“The patients. The families. They’re all in my head.”
Our Co-Founder David Nott recently travelled to Rafah, Gaza, to help treat the thousands suffering from war injuries, malnourishment, and everyday ailments that have progressed to life-threatening conditions because of delayed treatment. Here, David shares what he witnessed, what the urgent medical needs are on-the-ground, and how those he met are tattooed onto his mind.
After travelling from Cairo and getting closer to Gaza, it was quite a shocking experience. At the Rafah crossing, you could see miles worth of trucks in a queue trying to get in.
Driving through Gaza, it was like an enormous refugee camp with tents everywhere. Every single place that wasn't occupied by somebody had a tent on it. Most of the tents were so packed against each other it was difficult for people to walk.
"Thousands and thousands of people were in a small area. They had nowhere to go."
Treating those more likely to live
The hospital I was working in was called Al Najjar Hospital, the only semi-functioning hospital in Rafah. It was small, with a limited number of beds, but ended up housing thousands of people. Every corner was full. Patients were in the corridors, all over the wards, lying on the floor, five people where one might stand. There were people on the floor that were dying, some that had died - people crying out for help.
I had to step over people to get to patients. I had to make rapid decisions on whether or not they could be saved – decision-making techniques that we teach to those that attend our courses.
The hospital only had two operating theatres. There was no intensive care unit and no ventilators, so I had to decide which patients should be operated on with the best possible outcome. On ward rounds we reviewed those that had been treated, but many had infections because of limited sterile space or antibiotics.
18th century illnesses
"Because thousands of people have been compressed into small spaces, and many haven’t sought medical care for their everyday conditions, the clinical needs in Gaza today are astonishing."
It’s not just war wounds that doctors face – ruptured appendices, hernias, ulcers, gangrene. General surgery has been delayed for months on end and people are dying or losing limbs as a result of problems that could have been resolved quickly.
This is the reality of trauma in war – some traumas that were not traumas to begin with become life-threatening – racking up death tolls even further.
"Outside of war wounds, 21st century doctors are dealing with 18th century illnesses."
Children with chest infections were developing a condition called empyema - their infections had become so bad that their lungs were filling with pus. I’d never seen that before – it’s an 18th century condition that you would never see today.
Post-operative care felt impossible. Say you amputate somebody’s leg, there’s nowhere for them to go to recover safely. Tents aren’t sterile and it has been so cold, with the wind coming off the beach.
Calm amongst the chaos
Despite the chaos, Gazan doctors are truly outstanding. They were so warm and helpful. They were grateful that people were there to help, and together we did everything we possibly could.
This war zone is different to the others I’ve been in. The volume of people and the lack of basic medical or human resources made it incredibly challenging.
They urgently need field hospitals, more staff, a huge amount of medical resources. They need more doctors, nurses, rehabilitation services, physiotherapists. But not only that, they need a safe place for patients to go to recover after operations. Their medical aid needs are huge and doctors in the field need to be supported.
"Seeing Gaza reminds me of the vital importance of our foundation’s work. Training doctors, operating on patients in war zones, bearing witness to doctors’ needs on the ground, I’m more driven than ever to help the charity grow so we can reach even more people in need."
The patients, the families, they’re all in my head. They will always stay in my head.
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“One day, change will happen. Until then, we’ll keep the flag flying”
On Friday 21st October, David was interviewed by the Chair of Action for Humanity, Dr Ayman Jundi, at the University of Central Lancashire (UCLan). He shared stories from the frontline, the bonds he formed in Syria’s underground hospitals, and how he copes with the monstrosities of conflict.
We were delighted to be joined by over 200 attendees, consisting of supporters, medical students and UCLan staff members. All listened intently as David offered a personal insight into his work and mind.
Becoming a war doctor
“Back in 1993, I’d just become a consultant surgeon at Charing Cross,” shared David. “I was watching the news about the Bosnian war and the terror going on there. Similar to Ukraine, Sarajevo at that time was being shelled heavily. I remember the story of a man looking for his daughter. He found her, pulled her out the rubble and took her to hospital, but there was no doctor there.
That’s when I thought, I have to do something.
The following morning, I couldn’t wait for the sun to come up. I called Médecins Sans Frontières (MSF) and two days later I was in Sarajevo.”
David’s experience in Bosnia - performing difficult surgeries on injured civilians in the freezing cold – lit a fire in him and he was soon grabbing every opportunity he could to take unpaid leave and travel to where he was needed. In 2012, David’s work in Syria began.
