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.
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.
April 2021 Newsletter: 10 Years of Conflict in Syria
10 Years of Conflict in Syria
Welcome to the David Nott Foundation’s April update. To those observing, we hope that you had a restful Easter and were able to come together with loved ones to celebrate. Today, we at the Foundation have been profoundly saddened by the new that His Royal Highness The Prince Philip has passed away. We wish to express our deepest condolences to Her Majesty The Queen, and the Royal Family. It has now been ten years since the civil war erupted in Syria. The price paid over the last terrible decade by Syrian civilians is incalculable, and millions still reside in vulnerable, crowded camps. Children have lost schools, friends and family members. So many thousands have lost their homes, businesses and loved ones. Hospitals, deliberately targeted by the Syrian regime now struggle to cope with the COVID-19 pandemic. As a show of solidarity with the Syrian people, the David Nott Foundation dedicated our social media accounts to small NGOs, individuals, civilians, humanitarians and journalists who have lived experience of the civil war. We hoped to provide a platform through which to amplify these voices. We encourage you to look back through our Tweets and Re-Tweets (@NottFoundation) to read first-hand accounts of the atrocities and reflect on the profound loss that we all feel after ten years of conflict. The David Nott Foundation has taken our HEST course to Syrian surgeons before, and plans to again soon. You can view an interactive map of where we have taken our training course by visiting the ‘Overseas Course’ section of our website. Good luck to our RPHM RunnersWhile we’re on the subject of challenge running events, the Foundation would like to wish good luck to our Royal Parks Virtual Half Marathon runners for the 11th of April. We asked some of those competing to raise money for the DNF what inspired them to do so:
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Cycling across Europe!
Beginning on 1st September, a group of friends from the USA and the UK, will be taking on the “challenge and opportunity of a lifetime” to raise funds for the David Nott Foundation and STAR, Inc.
Led by Tony Williams and Tom Nero, the team had planned to cycle Route 20, the longest road in the US, starting in Massachusetts on the east coast and finishing in Oregon on the west. However, due to Covid-19 movement restrictions being imposed in various states, the itinerary had to be rearranged and the team are now circum-cycling Italy.
The route will take the team from Milan, anti-clockwise around Italy. The distance is over 2,000 miles with 19 miles of ascent, making it the toughest challenge event taken on for the DNF so far!
The team have set an ambitious target of $250,000 to match the extraordinary scale of this challenge.
As they prepare for “Over 3,000 miles of saddle soreness,” Tony is proud to announce, “With only two months to go till we start our cycle ride, I am very excited that we now have pledges and donations exceeding $157,000 (split almost equally between the US and the UK charities). This is HUGE and a true reflection of the worthy causes we are supporting. A $50,000 challenge gift will match future donations up to that amount.”
We are completely bowled over by their support and cannot wait to update you on their journey across Europe. The team have also set up their own website dedicated to bringing you the latest news on their once-in-a-lifetime trip. Check it out by clicking here.
If you're feeling inspired, please get in touch with your own fundraising challenges - we love to hear from you!
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.
War Doctor Heroes: Meet Dr Ayman
Meet Dr Mohammed Ayman, a Syrian vascular surgeon and our latest War Doctor Hero.
We first met Ayman back in 2013, when David Nott was volunteering in Alzarour Hospital, Aleppo. Whilst treating patients, David was able to teach Ayman and his team a variety of specialised surgical procedures that Ayman was later able to use to save casualties.
At this time, medical workers and facilities were a target. As Ayman put it, "the hospitals in Aleppo were a kind of magnet for attacks.”
It was too dangerous to go outside as barrel bombs and missiles could fall at any time so Dr Ayman and his colleagues had to work, sleep and eat in their underground hospital.
The heavy siege also meant resources were always in short supply. They lacked the right sutures to stitch up patients and there wasn’t enough food and milk to feed malnourished children. Nonetheless, Dr Ayman did what he could to take care of his patients. “All the Syrian people in Aleppo needed us, so we had to be stronger for them and we had to adapt to the new situation as best we could. We wanted them to always feel that they were not alone.”
