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 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.”
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.
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.
DigiHEST: How we reached 29 countries in two days.
In December, 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 Nott 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.
COVID-19 has changed the way that we are able to deliver our training courses in 2020/21. The DigiHEST pilot study is extremely encouraging to our team as it shows that not only can we continue to deliver a high quality training product, but the use of live-streaming technology has implications for the future democratisation of surgical training for the austere environment. Our aim is to get back on the road and delivering face-to-face courses around the world again as soon as possible, but the hard work that has gone into piloting the concept of DigiHEST will inform how we can best deliver training in the future.
War Doctor Heroes: Meet Dr Marah
Dr Marah, a medical student from Homs, Syria knows that no matter how young a physician is, they should always be updated with the best skills and practices.
The shortage of medical staff, surgical equipment and training programmes are significant barriers to quality healthcare in her region, and these problems are worsened by a poor socioeconomic situation.
After studying medicine for only two years, Marah assisted in a Mastectomy operation on a fifty-year-old woman. Owing to the anaesthetist’s lack of experience, the patient was not under good anaesthesia and experienced a great deal of pain during the procedure. Although Marah was very anxious, she looked after the patient and decided that surgery was what she wanted to do for the rest of her life.
In 2019, we invited Marah to attend our overseas HEST course in Lebanon where she was taught how to perform many complex surgical procedures and was able to build up her confidence. She told us that the training course inspired her to “use every source of power I have to help the patients and that no matter how hard the situation is we should always remember that patients must be our first priority.”
Marah hopes her country finds peace soon and believes that by working together and supporting each other, her people can improve their future. We are confident that Marah will make a brilliant surgeon and we are proud to be supporting her on this journey.
Taking our Training Online
To do what we can for our surgeons, we have launched a fortnightly webinar series led by David Nott and our faculty. During these sessions, we invite medics from low-resource settings to present their surgical cases to each other and to our training faculty so that they can share experience and advice.
We’ve also launched a COVID-specific webinar series which aims to provide any information, support and advice that we can to surgeons, particularly around how to look after their own safety when operating on COVID-positive or unknown patients. David has brought on UK-based intensivists and anaesthetists to help with this and we are pleased to have opened it up to medics beyond our list of surgeons.
These online sessions have been very well received by the doctors. Lucien Wasingya, who we trained on a UK-based course back in 2018, said: "With advice from David and others from across the world on this webinar, I hope we can improve protection for our surgical teams and continue to provide surgery for those that absolutely need it."
We plan for these webinars to endure beyond this pandemic as an excellent way of supporting surgeons and keeping in touch with them.