The anaesthetist in a war zone
It takes a team to save a life in a war zone. Recognising the vital need for anaesthetists in conflict, we developed a bespoke anaesthesia course, to prepare anaesthetists for working in war hospitals. One of our experienced trainers, Dr Hussein Nagi, recently taught anaesthetists from Kuwait who are heading to Palestine.
Managing pain in different ways
“Treatment and anaesthesia do not end in the operative theatre. In a war zone, you could have a whole ward of people with post-operative pain, for example after amputations. Anaesthetists must do what they can with what they have to continue their care," shared Dr Nagi in Kuwait.
"A colleague once shared that a boy was screaming in the night with phantom limb pain after getting an amputation, he was shouting ‘my toe is hurting’. His toes were not there.
They found a stock of epidural kits in their hospital (for maternal care) and gave it to him through a catheter – the boy was almost pain free. You can resolve severe pain, by nerve blocking, with a range of drugs. You just need to be able to adapt to your environment.”
Our course teachers share tips and tricks just like this, with the goal of making anaesthetists adaptable to the challenges of a conflict-affected environment.
The science behind war
A trainee from Kuwait, during our latest HEST-A course in the Middle East, shared: “The trainers were combining their war experience with theoretical teaching, which added a lot to the course – showing us what to expect.
There were three main sessions that I learned the most from. Damage control, the ballistics science behind bullets and bombs, and the chemical weapons session. They’re not taught during medical training so knowing more about them, how to deal with these situations, understanding the science to then anticipate what we may meet in A and E, was the highlight of the course.”
Triage is critical
“It was an impressive course. The most interesting part for me was the triage, and making decisions using the information we have learned over years in studies, but applying it to a conflict zone.
"You have to adjust and accommodate to different situations, especially areas where you don’t have all the resources."
Gaza today urgently needs resources, food, water, equipment and man power. From what we hear from doctors on the ground, medical resources are much needed. It is very desperate.”
We have trained over 80 surgeons and anaesthetist in the UK and Kuwait who have, or intend to, volunteer their skills in Palestine's frontline hospitals. We will continue to upskill doctors in support of the people of Gaza.
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Preparing 36 Kuwaiti doctors for surgery in Gaza
With support from the Foreign Common Development Office (FCDO) and Kuwaiti Red Crescent Society (KRCS), we upskilled 24 Kuwaiti surgeons and 12 anaesthetists who intend to volunteer as humanitarians in Gaza. This marks our first direct partnership with the UK government.
Faculty Lead: Dr Ammar Darwish. Surgical Faculty: Dr Mahmoud Hariri, Professor Steven Mahoney, Dr Saladin Sawan, Dr Juan Robinson. Anaesthesia Faculty: Professor Pete Mahoney, Dr Oliver Harrison and Dr Hussein Nagi.
Kuwait is home to over 4.2 million people. Sandwiched between Iraq and Saudi Arabia, Kuwait is a small but influential country in the Middle East. As the war continues to wage in Gaza, a number of Kuwaiti doctors have plans to volunteer their skills on the frontline. Upon invitation from the FCDO and KRCS, we were pleased to upskill 36 doctors and prepare them for complex trauma injuries.
Our Co-Founder, Elly Nott, said:
“Recognised by the UN as a Humanitarian Center and embodying the values of charity and humanity, Kuwait is a natural partner for the David Nott Foundation. During this mission, we trained 24 surgeons and 12 anaesthetists in partnership with the Kuwaiti Red Crescent Society and the British Embassy, Kuwait.
The doctors have been trained in surgical skills essential for saving life and limb and will contribute to relief campaigns and humanitarian initiatives in the region. There is sadly no end of need for their skills in the world at present and we look forward to further collaboration with our colleagues here in Kuwait for the benefit of those who suffer in conflict.”
The skills required by doctors in Gaza at this time extend far beyond surgery. Being calm in a crisis, able to adjust to the needs of the patient in front of you and adapt to the hospital’s resources – or lack of - are absolutely vital. Doctors and anaesthetists that rely on innovative surgical tools or drugs will only have so much impact in active war zones.