The first Syrian mission
“I was in Libya with MSF. It was then that I got a call about a conflict in Syria. I first travelled to Atmeh in Northern Syria, which was very dangerous. The medical set-up was not good.”
There were few ambulances in the region, so cars and vans were used to transport the injured to make-shift hospitals. They’d screech to the entrance and beep their horns to alert doctors inside.
“The hospital we worked in at that time was a converted house. The dining room was the operating theatre, the kitchen - A and E, and bedrooms were turned into wards.
At the beginning of the conflict, there were incidents of people making bombs in their homes. Unfortunately, there were many accidents, leading to awful blast injuries and loss of limbs.”
Action for Humanity
Following Atmeh, David began working with Action for Humanity (formerly Syria Relief) to lead multiple surgical missions in Syria.
“Starting my work with Syria Relief, now Action for Humanity, was the best thing I’ve ever done. They helped me enter the heart of Aleppo, which will always stay with me.
In Aleppo, I was predominantly teaching, so skills were left with the doctors living there. I did some operations to show them how to do things, but after they learned a procedure, I would assist and help. They knew what to do.”
“I was determined to get them out”
Working shoulder to shoulder with Syrian doctors naturally led to strong friendships built on the foundation of shared humanity. In 2016, bunker-busting bombs were destroying buildings and obliterating underground hospitals in Aleppo.
“I thought everyone I’d come to know, all of the doctors I’d met, were going to get killed. I was determined to get them out.”
David contacted President Assad’s office and after four days of trying, his call was connected and he made his case with passion. David will never know if his efforts contributed to the ceasefire that later followed, but he was elated when his friends were granted safe exit from eastern Aleppo.
“There were so many wonderful people working incredibly hard to get a ceasefire. I hope I was able to play a small part.”
Coping with conflict
When asked during a very engaged Q and A how he copes working in conflict zones, David shared:
“You have to be resilient. It can’t be taught to be honest - it’s learned with life experience. There are some things that are out of your control though – the terror that someone might come for you.
After Aleppo, I needed treatment, which helped. But if it’s terror during work or a patient case, talk about it, share the load, you’ll get through the hard times and become more resilient over time.”
A Masters of Disaster Medicine student at UCLan asked, ‘What can we do about healthcare systems being targeted in conflict?’
“Healthcare is indeed used as a weapon of war,” said David. “It’s like a form of psychological warfare. The act of killing a doctor takes down the psychology of whole communities.
We’ve stood on podiums and talked about how we need to protect doctors, written a letter to the Prime Minister, raised placards on a protest in London. We’ve got to do what we can to support healthcare workers.
One day, change will happen. Until then we’ll keep going, we’ll keep the flag flying.”
Meeting Heston
The event ended with a reception, giving guests a chance to meet our team and our one-of-a-kind surgical simulator model, Heston, beautifully presented by Manchester’s Friends of David Nott Foundation (FDNF) Society.
Dr Ayman Jundi, Chair of Action for Humanity and Clinical Senior Lecturer and Disaster Medicine Course Leader at the University of Central Lancashire, said:
“I was honoured and privileged to have a conversation with David Nott. His honest, down-to-earth and inspiring approach engaged the audience and instigated a wonderful and fulfilling discussion.”
"The skin is alive - it's all because of you."
“Here – you do it.” These were the words of our Co-Founder David, as he handed a skin grafting instrument to Ivan, a junior doctor in eastern Ukraine attending our surgical training course.
During a Russian shelling, a woman suffered catastrophic leg injuries. Working to repair her wound during a mission in Ukraine, David used the surgery as an opportunity to train local doctors.
He showed them how to perform a skin graft to treat the injury – and that wrapping the graft in fluffy gauze can help with healing. This technique differs to standard wound treatment, which often involves the application of antiseptic spirits and bandages.
David and Ivan have kept in touch since his returned to the UK – a common story for David and our trainers. We are proud to have created a supportive community of war doctors that can ask questions or share cases with us at any time, from anywhere.
When Ivan looked at his patient’s wound in recovery, he was overwhelmed with joy to see that it was healing. During a phone call, he shared with David:
“The skin is alive! It’s all because of you.
I’ve started a little revolution in my hospital. I’ve started to do what you do - using the fluffy gauze for skin grafts. The patient’s granulation (tissue that is an important component of wound healing) is awesome. We haven’t needed to use any antibiotics.
It was one of the best moments of my life doing this operation. I can only say thank you for your knowledge.”
Ivan, a junior doctor facing the horrors of his country’s war, is now armed with a skill that can be used to treat devastating injuries. He plans to teach this technique to his peers – and potentially even senior doctors who typically use other methods.
