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.
Dr Rebekka Troller, from student to war doctor trainer
Dr Rebekka Troller, Colorectal Robotic Fellow and Emergency and General Surgery Consultant at Medway Hospital NHS, is one of our talented trainers. Here Dr Troller shares her journey into humanitarian work and her transition from student to teacher.
From student to teacher
I first met David at St Mary’s Hospital in 2019. I was the Trauma Fellow there and, in all honesty, – I didn’t know who David was! When people found out he was the Trauma Consultant I’d be working with they thought I was very lucky. I was quite embarrassed that I didn’t know him, but maybe it’s helped us have such a comfortable working relationship today.
When discussing my career, I told him that working with Médecins Sans Frontières (MSF) has been my life-long ambition and is the reason I started studying medicine. It was also the main reason for me leaving Switzerland and coming to the UK, where I could work and train internationally. David was really encouraging, giving me guidance on how to enter the humanitarian field. To gain an insight into the work, he asked me to attend the Foundation’s upcoming STAE course.
It was one of the best surgical training courses I had ever experienced.
After taking part in the STAE course, I registered to work with MSF in 2019 and David asked if I’d consider being a trainer for the Foundation, teaching trauma surgical skills to war doctors in need.
Transitioning from someone who had experienced the course first-hand, to teaching, was really exciting. Being faculty at the Foundation and teaching multiple courses was also a great preparation for my work at MSF. In particular it helped me gain valuable skills for a mission in Cameroon, where I worked for two months as the only surgeon in a remote conflict area. In this situation I was really glad to know the techniques we teach at the courses, and it was reassuring to know that I can reach out to all my friends and mentors at the Foundation for advice, at all times.
Ever since I was little, I always knew humanitarian work was what I wanted to do. Seeing someone like David do what he does is a real inspiration and motivation for me.
He has always told me – if you want something, just go for it – this has always stuck with me.
Teaching war doctors for the first time
My first mission with the Foundation was in Yemen in 2020. I was teaching the cardiothoracic part of the course, helping the doctors perform thoracotomies or cardiac repairs at speed. I also supported the doctors throughout the course, as they learned other fields such as vascular or abdominal surgery.
I was very excited to be a part of the course. It was a small team, but a big adventure. It can be tense during travel through checkpoints, as we were never sure if we’d get through, but the team and our MSF partners were fantastic.
Yemen is also such a beautiful country. The mountains, scenery and people are beautiful - some even became friends. On the course, the 30 participants were very eager to learn. Many came with a lot of experience, but everyone learned something new - a technique they could improve or a surgery they’d never performed before.
Leaving a lasting legacy
The course is so important because we bring the training to them. For many doctors in conflict zones, even getting access to emails can be difficult, so bringing a course to their doorstep is so valuable. We want to reach every doctor who might be in need of new skills. Our aim is to leave them with knowledge they can share with their own colleagues or other people in their hospitals.
In some cases, we travel to dangerous regions because we want to empower local surgeons with life-saving knowledge. From speaking to participants, I know that the work of the Foundation is very much appreciated.
One participant told me they can feel forgotten, but by showing up we are saying: “We see you. We are thinking of you. You are not alone.”
Stories that stay with us
Being a faculty trainer means I get to meet very special individuals. Many war doctors live busy lives, working in under-resourced hospitals 24/7. I met surgeons from Syria who were working 10 hours away from their families, risking their lives on a daily basis. Despite these sorts of circumstances, the doctors are often very cheerful. They are grateful for life, which is incredibly humbling.
Now that we’ve entered 2022, the Foundation has big plans for surgical training courses this year. I can’t wait to get back on the road with the team – doing what I love.
Another successful STAE course
This month, we were honoured to train 14 doctors from Afghanistan, Syria, Palestine and Ethiopia on our latest Surgical Training for Austere Environments (STAE) course. Over five days, the group participated in bespoke surgical workshops, specifically designed for treating traumatic – and often unique – injuries caused by war and catastrophe.
Starting the week off in Brighton and Sussex Medical School, the participants practiced an extensive range of cardiothoracic procedures, such as fast and efficient thoracotomies (gaining access to the chest), heart repairs and how best to manage injuries to the lungs.
Aided by videos taken by our Co-Founder, David Nott, during overseas missions, the group also learned how to repair blood vessels – a vital skill for managing severe blood loss.
