Orthopaedic surgeon Dr Thomas Schaefer, from Albany in Western Australia, recently returned from his second field placement to Gaza, Palestine, with Médecins Sans Frontières (MSF). As the number of Palestinians injured by live ammunition since March 2018 reaches 7,500 at the time of writing, he reflects on the progress teams have made in caring for young patients needing long term treatment for severe gunshot wounds and multi-drug resistant infections
I first worked in Gaza in January and February 2019, treating people who had been shot and injured by the Israeli army during demonstrations at the fence that separates the blockaded enclave from Israel.
The injuries I saw on patients in Gaza were, from an orthopaedic point of view, horrendous. The majority were gunshot wounds, mainly to the lower legs – which means a lot of people who are maimed and can’t walk.
I was shocked by the ages of the patients: most were young men between 18 and 30 years of age. We witnessed gunshot injuries in boys as young as 11 years old.
The demonstrations at the fence, still ongoing and occurring every Friday, would result in new patients each week. During January and February, our MSF teams were seeing around 20 new patients weekly with wounds from live ammunition.
Meanwhile, the local Ministry of Health was – and still is – inundated with new patients each week, with injuries caused by exploding tear gas cylinders or rubber bullets, as well as inhalation injuries from smoke. These patients add to the regular load of healthcare for 1.8 million people.
When I first arrived in Gaza, I was horrified to see patients in our clinics who had been injured up to 10 months before, when the demonstrations first started. These patients sometimes still had open fractures, soft tissue defects open to the bone and severe infections.
The local health system in Gaza is simply overwhelmed and flooded with people who need treatment. I compare it to my home, Western Australia, where in Perth you have 1.8 million people and four to five major hospitals.
If we had 10 to 20 people coming to our Perth hospitals each week with open fractures needing long term treatment, we would very quickly be overwhelmed too. So it’s not a lack of willingness or expertise on the ground in Gaza; it’s really just that the facilities are running out of resources.
Right now, it remains very difficult to refer any patients for treatment outside of Gaza. And still, every Friday, there is a fresh group of people who are shot and injured and need urgent care.
“If in Western Australia we had, every week, 10 to 20 people with open fractures needing long term treatment, we would very quickly be overwhelmed too.”
Gunshot wounds prone to infection
On my first assignment in Gaza, the patients we were receiving could be grouped into categories, or ‘waves’.
The first wave of patients would arrive at a local hospital after being shot. The bullets tend to create an extensive damage zone to the leg on the exit side, with large bone and soft tissue defects, and most people have open fractures where the broken bone is not covered by any soft tissue.
These injuries are a challenge to treat. When patients arrived at the local hospital after being shot, they would be provided with initial treatment which consists of stabilising their fracture and cleaning the wound tissue. Unfortunately, patients were often discharged after this, and we faced a lot of challenges in reaching them for further care – sometimes only seeing them two to four weeks after they had been shot.
Gunshot wounds by their nature are prone to infection, and coupled with the lack of hygiene outside of the hospitals we started to see many patients arriving with infected wounds.
These patients make up a second wave, of people who have developed severe infections in the bone, also known as osteomyelitis. This condition is very difficult to treat; these patients will require months, if not years, of multiple surgeries, dressings, antibiotic treatment and physiotherapy.
What makes these cases even more frightening, is that most of these patients have an infection that is resistant to most antibiotics.
Getting a grip on osteomyelitis
Returning to Gaza in August, I saw that the situation is still critical. But the progress our teams have made is really exciting. Right now, MSF is the only provider of specialised multidisciplinary treatment for osteomyelitis in Gaza, a condition we estimate is currently affecting more than 1,000 people in the territory.
We have opened a microbiology lab with the capacity to test bone samples to identify multi-drug resistant bacteria. We also have an infectious disease specialist on site, who formulates an appropriate antibiotic treatment plan, and a plastic surgeon who provides the specialised surgery to treat the soft tissue defects. We combine this with the orthopaedic treatment plan for each patient. This multidisciplinary team approach has opened a new chapter in our care.
Most patients with multi-drug resistant infections require intravenous antibiotics, meaning they are on the ward for three to four months. To allow for this, we have two inpatient departments and are in the process of opening a third.
“Osteomyelitis is very difficult to treat: these patients will require months, if not years, of multiple surgeries, dressings, antibiotic treatment and physiotherapy.”
Our teams are currently providing care for over 600 active patients in our clinics – from dressing changes to wound care and ExFix (external fixation) adjustments, as well as an extensive physiotherapy program. The previous MSF program for treating burns, which are very common in Gaza due to open gas fires, is also continuing.
Through this combination of surgical and medical treatment (with medication), we are finally finding solutions for the long term survival of most people’s limbs.
On a personal note, it was really rewarding to see Palestinian staff, including doctors and nurses, who I had trained on my first assignment now providing quality care in our inpatient department. The other amazing thing was catching up with patients I had met at the beginning of 2019. One patient for example, who I operated on in January with muscle flap surgery to repair a large defect in his leg, has now healed and I was able to take his ExFix off.
Unfortunately our patients with osteomyelitis will always live with the risk of the condition re-flaring – I have seen it come back 20 years after the initial injury. But many are improving a lot with physiotherapy, and walking again, and that is hugely encouraging to see.
The road ahead
So what about the remaining ‘waves’? Although we are doing our best to treat people quickly, a third wave of patients will be formed by those who will unfortunately require an amputation because their legs cannot be saved.
These people will need a lot of support in order to have a prosthesis fitted. They will also need psychological support to help them adapt to the loss of their leg, to understand that it’s not the end: with a good prosthesis, they will be able to drive a car and get a job.
That’s where the fourth wave comes in: patients who will have serious and ongoing mental health needs because of what they have experienced. These injuries will have a lifelong impact on these young men and their ability to function in society – but through our health promotion and social support team, and local peer counsellors who were injured themselves, we can help our patients to deal with the immediate trauma of their situation and prepare them to make the most of their future.