Although unusual for a junior doctor to teach senior consultants, in war, titles are stripped away. All that matters is the sharing of knowledge and saving of lives.
To carry out the next phase of the patient’s skin graft surgery, David offered his help over Skype. Ivan and his father, a Chief of Surgery based in Kharkiv, will work together with David to rebuild the woman’s leg and remove as many traces of the evidence of war as possible.
Surgery over Skype isn’t new to our Co-Founder. During the historic siege in Aleppo, David guided surgeons online as they reconstructed a man’s shattered jaw. The Syrian surgeons, Dr Assaf and Dr Baydak, successfully carried out the operation and put the man’s face back together again.
The stark similarities between Syrian and Ukrainian conflict do not go unnoticed. As witnessed in Aleppo, healthcare workers in Ukraine are in urgent need of our support. As the war continues to wage on, we are more driven than ever to train doctors and help them prevent needless deaths.
“You have given me new breath in surgery,” shared Ivan. “You were not scared to come here and share knowledge. Thank you.”
More on our training in Ukraine
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.
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.”
Operating and Teaching in Yemen: an Interview with David Nott
In April, David travelled to Yemen with Ammar Darwish, Mounir Hakimi and Asan Raffee to deliver both teaching and hands-on surgery in the World's worst humanitarian crisis. Below is a short interview that we conducted with him on his return.
How did this trip come together?
It came about with a telephone call from Syria Relief. Mounir Hakimi (of Syria Relief) had been in contact with several of the doctors who had been working in Marib. They were operating on a large amount of cases and they wanted help. Some of the surgeons who were there had difficult wounds or injuries presenting, and they wanted advice and teaching on how to cope with those injuries. That was how we heard about it.
The Syria Relief - DNF Team break their fast in Marib.
What did you see of the city of Marib?
It was pitch black at night when we arrived. We landed in Seiyun and it was a 6 or 7 hour drive to Marib. We arrived very early in the morning and went to a hotel local to the hospital. A few hours later, in the morning, we went to the hospital and were very much welcomed by the medical team working there.
What was the hospital like?
We had a very nice tour around. The Medical Director was extremely enthusiastic in showing us exactly what they had been able to continue to do. They had a very good blood transfusion bank, they had very good blood chemical laboratories. They had an intensive care unit, they had well-stocked theatres and they had a good array of back-up support. There were a lot of nurses on the wards.
At the time, Marib was becoming the epicentre of the civil war. Could you see that that hospital and its staff had been affected by escalating conflict within and around the City?
Yes. It was the epicentre. And it still is. The fighting is intense. Probably about 15km north of Marib. At the moment, Marib has about two million refugees and it is very densely populated. The fighting is continuing and obviously the hospital that we were in was the frontline hospital to accept all those casualties that were wounded. Both civilian and non-civilian.
We heard jets going over the top and we also heard rockets coming into Marib. You were aware that you were in a very hot war zone.
Who did you meet at the hospital?
Some were senior doctors. Some had just come in the last couple of months from Egypt to help out. There were quite junior doctors. There were those that required quite a lot of teaching and understanding of how to manage injuries. The hospital had stopped almost all of its elective surgeries. They were focusing purely on the war-wounded patients. Unfortunately those patients that had cancer problems weren’t really dealt with at this time.
Which case stands out the most in your memory?
I think the case that stood out most was after the teaching we gave the night before on gunshot wounds to the chest and abdomen. The surgeons had never done a thoracotomy before for a gunshot wound to the chest. The following night we were called back to the hospital with a surgeon who had watched our lecture and we found there was a patient who needed a thoracotomy. Because we were there, we were able to show him exactly how to do it and exactly how to extend this incision onto the abdomen and do a thoracoabdominal procedure. The patient did extremely well and thanked us a couple of days later.
We discussed a lot of reconstructive work. Most of the flaps that we discuss on our HEST course, we did in Marib. There was a lot of surgery done with a view to the surgeons being able to do that kind of surgery when we left.
Going forward, what do you think the Foundation's work in Yemen is going to look like?
I think that we will be going back to Marib, and I think we will continue to go back and support them both with teaching the DNF HEST course and perhaps this time taking our models with us as well so that we can run a course during the day or the evening and then operate as well. I think the future of the DNF is operating as well as hands-on teaching as well as the classroom for some courses. The future lies both within the operating theatre and the classroom.
I think we had developed a significant rapport with the doctors such that I heard recently that they desperately want us to go back again to show them more and more. I think that is the perfect opportunity for the DNF to show what it is worth really.
