Mosul to Manchester: Our war surgery training in practice
Dr Moez Zeiton is one of our surgical trainers. As a humanitarian surgeon, Moez has witnessed the realities of war, but never expected to see similar horrors on British ground. Here, Moez shares his journey to joining our teaching faculty and how he’s used his surgical skills around the world.
Moez’s first exposure to medicine was through his father training as a general surgeon and specialising in oncoplastic breast surgery.
“I sort of drifted into medicine myself. I loved biology at school, but my love for the sciences and in particular, my inspirational high school Biology teacher shaped my decision to study it. When I started the course at the University of Leeds, I remember loving the anatomy and dissection work and knew surgery and acute trauma were fields I was interested in,” Moez shares.
A fork in the road
“My entry into humanitarian work started by accident. I always felt a connection to the Middle East through my family and having regularly travelled there as a child to visit extended family and friends.
So, when the Arab Spring uprisings in 2011 arose, I got involved with charitable initiatives sending medical aid and worked on advocacy, opinion pieces and articles. I knew I wanted to be there on the ground, so I negotiated a one-year sabbatical from my surgical training. At the age of 25, I left for Libya to do my part.”
Moez worked with non-government organisations and local Libyan doctors, opening him up to the world of humanitarian health. This led to him taking on a voluntary role as National NGO Coordinator for six months. He also attended courses on analysing disrupted health systems with the World Health Organisation (WHO).
Taking part in our training
After his sabbatical, Moez continued his surgical training in the UK and fed his interest in humanitarian surgery with research. He was part of The Lancet’s series on health in the Arab world and commission on global cancer surgery. He also attended the Scholars in Health and Research Programme at the American University of Beirut.
Working at a major trauma centre in the UK, Moez worked alongside some of our senior faculty and was introduced to our Surgical Training in Austere Environment (STAE) course. He was one of the first doctors to benefit from our scholarship programme, attending our STAE course in 2017.
“On the final day of the course at the Royal College of Surgeons, I met people from WHO and Aspen Medical International who were looking for doctors to help with trauma victims in Mosul, Iraq, following ISIS invasion. Two months later, I found myself there, with a group of expat and Iraqi doctors.
Immediately, I was able to put my new war surgery knowledge to practice - damage control and how to save lives and limbs.”
War wounds in Manchester
Two weeks after returning from Mosul, Moez was unexpectedly faced with war injuries in Manchester – blast wounds following the Manchester Arena bombings.
“The injuries I saw were very similar to what I’d seen in Iraq and had been teaching on the Foundation’s courses - blast injuries from shrapnel and metalwork. I was able to use what I’d learnt but now in my home country.
Although it was shocking and very stressful, things worked seamlessly in our hospital and the camaraderie, hard work and collaboration I saw across 7 or 8 local hospitals that received injured patients was unlike anything I had seen before. I truly saw the NHS at its best.”
Becoming a trainer
“After my return from Mosul, I was invited to join the Foundation’s orthopaedic faculty. Being part of the Foundation’s faculty for the past 5 years, teaching the skills I learned on that STAE course in 2017, is incredibly special.”
For the first time, Moez led the orthopaedic section of our recent course in Gaziantep.
“Although I had been teaching on the STAE course in London for some time, the oversea HEST course required a slightly different approach. I needed to prepare and familiarise myself with the course material. Attending the Train the Trainers course which was put on by the Foundation really helped with this.
The 26 Syrian surgeons we trained shared incredible stories and the cases they faced during conflict with limited resources. Rather than teaching, I facilitated discussions around patient cases, learning from shared experiences and taking things back to fundamental principles. I learned just as much from the inspiring candidates as they learned from me!
This was also the first time that I had delivered an all-day comprehensive professional course in Arabic. It was extremely challenging considering I’ve only practiced medicine in English. However, the feedback and appreciation that I received from attendees is certainly one of the best achievements in my career.”
Leaving a legacy
Looking to the future, Moez wants to continue serving those in need in the UK and around the globe.
“I feel passionately about my humanitarian work and want to continue this in tandem with my NHS role, ideally doing one or two missions a year.
The NHS is such a huge organisation and has a vast resource of skills, knowledge and cultural experiences that can be tapped into. The world is incredibly connected. No matter how far away they may seem, conflict and disasters that happen in other countries continue to affect us directly or indirectly through human migration, security and the economy. We should be using our training and unique cultural experiences to help others around the world.”
Help us train more war doctors
How we rose to the challenge of COVID-19
The coronavirus impacted our ability to deliver the in-person training we are internationally known for. Despite this challenge, we found new and effective ways of supporting war doctors around the world. Here are a few of the things we got up to.
DigiHEST
In December 2020, we piloted our first ever Digital Hostile Environment Surgical Training (DigiHEST) course. We transformed an office space, generously provided by Whitby Wood, into an operating theatre and our friends at Redux Content decked the place out as a recording set.