Equipped for every emergency
As the week progressed, every doctor was exposed to a different but equally vital field of medicine, from plastic surgery to orthopaedic trauma. This is key, as we know war and catastrophe can present patients with often varied and complex injuries.
In conflict for example, it is not uncommon for junior doctors to be the only healthcare workers left in hospitals. This means they need to step into a number of roles, from cardiothoracic surgeon one day to paediatric specialist the next.
New obstetric simulators
On the last day of training, the participants completed a range of obstetrics workshops in the beautiful new facilities of the Royal College of Obstetricians and Gynaecologists in London. Using our new simulators (pictured below), the group refined their C-section techniques and learned how to address emergency scenarios, such as breech births or neonatal resuscitation.
Listening and learning
We were honoured to be joined by doctors from Palestine, Syria, Afghanistan and Ethiopia, and each country is recovering from - or still facing – conflict. To ensure we continue to deliver the highest quality training and meet the needs of our doctors, we listen to participants’ experiences of their home countries.
Dr Naseebah Nayef left Syria in 2013. She shared with us: “(During the war) I treated Syrian protestors in my private practice. Post-that, my house was bombed, and I had to flee with my three children from Syria. I am so very, very grateful for being a part of this course.”
Merry Christmas from our Chief Executive
The end of the year provides us with a moment to reflect on what has passed and think about the future. It has been a year of many challenges and difficulties, but I am so grateful for the incredible ongoing support we have been so honoured to receive from you all.
I have found joy this year in the time I have spent with the doctors we have had the privilege to train on our courses. Speaking with doctors from Mosul, Iraq, on our HEST in November and from Ethiopia, Palestine, Afghanistan and Syria on our latest STAE course; they provide such inspiration to us as a team.
Thanks to your generosity, we have a full programme of training planned for 2022 and cannot wait to get started. It is our ambition to run six Hostile Environment Surgical Training (HEST) courses and re-start our Obstetric and Neonatal Care specialist courses. We will have two more cohorts of scholars on our scholarship programme and continue to deepen and strengthen the relationships we have built with healthcare workers and partner organisations over the previous six years.
To our DNF community, we wish you a very Happy Christmas and New Year. We truly couldn’t do what we do without you.
Meet war doctor trainer, Dr Una Walsh
Dr Una Walsh, General Surgeon and Major Trauma Fellow at St Mary’s Hospital London, is the newest member of our faculty. Here, Dr Walsh shares her experience of our latest course in Iraq, where she was responsible for teaching abdominal and paediatric trauma.
Joining the Foundation
I first met Professor Nott in 2016, when I worked as his Registrar at Chelsea and Westminster Hospital. Since then, I am privileged to call him my mentor. It quickly became very clear to me that our thoughts were aligned on global health and inequalities, and I was keen to get involved and help in whatever way I could.
I was quite junior at the time - a 3rd year Registrar - but I knew if I continued my training, stuck with it and pushed hard, I could use the skills and operative knowledge I gained to join the Foundation and further their aims abroad.
This required a considered rethink on my career path and after discussion with Professor Nott and deanery tutors, I made the decision to switch training from breast to colorectal surgery and create a path towards emergency and trauma surgery. This also laid the groundwork for a humanitarian-focused career. I have since completed general surgery training, joined the Foundation’s faculty and currently work as a Major Trauma Fellow alongside Professor Nott at St Mary’s Hospital London.
A pull to help those in need
My first experience of humanitarian work was with Sir Magdi Yacoub’s charity, Chain of Hope, based at the Brompton in London. Through a chain of volunteer surgeons and medical doctors, Chain of Hope identifies children with congenital heart disease in urgent need of surgery not available in their own country and arranges transfer to centres in high-income countries that sponsor their surgery. They also have an active training programme, whereby teams fly out to operate or train local teams across the developing world. My role is to travel to low- and middle-income countries and provide aeromedical escort for children to sponsor centres for life saving heart surgery.
On behalf of the charity, I have retrieved children from Zambia, Haiti, Sierra Leone, and the Ivory Coast. This work is extremely rewarding working with a fantastic charity, plus I have a very lovely collage of pictures of the children I have helped, recovered after surgery. This work has also given me a wealth of experience in mission planning and the nuances of humanitarian work including navigating many and varied world airports with understandably terrified mothers and often babies in tow.
Whilst, heart-warming work it feels like a very small drop in the ocean - that's what drew me towards global health as an entity. The ability to help more than just single individuals.