This mission epitomised what the DNF is all about. The DNF goes out to the field, it saves lots of lives as well as teaching the doctors so that they can continue to save lives. The DNF leaves a legacy.
You can read Ammar Darwish's story of the mission here.
David Nott and Ammar Darwish Return from Yemen Mission
Surgery on the Frontlines of the Yemen Civil War
Ammar Darwish's experience of operating and teaching in the world's worst humanitarian crisis.
"The Yemeni medical staff in Marib sent a call for assistance as they have been extremely overwhelmed with injured patients from the war"
David and Ammar were called up by Syria Relief to assist the medical staff in the city of Marib, who were facing an unprecedented number of patients injured in the intensifying conflict of which the city had become an epicentre. The team left London excited to get back to their roots, operating in areas of conflict and austere environments.The team left London ready to begin the long journey to Yemen, where they would meet with Syria Relief - a charity that provides support to Syrians needing medical intervention, food, education and other necessities. The team arrived at Seiyun airport in Yemen, and travelled through the night to reach the hospital in Marib that was to be their home for the next two weeks.
Marib is just 10 or 15 kilometres from the front-line of fighting, a grim reality that was ever-present as the team arrived and changed immediately into their theatre clothes.
After meeting the local medical team David, Ammar, Mounir and Dr Asan Rafee had a quick tour and then immediately started working. For the patients at this trauma centre, there was no time to lose.
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"This is one of the first operations that we dealt with. A gunshot wound to the abdomen in a young man who was left in a state of shock. He bled a lot and we had to do a trauma laparotomy and damage control surgery. We operated on him immediately.
David is just behind me in the background. He is getting ready to go to another theatre to deal with another case."
Although the local surgeons are very experienced, they have not dealt with many of these cases before. David and Ammar spent many hours training the local surgeons, imparting their years of knowledge gained through war surgery and taking them through complex operations.
They opened the chest to stop the bleeding, performed damage control surgery and took the patient into intensive care. All the while, David and Ammar were teaching their local counterpart how to perform this procedure, and to deal with these injuries.
After 7 days, the patient was discharged. His life had been saved.
"This is the team after a long day of operating, dealing with different kinds of injuries. We sat down, I think it was almost 8 O'clock in the evening to break our fast after a long day of operating - I think 12 or 13 hours of operating".
"When everything had calmed down, especially at night, we used to give teachings. David gave lectures on different kinds of injuries and how to manage those injuries. David did the main teaching, and Mounir and I helped to translate".
The team did around 45 operations in Yemen. This ranged from life-saving trauma surgeries to complex reconstructive surgeries.
They returned home to the UK ready to deploy again as soon as possible, to wherever they are needed.
The mission itself was organised and conducted by Syria Relief. Head to their website (https://syriarelief.org.uk/about-us/) to learn more about them.
BBC Radio 4 Today Programme
Following our September STAE Course, David Nott and one of the Libyan surgeons we trained were featured on the BBC Radio 4 Today Programme with Mishal Husain. Referred to as 'Sara' to protect her identity, this surgeon spoke to David and Mishal of how she, and other doctors working on the front lines of conflict, are often placed in situations for which they are ill-equipped.
When the Libyan Uprising began in 2011, Sara was a fourth year medical student. Many of the experienced nurses and doctors had left the hospital at this time, leaving the junior doctors and medics to take on everything. Often finding herself alone in the emergency department, Sara was confronted with hundreds of casualties each day.
The STAE Course (Surgical Training for Austere Environments) was set up by David Nott in 2013 to train surgeons, like Sara, to work in austere and hostile environments, where there are often drastic shortages of medical supplies and resources.
During the course, Sara learnt that "you can manage and do operations without much equipment” and in the future, she hopes to take her expertise to field hospitals, because "that's where they really need me."
You can listen to the full story here - skip to 2 hours 40 minutes!
David Nott named as one of the BA 100
We are very proud to share that David has been named as one of the BA 100, a list that celebrates the top one hundred makers of Modern Britain. Curated by British Airways to commemorate their landmark centenary year, those featured represent the best of business, environment, fashion, film and entertainment, food and drink, music, art and design, philanthropy, science and technology, and sport.
The BA 100, which also includes Olivia Coleman, Dame Jane Goodall, Mary Berry and the entire England Rugby team, celebrates the inspirational people who have contributed towards making Britain the creative, open-minded and welcoming place that it is today.
We are delighted that David has been selected and that the work of the David Nott Foundation has been recognised.
You can read more about the BA 100 here.