Over the course of a weekend, David was joined by DNF faculty members Ammar Darwish, Rebekka Troller and Pete Mathew to present an ambitious programme of surgical training that was live streamed around the world. Modules covered included abdominal trauma, neurosurgery, maxillofacial surgery, ballistics and more. David was also joined by special guest lecturers Mounir Hakimi (orthopaedics) and Shehan Hettiaratchy (plastics) to form a world-class team of surgical specialists ready to reach out to surgeons in conflict zones and austere environments.
We were joined by up to 100 doctors from around 29 countries over the course the weekend, who were additionally able to pose their questions in real-time to the presenters and ask for advice on cases presenting to them in their localities.
Webinars
Throughout 2020 (and re-starting in 2021), we ran webinars for doctors in conflict zones. These webinars, led by David, saw doctors submit difficult or interesting cases and discuss together the best course of action for treating individual patients. David and our Faculty also delivered lectures during these sessions.
Creating a global network
Our webinars led to the creation of a thriving online community of surgeons, each able to send photos and submit descriptions of cases for the purpose of collaboration with other David Nott Foundation alumni around the world. This forum has been an incredible thing to witness - rapid surgical feedback and collaboration between doctors in conflict zones.
Despite rising to the challenge of coronavirus, we are delighted that our in-person surgical training has resumed.
Find out more about our courses
David reflects on his latest mission in Ukraine
Our Co-Founder David Nott recently travelled to Ukraine with UOSSM International, performing life-changing surgeries and offering guidance to doctors across the country. Here, David shares his reflections on what will remain a memorable and emotional mission.
My latest mission to Ukraine was an incredibly important one for me. I travelled everywhere, north, south, east and west.
I initially started in one hospital. When they knew what I could do, I was asked to go to more hospitals, and it started to snowball from there. I began by treating a number of old war injuries, people that had holes in their legs and arms, loss of shoulders and big fragmentation wounds.
It was clear that Ukrainian surgeons wanted support with plastic surgery. Many didn’t know how to rotate flaps, some had never seen one before. Many had never done war surgery at all. So, I spent my first week just operating and operating - doing all I could.
At one point, I had 14 or 15 people in an operating theatre all bent over watching what I was doing. It's a great way to teach - I stood back and told them where to make the incisions. They were delighted to learn.
I reconstructed a patient’s shoulder that had been blown off and other serious blast wounds. When I went back the next day to see one of the blast patients, they gave me a thank you plaque which was incredibly kind. They were desperate to have somebody show them what to do – someone there to help them.
I travelled all over the country to regions that have now been heavily bombed. I saw how refugees in Lviv are gathering in a railway station, and the fantastic work that NGOs are doing there. There are thousands of people, all being fed and sheltered with the help of outstanding charities.
Now having seen the devastation, it feels like the exact same tactics as in Syria. When I was in Aleppo in 2016, the whole region was completely and utterly destroyed. What we’re seeing in cities like Mariupol – the destruction - feels very similar to what I witnessed in Aleppo.
Teaching has carried on here in the UK. I taught a doctor called Oleksandr who contacted me when I was back home. He watched me repair a serious leg wound in Ukraine and had seen the condensed training videos we made for surgeons there, but Oleksandr was now the lead surgeon faced with a similar blast injury.
I guided him through his surgery remotely, as he took a flap of skin from behind the knee to repair and close the wound.
"I was quite nervous, but it went well thanks to David Nott. He showed us ordinary doctors how to fight on the medical frontline." - Oleksandr
Oleksandr and his colleagues are treating awful injuries that no-one should ever experience. But the injuries will keep coming, so it’s my hope that they will pass on what they’ve learned. By sharing my knowledge and 30 years of war surgery experience, a lasting legacy is created.
There’s a huge amount of work to do. I think surgeons and healthcare professionals in Ukraine will be faced with war wound reconstructions for many years. Plastic surgery will be incredibly important as the conflict continues – and far into the future too. The Foundation will do all we can to help doctors navigate this war and its aftermath.
We translated our war surgery training into Ukrainian
In response to the Russian invasion of Ukraine, we turned our life-saving course into a condensed recording and translated it into Ukrainian. We now invite every Ukrainian surgeon to contact us to receive this life-saving war surgery resource.
When the crisis began, our Co-Founder David Nott worked around the clock to condense our surgical training course 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.
Taking the training one step further, we’ve translated every chapter into Ukrainian to ensure our life-saving resource reaches every single doctor in need, no matter their ability to understand English.
Contact us if you're in Ukraine
Our Co-Founder, David Nott, said: “After Russia invaded Ukraine, I knew I had to get there. I had to help. Thankfully, I was able to get into Ukraine, volunteering my surgical skills in multiple hospitals right across the country and sharing our training recordings with the doctors I met.
Although a powerful resource, it quickly became clear that many didn’t speak English well and I knew we needed to work hard to ensure our training was even more accessible.
We’ve worked around the clock with Absolute Translations to translate every single chapter into Ukrainian and are now on a mission to ensure every doctor in the country has access.”
If you are a Ukrainian healthcare professional or know of doctors in need of help, we are here for you. Email us at [email protected] for access to our translated resource.
Many thanks to the team at Absolute Translations for their hard work and dedication.
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.