One patient that Ayman especially remembers was an 11 month old baby girl. Her father carried her to the hospital after she was wounded in a bomb explosion. She had a severe leg wound and the orthopaedic surgeon wanted to perform an amputation. Fortunately, Dr Ayman knew there was a chance her leg could be saved. He successfully performed a vein bypass to restore the blood supply and later her leg was externally fixated so that the bone could heal properly.
To Ayman’s immense happiness, the little girl recently started walking.
Ayman is one of fourteen surgeons who will be joining us for our next UK-based training course. He hopes that the skills learnt on this course will enable him to better serve the Syrian people when he is able to return to his home country.
You can read about some of our other War Doctor Heroes by clicking here.
War Doctor Heroes: Meet Dr Koma
We are delighted to feature Dr Koma Akim, a general surgeon from South Sudan, as our latest War Doctor Hero.
South Sudan is the world's youngest sovereign state, having gained its independence from Sudan in 2011.
Since December 2013, the country has been embroiled in a civil war that has resulted in the displacement of more than 4 million people, and contributed to the endemic poverty that affects 80% of the population. Conflict between nomadic people, particularly over the issues of cattle and grazing rights, has compounded the violence, yet health resources and medical professionals remain scarce.
Dr Akim is one of only a handful of general surgeons in the country, and regularly deals with gunshot and arrow wounds as a result of cattle rustling. Those who make it to his hospital are often in a very bad way, suffering from internal bleeding and broken bones. Without any advanced orthopaedic instruments, Koma must often treat these fractures non-operatively, even though his patients would benefit from external fixators or skeletal traction.
Alongside his work in the district hospital, Dr Akim has also undertaken humanitarian missions in Ganyiel, in the Unity State of South Sudan. Koma recalled performing an emergency C-section for a retained second twin in the midst of the fighting here. In spite of the high maternal mortality associated with this complication, Dr Akim was miraculously able to save the lives of both the mother and her two babies.
These experiences motivated Koma to learn more and enhance his skill set, so that he could continue to alleviate the suffering of ordinary people in his country.
In 2019, Dr Akim attended our London based Surgical Training for the Austere Environment course (STAE). On this training programme, he learnt how to properly expose blood vessels and said “being able to practise it means I have the confidence to do it in a real situation. If I can do it, I can teach it.” This skills-sharing is a vital part of what we as a Foundation hope to achieve. By training one doctor on our course, we give them the knowledge and skills needed to teach countless more.
It is Koma's ambition to become a role model for the next generation of South Sudanese doctors. He hopes to inspire more to become surgeons in order to better serve the people of war torn South Sudan and told us that "my skills and theirs will be more needed here, in South Sudan, than anywhere else in the world."
To help us train more surgeons like Koma, you can make a donation here.
Yemen HEST January 2020
The DNF team, in partnership with MSF Spain, recently returned from our latest mission to Yemen which brought in 31 surgeons from across the country for a specialised five-day training course. Since 2015, Yemen has been the stage of one of the world's worst humanitarian catastrophes. Hundreds of thousands of Yemeni citizens have already lost their lives, and as the fighting continues, many more are in need of urgent medical treatment and supplies. At the front-lines of this conflict are the surgeons and medics who face the challenge of saving lives without losing their own, all the while limited by a lack of resources and insufficient training.
Our Hostile Environment Surgical Training course (HEST) was designed to confront this problem. Over the course of five days, our Faculty, comprising David Nott, Ammar Darwish, Pippa Letchworth, Pete Mathew and Rebekka Troller instructed surgeons on a wide range of trauma topics. By equipping these medics with the necessary knowledge, confidence and skills that they need to treat patients, we can improve the medical outcome for countless people.
The regions where HEST is taught often rule out cadaveric teaching, so the Foundation’s whole body simulator, Heston, was employed for training. This state of the art, bespoke simulator mimics the look and feel of real human flesh and features the full range of organs, blood vessels and key anatomies needed for facilitating learning.
Supporting Heston, we also deployed our neonatal models and our new VR learning experience, which simulates a mass casualty event. This immersive experience focuses on the triage of ten patients using International Committee of the Red Cross categories: serious wounds, second priority, superficial wounds and severe wounds.
To date, the Foundation has trained 803 medics across 28 courses, benefiting an estimated 1.7 million patients. Through this global network of war doctors, we can raise the standard of medical care worldwide and continue to save more lives and limbs. To help us train even more surgeons, you can donate here.