Consultant Anaesthetist and DNF Faculty Trainer, Professor Pete Mahoney, said:
“In conflict zones, there may not be reliable electricity, water or access to medical gases such as piped or cylinder oxygen. You need to be able to pivot and use something called ‘draw-over’ anaesthesia to deliver suitable medication. This is when the use of simple masks or a bag can be used to pull volatile agents (anaesthetic medications) into the patient’s body.
We also taught the Kuwaiti doctors how a simple anaesthesia machine can be constructed from components as they may need to build one in the field with whatever the hospital has. It is critical that humanitarian doctors are able to adapt.”
We know from our Faculty Lead in Palestine that doctors on the ground don’t always have the time or available tools to fix bones together with metal pins. To give doctors other options that require less equipment, we taught Kuwaiti doctors how to set bones with plaster casts, which can help breaks to heal in the absence of pins.
The British Ambassador to Kuwait, Mrs Belinda Lewis, said:
“The fact the UK government’s first partnership with the amazing David Nott Foundation took place in Kuwait is testament to the strong and productive relationship between our two countries. This combination of British and Kuwaiti expertise will undoubtedly support the medical response to the dreadful suffering in Gaza.
I am grateful for the assistance of a number of people in Kuwait who have helped me to bring in this expert team from the UK, and I would like to pay special thanks to Professor Ghassan Abu Sittar, veteran war surgeon and humanitarian, who first suggested this valuable partnership to me.”
President of the Kuwaiti Red Crescent Society and former Minister for Health in Kuwait, Dr Hilal Al Sayer, said:
"On behalf of the Kuwait Red Crescent Society, I extend my appreciation to the British Embassy for their facilitation of the training course throughout this process. I also extend our sincerest gratitude to the David Nott Foundation for their invaluable expertise. Their guidance has empowered our esteemed consultants with the skills needed to navigate the complexities of emergency medical care as volunteer medics in conflict zones whose dedication serves as a testament to the spirit of humanity that defines our National Society.
Last, but certainly not least, I extend my heartfelt thanks to the National Bank of Kuwait for their generous support, we are truly grateful for their partnership.
I am immensely proud of the collaboration that has characterized our time together and am confident that we will carry forward the lessons learned in our shared mission to serve humanity with compassion and expertise."
Until we can support and upskill doctors on the ground in Gaza, we will continue to do all we can from a distance. The delivery of our surgical and new anaesthesia courses to Kuwaiti doctors who intend to enter Palestine as humanitarian volunteers, forms part of our unwavering commitment to the ongoing crisis.
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103 surgical life savers in Tripoli, Libya
We’re back from a week in the Libyan city of Tripoli after completing a first-in-our-history mission. We upskilled 103 doctors – the largest number trained on one mission – and trialled our brand-new obstetrics and gynaecology course.
Libya’s history is marked by political turmoil and civil unrest. The uprising against the rule of Gaddafi led to brutal violence against Libyan civilians and instability across the country. Today, 13 years after the ruler’s death, conflict between armed groups continues and Libya’s security remains fragile.
Outside of politics, Libya has been devastated by natural disaster. In September of 2023, heavy rain caused the collapse of two dams, leading to horrific damage and the loss of thousands of lives. Wounds inflicted by violence or natural disasters often require rapid surgical care, with a need to focus on controlling the worst of the damage first.
Surgical toolkit for any crisis
In a bid to empower Libyan doctors with skills to treat wounds caused by war or natural disaster, we partnered with the Libyan Board of Medical Specialties to deliver four surgical training courses in parallel. Over five intense days, our team of expert trainers delivered two trauma surgery courses, two anaesthesia courses and a brand-new obstetrics and gynaecology course.
According to a 2023 UN agency report, a woman dies from pregnancy or childbirth every two minutes. During conflict, women are less likely to seek maternal care and hospitals are under-staffed or under-resourced. That's why our trainers created a bespoke obstetrics and gynaecology course to help doctors better protect mothers and their babies in war and catastrophe.
During the week, we trained 103 doctors. Doctors we’d previously upskilled in Libya also joined our training faculty and led the teaching of a number of our modules for the first time. Dr Aisha Alghamji was one of them.
