A REGION IN TURMOIL
For the past 15 years, the Middle East has been the ground zero of a growing number of conflicts, including Iraq, Syria, Lebanon, Yemen, and Palestine. The destruction of key health structures, the lack of staff and the impoverishment of populations, have drastically limited recovery opportunities for direct and indirect victims of conflicts.
After the Iraq War began in 2003, many people suffered life-changing injuries, Often these injuries were left untreated and they worsened as a result. People were left immobile, sometimes bedridden and unable to eat or speak. Victims of bomb explosions, bullet wounds, shrapnel and severe burns require very specific operations; specialising in orthopaedic, maxillofacial, and plastic surgery.
When we initially opened this hospital nobody thought we were going to stay 10 years, but after 4,500 admissions and more than 11,000 surgical interventions, it’s clear we have work for the next 10 years, and one hospital is not enough.
Three years later, MSF responded to the heavy casualties from the Iraq War by establishing a Reconstructive Surgery Programme (RSP) in Amman, Jordan, to treat the seriously war-wounded without access to proper healthcare.
The RSP was originally set up to treat war-wounded Iraqis. However, as violence spread across the region, with the 2008 Gaza War, and the Arab Spring in 2011, the programme began admitting patients from Syria, Libya, Yemen and Palestine.
In 2015, in response to the increasing need for reconstructive surgery, the RSP moved into an independent eight-floor hospital in Amman, in order to increase the quality of care and to admit higher numbers of patients. This hospital, where the RSP is remains today, has 148 beds, an operation theatre with three surgery rooms, as well as a physiotherapy and psychosocial department.
There is immense progress and success with which the surgery team manages to redress both the malfunctions and the aesthetics of the injured body parts. These achievements, which we are proud of as humanitarian surgeons, have had a considerable contribution to rehabilitating the victims and helping reintegrate them into their societies.
THE RECONSTRUCTIVE SURGERY
The surgeons at the RSP perform operations specific to war wounds inflicted by bomb blasts, bullet wounds and burns from conflicts in the Middle East. As a result of the regularity with which they treat such injuries, they have developed unique experience and skills. In tandem with physiotherapy, the reconstructive surgery aims to restore functionality and mobility to patients who have had their bodies and lives altered by weapons of war.
The RSP's surgical team consists of four orthopedic surgeons, one maxillofacial surgeon, and one plastic surgeon –– all from Iraq and Jordan –– who have, over the past 10 years performed more than 11,000 surgeries on over 4,500 patients. On average five to six operations are performed every day at the RSP.
Often the result of bomb explosions or bullet wounds, patients come to the hospital with injuries that reduce or completely prevent them from using their limbs.
In response to these injuries, surgeons perform a number of complex operations to manage bone defects. Hand surgeries and soft-tissue surgeries, such as nerve and tendon surgeries, are also performed. In addition, injuries with bone infections, typically osteomalitis, are treated at the hospital, through a very strict and regimented antibiotic stewardship programme.
PLASTIC AND BURN SURGERY
Many patients in the RSP, particularly women and children, are victims of serious burns, often caused by bombings and explosions, or other violent incidents. Typical cases involve severe skin contractures that impair joint functionality, impede vision, and compromise a patient's ability to eat and speak. In order to improve the functionality of the affected areas, the plastic surgeon at the RSP performs operations to release contractures followed by soft tissue coverings with skin grafts and skin flaps.
Patients who arrive at the RSP with maxillofacial injuries –- injuries to the neck, face and jaw –- are often victims of shelling, explosions and gun shots, with wounds such as fractures and bone defects, as well as skin and soft tissue defects that affect breathing, eating, or speaking. The maxillofacial surgeon at the RSP performs complex surgeries in the affected areas, often refiguring the jaw and mouth with metal plates and skin grafts, which restore the patients’ ability to eat, drink and speak again.
“Many patients who come to the RSP with maxillofacial injuries come with severe injuries to the face, sometimes even missing their whole lower jaw, bottom lip, and teeth. As a result their speech, eating and sometimes even breathing is compromised. In response we perform special reconstructive surgery to rebuild the lower jaw, mouth and teeth. It’s an incredible sight, to see people talking, eating and laughing again, after having lost so much.” Dr Rasheed Al Sammaraie, Surgical Coordinator.
Patients at the RSP come from different countries in the Middle East, each suffering under conflict. As well as sharing a common language, patients share the residual trauma of war. While being treated at the RSP, sometimes for as long as one year, these war-wounded patients live, eat, sleep and share their stories together.
They are of all ages, from infants to adults, men and women, and together they are bound by the fact that their lives were impacted by wars. The patients all stay at the hospital in Amman for many months, sharing coffee and war stories, all with the hope of getting treatment that will put them back on their feet and allow to return home with dignity.
I went to sit outside for a bit. Suddenly a bomb was dropped in the valley... The shrapnel from the explosion hit our house.
