleeding, are more likely to survive. For these patients, minimising all infusions, including blood, appeared to be safe, preserved scarce blood stocks and could even be considered clinically beneficial.
The most startling finding was that patients could survive major trauma with haemoglobin concentrations down to 4.8g/dL, with the majority between 5 and 7 g/dL.
Humanitarian war surgery is often characterised by poor conditions, resources and isolation. Transfusion supplies (and clinicians available to administrate blood) can be severely limited. Nott’s approach in Syria was borne from necessity, yet all patients selected for surgery lived.
Russia’s invasion of Ukraine is forcing hospitals underground and resources will soon become scarce. This observation of quick judgement, early surgical intervention, minimal whole blood transfusion and better-than-expected outcomes in Aleppo, should be considered by healthcare workers treating patients in Ukraine.
David Nott, our Co-Founder, said:
“Some of the conditions within which I’ve worked have been incomprehensible. But we trauma surgeons must do all we can to save lives, no matter the resources available.
In ideal circumstances blood stocks would be bountiful, but conflict strips hospitals of that luxury. This research suggests rapid surgical intervention to control blood loss, with limited blood transfusion, can lead to good outcomes. Although more research is needed, this insight could help surgeons in Ukraine save more lives.”
Two war doctors, one family
On day one of our HEST course in Erbil, Iraq, our Chief Executive Elly Nott had the pleasure of meeting two participants from Mosul. Together, Dr Basma Haqi Ismael and her daughter Shahad, a medical student from Mosul University, are delighted to learn surgical skills that will serve their community in times of need.
EN: I’m delighted to meet you both. Can you start by telling us who you are and where you’re based?
Dr Basma: I’m Dr Basma and I work with MSF. I am very grateful (to be here) because I help many people, especially people after war and disaster. Especially the people of Mosul post-war.
EN: And you must be very proud that your daughter is close to qualifying as a medical student.
Dr Basma: I am very proud of that… I always transfer what I see in MSF hospitals and give lots of information to her so she can get revision from that also.
EN: And is your mum an inspiration?
Shahad: She has always been an inspiration! I always wanted to be like her, in medicine, in life, in everything!
EN: That’s wonderful. And where are you training?
Shahad: I’m at Mosul University and training at Mosul Hospitals.
EN: There’s quite a lot of practical work on our HEST courses, are you looking forward to getting involved on our practical work here?
Shahad: Yes! I have found it was very nice to attend and gain some experience.
Dr Basma: This training will be very beneficial. The (course) information comes from many countries and can be beneficial and transferred to people inside Iraq - and other countries too.
EN: Absolutely, that’s the great thing about this course. It’s the accumulation of about 30 years of experience in various parts of Africa, the Middle East, Asia.
Dr Basma: Yes, emergency skills. I have experience of more than 20 years – but yesterday I was learning about lung twisting. It is for vascular thoracic surgery.
EN: The lung twist was a new skill?
Dr Basma: A new thing for us. We can transfer this information to our surgical department, for any blood loss or vascular injury. It’s very beneficial for the patient.
EN: So, you’ve already learned something new on day one of the HEST course?
Dr Basma: Yes, we’ve learned new information.
EN: And did you try the lung twist on our model Heston?
Dr Basma: Yes, very good. We also tried the open-heart cardiac massage. (We are) very grateful to do this training. For my daughter, transferring this information to hospitals, friends, medics, doctors – it’s beneficial for all.
Dr Basma: At this time, I worked at Al-Jamhoori Teaching Hospital in Mosul. I help many people with MSF Belgium. Most of the people who come by have many deformities.
EN: With the injuries that you see. Are many of them the result of conflict?
Dr Basma: Yes, we’ve received many injured people from Mosul, but also many, many with psychological problems.
EN: Is there a particular patient that’s stayed with you?
Dr Basma: Most of the cases we receive are post-burn deformities, especially during ISIS. Explosions causing burns. Most of these patients are crying, saying I want to be saved. Always, I remember my daughter, and most of the time I am crying with the patient.
EN: I have two daughters, I can understand that. What are your hopes for the future?
Shahad: For me, I want to learn. In the future, all I want to be is a good doctor. I want to be like my mum! That’s all. She is doing very well in her career, and that’s all I want.
EN: That’s wonderful.
Dr Basma: We are so grateful (to be on this course). We want you to come to Mosul! We have heard very nice things about David – a great man. Many people pray for him.
We rapidly delivered war surgery training to 573 doctors in Ukraine
In response to the Ukrainian crisis, our Co-Founder David Nott and Former Consultant Surgeon at St George’s Hospital Henry Marsh joined forces to deliver a 12-hour surgical training course to over 570 healthcare professionals on Saturday 5th March.
After the Russian invasion of Ukraine, David Nott rapidly developed a surgical training course for doctors who are working, or will work, to save lives in Ukraine as the devastation continues to unfold.
David condensed our 5-day surgical training course into a comprehensive 12-hour course online. To ensure healthcare professionals in Ukraine are best prepared for complex war injuries, the course included triage, damage control, burns, cardiothoracic, orthopaedic, paediatric, and plastic surgery sessions. Former Consultant Surgeon and pioneer of surgical advances in Ukraine, Henry Marsh, led the neurosurgery session of the course.
The attendees learned a range of skills that can be used when faced with limited resources, from learning how to create make-shift pelvic binders to knowing when to operate without a CT scanner.
Vadim Corjos, a General Surgeon from Ukraine based in the UK, said:
"(The David Nott Foundation surgical training course) in essence is the fullest and deepest course for surgeons who are in war zones. Providing this course for (Ukrainian) surgeons gives a very good base to save more lives in war and conflict areas. I have no words to appreciate this great effort. Thank you and God bless."
David Nott OBE FRCS, Consultant Surgeon at St Mary's Hospital and our Co-Founder, said:
“At the frontline of conflict zones are medical teams working tirelessly in often under-resourced and ill-equipped hospitals. Many have never experienced traumatic war injuries.
When the crisis unfolded in Ukraine, we knew we had to spring into action and condense my 25 years of war surgery experience on the frontline into a 12-hour course for those in need.”
Henry Marsh CBE FRCS, Former Consultant Neurosurgeon at St George’s Hospital, said:
“I hope and pray that my Ukrainian friends and colleagues will not need to apply all that they learn from the David Nott Foundation webinar.
But we must do what we can to prepare them for the possible horrors ahead as Russia continues with its evil and murderous invasion.”
Thanks to Nick Southwell and Terry Hancock for providing technical support and advice on this course.