It really was paralysing
Dr Alghamji shared: “I remember I have a case of a 70-year-old lady. We found there was a huge bleed in her tummy. Most of her blood is – in minutes – almost drained out. It really was paralysing – what to do? She doesn’t have that much time.
"That lack of knowledge paralysed me. She is a living, human being – with dreams, hopes, a whole community. She is part of it. It keeps haunting you, that feeling. What I could do differently?"
She lost her life.
After 2018 when I attended the course with the Foundation, there is something shifted in my way of thinking. It did that thing for me, that confidence the surgeon needs to do more than their best – to run the extra mile for the patient.
I faced another case similar to it (this lady). I told immediately to me brain – ‘damage control! Damage control!’. I was able to send her home. She is alive, she is a grandmother, she is everything.”
A resilient healthcare system
Dr Moez Zeiton, Consultant Orthopaedic Surgeon and our Faculty Lead for Libya, said: “It is a privilege to have had the opportunity to lead the single most ambitious series of courses for the foundation, training over 100 doctors in a week. It was a huge effort from the foundation’s team and superb faculty to get over the line.
Candidates in Libya travelled from every part of the country with many travelling over 1000km to participate in our surgical training. Their eagerness to learn and share their own experiences was evident and they will now be equipped with the skills needed to deliver high quality care to their patients. "
This marks the beginning of continued training in Libya and a commitment to gifting doctors with extensive trauma skills to handle any challenge.
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Our second mission for Palestine's medical workforce
In the ongoing Israel-Gaza conflict, tens of thousands have lost their lives and hundreds of thousands are now displaced. Hundreds of casualties have been reported in the West Bank. Our commitment to supporting affected communities continues and we will do all we can until we reach doctors on the ground.
Despite recent escalation, Palestine has been engulfed by conflict for decades. Recognising a need for upskilled doctors, we first delivered a Hostile Environment Surgical Training (HEST) course in Ramallah in March 2017 and another in 2022 in collaboration with Juzoor. We also taught Palestinian surgeons on our latest UK Train the Trainers course, giving them the skills needed to teach their own peers.
“I love Ramallah. But we don’t have control of our borders,” shared Dr Salwa Najjab, Co-Founder and Chairwoman at Juzoor in 2022.
“We are living in a big prison. Our people should be exposed to the world. We are very happy and thankful to the David Nott Foundation, to come and see what we are doing, to understand our situation and see it in their eyes.”
Following the resounding success of our Hostile Environment Surgical Training (HEST)-UK course for doctors heading to Palestine, we once again joined forces with Palmed to train another group who intend to offer their skills on the frontline.
At Bolton University, we taught six anaesthetists and 31 surgeons from the UK, Germany, Ireland, Denmark, and Norway. The doctors share a common passion for using their hands to help those affected by the aggression on Gaza.
Dr Israar Haq, a general surgeon who joined our course shared, "If you have any grain of humanity in your heart, you want to help."
BBC spotlight
BBC-Northwest took notice of our efforts and joined our training. They spoke with experienced surgical trainer, Dr Rebekka Troller, who shared: "The aim is to give the doctors the skills to do damage control, save lives, be the first to respond, and stabilise a patient before they can be transferred."
Our presence at Bolton University also attracted attention from university professors, medical students and doctors. They explored our world-class teaching models and extended a warm welcome to our team in appreciation of our commitment to war doctors.
Our latest course for Palestine reaffirms our unwavering commitment to helping communities facing the horrors of war. We remain steadfast in our mission to empower medical heroes and make a lasting impact on the lives of those in need.
Addressing healthcare challenges in Moldova
In the wake of the escalating conflict in Ukraine, Moldova, a neighbouring country, is grappling with the concern of being somehow drawn into the war. To extend support during these challenging times, the David Nott Foundation, in collaboration with the World Health Organisation, conducted two specialised Hostile Environment Surgical Training-Anaesthesia courses in Moldova.