While working on her farm on the outskirts of Baghdad, Faleeha stepped on a landmine which exploded and left her with factures in her hand and severe damage to her face. Her left leg was so gravely wounded that at a local hospital it had to be amputated below the knee. After the amputation, Faleeha was referred to the MSF Hospital in Amman for reconstructive surgery. Here the orthopaedic surgeons operated on nerves in her hands and elongated the tendons in order to mobilise the joints. In addition, Faleeha, was referred to a prosthetic specialist where she was fitted with a prosthetic leg. Since then, the physiotherapy department have worked closely with Faleeha, helping her to walk on her new prosthetic leg, and to again use her hands for daily tasks.
When I arrived, I was in a wheelchair, I was completely dependent on my son to feed me, dress me and bathe me. I wasn’t able to use my hands at all. But since the surgeries and physiotherapy, I can do everything myself. I feel much more comfortable now, and I am hoping with more physio to return to my home in Iraq walking independently.
For the first time in more than two years, Ibrahim is able to open his mouth again.
The comprehensive treatment at the RSP comprises reconstructive surgery, physiotherapy and psychosocial care.
The unique achievement of the RSP lies in the consolidation of a comprehensive and holistic approach to rehabilitation, and indeed the vast number of patients that have been treated by the programme over the past 10 years. In 2016 alone, the RSP conducted approximately 3,500 physiotherapy sessions and 3,000 psychosocial consultations in addition to more than 1,000 surgeries
Physiotherapy is a core element of the patient rehabilitation process. After reconstructive surgery, it is vitally important that patients receive specific physiotherapy in order to develop functionality and build strength in the affected areas, as well as to prevent the possibility of contractures, which can severely limit mobility and therefore render the surgery ineffective.
The psychosocial care unit makes up the final element of the comprehensive treatment provided at the RSP, and is a vital service offered to those who have experienced the horrors and trauma of war. Psychosocial support helps identify specific issues among the hospital's children. MSF runs activities for the children of the RSP to aid with this process, such as educational classes and occupational therapy in the morning, as well as afternoon activities like music or art classes.
RESEARCH AND INNOVATION
INFECTION MANAGEMENT, MICROBIOLOGY LABORATORY, AND ANTIBIOTIC STEWARDSHIP
After a bomb blast in Iraq robbed Haider of his right arm and severely injured his right leg, he arrived at the RSP with a horrendous infection. It was clear to the doctors almost immediately that the infection was severe, as the bacteria was actually eating the exposed bone in his right leg.
After a bone debridement was conducted by surgeons, and acute tests carried out at the hospital’s microbiology lab, it was revealed that Haider’s bacteria was extremely resistant, and only one or two antibiotics in the world could treat the infection.
Through the teamwork of the lab technicians and the antibiotic stewardship programme, the correct antiobiotic was identified to kill off Haider’s aggressive infection. Without such treament, Haider would have certainly lost his leg.
More than 50 per cent of patients at the RSP arrive with chronic infection and more than 60 per cent of these infections are multidrug-resistant (MDR), reflecting the high levels of resistance in the region.
“If this bacteria isn’t treated, the only result would be the amputation of the limb. So we started with a specific antibiotic treatment and we saw little by little the bone and tissue recover. It was revealed after the third debridement, that the bacteria present in his bone when he first arrived had been treated successfully.”– Dr Nagham Khafaji, Antibiotic Stewardship Manager.
Since the opening of the project in 2006, it has been vital for MSF to find a way to respond to the severity of antibiotic resistance, which is a worldwide public health issue, and a particularly serious one when dealing with war-wounded patients in the Middle East. At the MSF RSP in Amman, patients are coming from countries where access to antibiotics is not regulated, where infection control and hygiene systems in hospitals have been destroyed, and where emergency life-saving treatment, not infection control, is the priority.
In 2015, the RSP implemented a microbiology laboratory in the hospital with the objective of improving the quality of MSF's medical interventions for patients with infectious complications of conflict injuries, and providing guidance for the management of resistant orthopaedic infections faced by other regional medical providers.
The Antimicrobial Stewardship Programme at the RSP aims to promote optimal antibiotic use in hospitals to help combat the ever-growing global threat of antibiotic resistant infections. This is achieved through the implementation of the 4 Ds: correct drug, correct dose, correct duration, and de-escalation of antibiotic therapy.
3D PRINTING PROSTHETICS
The implementation of a 3D-Printing project was introduced to the RSP through the MSF Foundation at the beginning of 2017, which aims to design and produce prosthetics for upper-limb amputees as an alternative to conventional prosthetics, as well assess the feasibility of other 3D-printed rehabilitation and prosthetic devices.
Although there are many prosthetic options for lower-limb amputees, there is little available for upper-limbs. As a result, the 3D-Printing team aims to target this population offering a customised lighter and cheaper prosthetic for patients, which is potentially significantly faster to produce than a traditional prosthetic.
For each patient, the team first assess the stump and the needs of the patient, and then make a scan of the stump, designing a socket and upper-limb prosthesis on digital software. Finally, the device is printed and customised to suit the patients’ needs. The aim of the project is to design and create upper-limb prosthetics unique to each patient, offering a cosmetic solution to their stump, as well as enabling them to carry out specific tasks.
This project is still a work in process, but will hopefully expand to meet the needs of other MSF missions in the future.