At the David Nott Foundation, if you train one surgeon, the knowledge is shared with many more in local communities helping hundreds - that ethos resonates really strongly with me.
Cutting-edge teaching technologies
The latest HEST course in Erbil, Iraq, was my first course as a Faculty Trainer. It was a really lovely introduction to working with the Foundation. I led the abdominal and paediatric sections of the course. This involved both lectures and skills training.
All the training equipment, funded by our supporters, is superb. We were able to provide near-to-life simulated training through the use of purpose-made and anatomically correct tissue, including bowel arteries and veins, hearts, kidneys, windpipes and even skulls. The hearts and kidneys were my particular favourites, truly amazing and life-like.
Then Heston – the anatomical model! It’s just the cherry on top. You can demonstrate the exact movements you’d make in surgery. For example, how to mobilise the colon to get to the kidney, or more importantly the major vessels which can often represent the most challenging of traumatic injuries.
Heston also has little magnetic buttons that keep the organs in the correct anatomical positions, which allows you to simulate exactly how you would move and access body parts. It’s a tremendously clever part of his design.
Humbling stories
Most of the surgeons I trained came from Mosul, so many had experiences of the war to liberate their city from Islamic state (IS) invasion.
I admired so much the strength and courage they showed - and listening to their stories was humbling.
When Dr Troller (another faculty member) was teaching a procedure called a resuscitative thoracotomy, one of the surgeons commented during the war that they'd done ten - and only one survived. This could be down to the catastrophic injuries caused by war, making procedures like this even more challenging.
After completing the course, they were equipped with helpful strategies, giving them confidence that future outcomes will be different for patients. This is the real-world value of this innovative course.
They were a very talented, welcoming and hard-working group of individuals and I’m really looking forward to training many more like them.
We’re back where we belong
We are delighted to be back training doctors on the frontline. Our latest Hostile Environment Surgical Training (HEST) course in Erbil, Iraq, equipped 31 local healthcare professionals with skills that will serve their communities. Our Chief Executive, Elly Nott, shares her experience of the course.
Our latest course in Erbil was an incredibly humbling experience. Facilitated by our partners at Médecins Sans Frontiers-Belgium (MSF), we were able to train 31 Iraqi healthcare professionals in the surgical skills they need to manage any case they might encounter in an emergency or conflict situation.
During the course, our faculty used our cutting-edge anatomical model, Heston (pictured below), to teach a range of surgical techniques for treating traumatic injuries. Model hearts and synthetic skin helped them practice how to manage cardiac injuries and chest tube insertion. Virtual reality headsets also immersed our participants in emergency scenarios, putting their mass casualty triage and decision-making skills to the test.
A number of the participants were from Mosul, a beautiful and historic city that freed itself from the oppressive rule of Daesh in 2017. The resilience, courage and grace of the doctors was an inspiration to us all.
We are so grateful for your support of our mission. Every donation helps us deliver world-class surgical training that saves and improves the lives of those most in need.
Training of Trainers: Future-proofing the Foundation
Last weekend, the David Nott Foundation invited 24 leading surgeons to London to attend a Training of Trainers course. The aim of the course was to introduce each surgeon to the HEST Course, with the hope that many will want to travel to conflict zones with the Foundation to teach it.
The Foundation receives many requests to run HEST courses, in so many locations affected by war. By expanding our faculty, we can reach more of these places in a timely manner.
The 3-day course was held at the iconic Wellcome Collection, a monument to the health sciences in Central London. Our extant faculty, led by David Nott, took participants through the different modules that comprise the HEST course. By the end of the weekend, participants felt ready to teach the course overseas. One participant said:
"David and colleagues have lots of experience and I am in awe of what they have been able to achieve. The practical tips in management of patients in humanitarian settings are equally valuable for trainees and established consultants in this country. "
Interspersed with surgical modules was discussion of the practicalities of attending humanitarian missions:
" I found the session delivered by Mr Hakimi on the practicalities of what to expect when travelling and working in countries where HEST is being delivered to be excellent and insightful."
We were additionally delighted to welcome students from the Friends of the David Nott Foundation Societies to the course. Delegates from Manchester, Leicester and Queen's University Belfast came to get a taste of their future humanitarian careers.
Training the Trainers has allowed us to invigorate the Foundation with new and enthusiastic teaching faculty. The DNF is poised to return to in-country HEST courses future-proofed and with more courses than ever.