The refugee influx and healthcare strain
Since Russia's invasion of Ukraine, Moldova has witnessed an influx of over 700,000 refugees seeking peace and safety by passing through its borders. Recognising the strain these precipitates to available healthcare resources, the Foundation has provided ongoing support over four courses since January 2023.
The anaesthesia (HEST-A) courses, conducted from December 11th to 16th, aimed to up skill 25 anaesthetists to better handle healthcare challenges arising from the crisis. The training spanned six days, with the first three days conducted in English and the subsequent three days in Moldovan.
Participants expressed satisfaction with the course structure, emphasising the benefit of discussions and supervised practical activity over a lecture-heavy approach. As the anaesthetists underwent training, they raised concerns about resource availability and hospital capacity in the face of refugee movements. In response, our highly skilled teaching faculty offered valuable advice and information.
Innovative training models
The courses saw three UK-based faculty members delivering in-person sessions, with an additional faculty member, the Foundation’s lead consultant for anaesthesia, delivering a virtual training session on chemical weapons.
The David Nott Foundation's HEST-A course in Moldova not only aimed to enhance the skills of healthcare professionals but also addressed specific challenges posed by the Ukraine crisis. By fostering collaboration with WHO and adapting the course content to local needs, the Foundation continues its mission of providing essential medical training in conflict zones to save lives and alleviate human suffering.
“There is nothing more heart-warming, more fulfilling, than seeing the impact of our work through the stories of those we teach. To see that connection brought to life is truly a testament to our mission.” - Hannah Graham-Brown, Programmes Officer at The David Nott Foundation
80 surgeons and anaesthetists upskilled in Kyiv, Ukraine
Our new Chief Operating Officer, Tim Law, recently returned from his first mission. Tim supported our trainers to deliver two surgical training courses in Kyiv. With logistical support from our partner World Health Organisation (WHO), 80 surgeons and anaesthetists from frontline cities learned how to treat mass trauma injuries using world-leading surgical teaching models.
To continue upskilling Ukraine’s frontline doctors, our team embarked on the challenging journey to Kyiv, first flying into Poland and travelling by bus to our final training location two days later. Despite a temporary bus breakdown in scorching heat and consequent concerns about entering Lviv before curfew, our trainers arrived safely in Kyiv and began preparing teaching materials, tools and models for the arrival of more than 80 Ukrainian doctors.
Over six days, our faculty of trainers delivered two condensed hostile environment surgical training (HEST) courses, rich in trauma surgery teachings and practical sessions.
This year, we expanded our course to include anaesthetics – a vital component of trauma surgery care. During this mission, two new faculty trainers, Dr Ian Tyrrell-Marsh and Dr Tom Dolphin, led our anaesthetics module and upskilled 22 anaesthetists from across Ukraine.
Doctors united in learning
Although united by a shared desire to manage catastrophic injuries, attendees came to our training from different Ukrainian cities.
Tim Law, our COO at the Foundation, shared: “Participation in the course was designed such that about two thirds of doctors came from front-facing oblasts or provinces. They came from Zaporizhizhia, Dnipro, Kyiv and beyond. Most of them were based in civilian hospitals.
A lot of their cities are subjected to bombardment on a reasonably regular basis. As we’re still seeing in the news, attacks lead to casualties of war, some of which are military, but many are everyday people.
Often civilian hospitals treat both civilian and military casualties, as many frontline fighters are transferred from military hospitals to make space for the next round of injured.”
Unrivalled education
Witnessing my first surgical training course in action – there is no doubt it is world-leading education.
"It was fascinating to be able to see the real value that the David Nott Foundation can add to the skills of medical professionals forced by circumstance to react to the challenges presented by armed conflict. It’s world-class education delivered by seasoned practitioners, and based on years of accumulation of course materials and conflict-specific skills.
The combination of experience within the training faculty, course material quality and the practical sessions with Heston, our human body war wound simulator, enables demonstrations that otherwise aren’t possible in Ukraine,” continued Tim.
Cadavers cannot be used for teaching in Ukraine, and our war wound model has been described by surgeons as even more effective than cadaver training.
Some shared that they’ve never had access to such state-of-the-art materials and were excited to be able to take our hand-made silicone hearts back to their hospitals to continue their practice of cardiac suture repair.
Remnants of war
Although the likelihood of active conflict in Kyiv has lessened, remnants of war can be seen in and around the city. Air raids are a common backdrop, often ignored by locals as they try to continue with their everyday lives.
On the road from Lviv into Kyiv, you can see signs of Ukrainian defence. Minefield markings, skull and cross bone signs and string between trees signpost dangerous land.
On the anniversary of Ukraine’s independence, approximately 40 Russian military vehicles had been lined up along the main street. A sign that although life goes on in Kyiv, national pride and the community’s acknowledgement of their country’s continued battle remains.
“We aim to continue to develop this world-class training, such that we can continue to deliver training in the world’s most challenging environments, enabling medical professionals to enhance their skills whilst remaining close to where they are most needed", shared Tim.
"We will develop our offering to include new modules on hospital management and surgical nursing and are in the process of building a second synthetic full-body simulator and of increasing the scale of our teaching faculty. Taken together, this should enable us to increase the scale, scope and quality of our future interventions. Thank you to our supporters for helping to make these dreams a reality.”
“As soon as Russia invaded, we started seeing the wounded”
After troops crossed Ukraine’s borders in March 2022, Igor Belkin, a surgeon from Zaporizhzhia, watched our translated war surgery videos in a bid to better treat devastating wounds inflicted by the war. Last month, Igor furthered his skills and training during our latest HEST course in Ukraine.
Faculty Trainers in Zaporizhzhia and Lviv: Professor David Nott, Dr Pete Mathew, Dr Ammar Darwish, Dr Rachael Craven, Dr Ian Nesbitt.
“On the night of the 7th of May, the first attack on our hospital took place. Hospital walls and communications were damaged,” shared Igor. “After that, the shelling of Orikhov became even more intense. The hospital was shelled again later in May, which led to it being evacuated.”
Igor was forced to transfer to a military hospital in the field to continue treating the injured. Right from the beginning of the war, he and his team were faced with severe trauma injuries - many of which they had never seen before. Patients with internal and external damage caused by blasts, penetrating wounds and severe burns were entering their doors for the first time.
“I decided I needed to study combat trauma. A medical colleague told me about videos made by Professor David Nott.”
Armed with life-saving tools
Just days after Russia’s invasion, we ran a 12-hour surgical training course on zoom with former consultant neurosurgeon and author, Dr Henry Marsh. Together, David and Henry trained 573 Ukrainian surgeons, giving them surgical techniques, tools and tips for treating a range of traumatic war wounds. It was only when David lost his voice 12 hours in that the training stopped.
As attention started to mount around our online training, we created a series of surgical training videos in a bid to reach even more doctors in need of life-saving skills.
“It (the video series) was very informative, clear and concise. In just a few hours of viewing I grasped the main fields of trauma medicine - damage control and important techniques for cardiovascular surgery.”
Upskilling 114 Ukrainian doctors
Last month, David and a team of our trainers travelled to Zaporizhzhia and Lviv to deliver our HEST course. 114 doctors and anaesthetists were empowered with the knowledge needed to treat neurological, plastics, vascular, cardiothoracic, paediatric, orthopaedic and abdominal trauma cases – creating a powerful network of multi-skilled surgeons.
“I was very pleased to attend this course and meet David personally. I got very concise, practical information and was able to practice my skills and learn how to provide assistance in areas of medicine I don’t specialise in.
I’m grateful to David, his entire team, and the foundation for sharing their great experience and imparting their knowledge of medicine in war zones”
Before the course, I used to use a technique called a lateral thoracotomy which involves turning the wounded onto their side (entering the chest from the side). Given the fact that chest injuries can make patients very unstable, this sort of movement could worsen conditions.
Now, I only do thoracotomies while patients are on their backs. This is a far better method for both surgeons and anaesthetists to approach trauma injuries.
I also learned how to use external fixations to secure bones and now perform fasciotomies on patients needing urgent pressure release in the limbs.
This sort of knowledge, acquired from experienced frontline doctors like David and the team, will help me and my fellow Ukrainian doctors save more lives.”
We’re committed to training and instilling confidence in Ukraine’s doctors until the war is over.
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Training anaesthetists in war zones
Dr Elma Wong is a consultant anaesthetist in Worcestershire Acute Hospitals NHS Trust. For the past ten years, Elma has taken several months of unpaid leave to volunteer in conflict zones each year. Elma and a small team of faculty recently returned from training 71 doctors in the Ukrainian cities of Poltava and Zhytomyr. Here, she reflects on her experience after delivering our first-ever anaesthetics HEST course module alongside Dr Rachael Craven.
After a decade of volunteering in war zones, Elma knows all too well how important education is. When she heard we were looking to deepen our impact by upskilling anaesthetists in conflict zones, Elma jumped at the chance to get involved.
“I’m interested in building up local workforces, making communities in conflict more sustainable. It’s about the longevity of the impact you want to have in a place.
The biggest gift you can give to a healthcare worker in a conflict zone is self-sufficiency – the dignity to be able to do everything themselves. It’s important to empower people to look after their own patients. A job well done is ultimately making yourself redundant.”
Training anaesthetists in war zones
“I first heard of the Foundation after reading War Doctor. As a fellow humanitarian, I could relate to David’s experiences. When I heard the Foundation wanted to develop an anaesthetics training module, it felt like a great fit for me.”
In October, Elma, David and a small team of trainers travelled to Poltava and Zhytomyr to deliver two HEST courses – Elma’s first time in Ukraine since the war began.
The team flew to Warsaw and with the support of our partner, UOSSM International, crossed the border before driving for most of the day to eastern Ukraine.
“During our first course in Poltava, there was a lot of unknown. We designed the module ourselves but didn’t know exactly who we’d be training or how it would be received.
In the end, we trained around 10 anaesthetists in Poltava and 12 in Zhytomyr and it was wonderful - I think they found it refreshing to have dedicated trauma training with practical advice. They were really excited to handle different kit and learn new techniques.”
Adapting in conflict
When it comes to war anaesthetics, there are two main considerations. Firstly, the injuries anaesthetists face in war are starkly different to cases seen in the west.
“Blast injuries from explosives are devastating to the body. Patients can have multiple life-threatening injuries and lose so much blood. The priority is stabilising the situation and giving blood.
We taught specific techniques for giving drugs and blood via the bone (intra-osseous), for when you can’t find a blood vessel. Many had not used this life-saving equipment and really benefited from learning this skill.
Many of these cases would need care on the intensive care unit - supporting patients with complicated head and lung injuries on our breathing machines and giving dialysis therapy to people with kidney failure as a result of crushing injuries.”
The other consideration in a war setting is reduced resources. Hospitals may be faced with electricity cuts or low oxygen supplies.
“We trained the groups on alternative anaesthesia machines - very different to ones we use in our hospitals here. They are portable enough to fit into a bag or small case and they can be life-saving in critical conditions - when you don’t have electricity or oxygen yet need to perform emergency operations.”
Teaching the group how to use basic machinery, available in most hospitals, will help them continue to save lives despite slashed resources.
“The rest of the world hasn’t forgotten you”
“Often, I think when you are stuck and living within conflicts, you feel the rest of the world has forgotten you.
But seeing people travel far distances to come and help, standing in solidarity with them, I hope shows them some humanity."
Contemplation on safe ground
“It can be challenging dealing with the trauma of what you experience on missions. Often its worse when you get back home and have time to process things, devastating things you’ve seen.
The more missions I’ve done, the more I realise the importance of looking after yourself. Finding time to have breaks, even on busy missions. In Yemen, we were working and living in the hospital. Each day around 5pm I would try and go to the roof for 10 minutes to take in some fresh air, watch the sunset, whilst listening to the atmospheric call for prayer from the nearby mosques. It was time just for me.
The important thing is to be kind to yourself - and ask for help when you need it.
When reflecting on my time in Ukraine, it’s difficult to know quite how to describe how I feel. ‘Privileged’ comes to mind – for being able to work hand in hand with people on the ground and support them as best I can.”
More on our training in Ukraine
Photographer: Annabel Moeller