Surgeon Brings Technology to Syrian War Victims

Troy Brown, RN

December 10, 2013

A Chicago, Illinois, orthopedic surgeon who recently returned from a 2-week medical mission to war-torn Syria often thinks of the people he left there. Samer Attar, MD, an assistant professor in orthopedic surgery at Northwestern University Feinberg School of Medicine in Chicago, was born and raised in the United States and is of Syrian descent.

"There is a critical shortage of physicians in Syria, and when I learned of the opportunity to go there and help out, I took it," Dr. Attar said in an email interview with Medscape Medical News.

"The most common injuries we saw were from bullets, shrapnel, burns, and crush injuries from debris and rubble. We tried to take care of whatever we could in the emergency department [ED] — cardiopulmonary resuscitation, chest tubes, suturing lacerations, splinting and casting fractures," Dr. Attar said. "Senior medical students managed and supervised the ED because there were no emergency physicians around. There was only 1 anesthesiologist for a handful of surgeons," he added.

"In the operating room, we debrided wounds, stabilized fractures, and performed amputations. The general surgeons performed a lot of exploratory laparotomies while the urologists repaired bladder injuries from bullets. There was 1 dedicated vascular surgeon, but his demand was so high he was always hopping from one hospital to another," Dr. Attar explained. "In the 2 weeks that I was there, he treated a number of patients whose femoral arteries were obliterated from projectile blast injuries. He harvested the contralateral saphenous vein in order to create bypass grafts.

"There were some nights it felt like the screaming never stopped, and there were some days we never left the operating room. Most of the victims were civilians, and a lot of them were children who would present with bullet wounds and limbs pockmarked with shrapnel," Dr. Attar noted.

Limited Resources

The hospital was small and spartan, but functional, Dr. Attar said, and although he was the only American there, this was not an issue for the local staff. "My role was to assist and support them and assess any needs. All of the physicians and staff share rooms for 6 to 8 people and sleep on the floor, and they all live at the hospital," Dr. Attar said.

"Many of them have the means to leave, and in spite of snipers firing at the roof of the hospital and missiles exploding meters away, they choose to stay out of duty and obligation to the suffering. The orthopedic surgeon I worked with has not seen his family in 9 months. They are a remarkable group of people capable of saving lives and limbs with very limited resources, but they still need all the help they can get," Dr. Attar explained.

"The devastation in some areas surrounding the hospital is immense, and the civilians there are trying to survive in an extremely hostile environment."

"Families and communities [were] torn apart. A whole generation of children [has been] physically and psychologically scarred. When missiles or bombs would hit civilian and residential facilities, [we witnessed] mass casualty events with families piling at the door, screaming, covered in blood, and carrying in loved ones and [had] no place to put them," Dr. Attar said.

In the Aleppo operating room where Dr. Attar worked surgical equipment was limited.

Dr. Attar and his colleagues had very limited medical equipment to work with. "A lot of the instruments were not of the best quality...but you do the best you can with what you have," Dr. Attar said.

Danger Has Driven Healthcare System Underground

"To complicate matters further, hospitals and healthcare personnel are systematically and intentionally targeted. As a result, an underground healthcare system has emerged where many hospitals have become provisional, makeshift facilities in undisclosed, unmarked locations," Dr. Attar explained.

Groups like the International Committee of the Red Cross and Médecins San Frontières are currently working in Syria. However, local Syrians are performing most of the healthcare and humanitarian work. They are working under hostile conditions and risking their lives every day, Dr. Attar said.

Operating to the sound of airstrikes and gunfire was among Dr. Attar's most difficult challenges. "Knowing that at any moment the hospital could be destroyed from a direct hit or from collateral damage" made him afraid "every day," he said. "But when I realized the Syrian doctors and nurses around me were risking their lives and have been living this way for a year and likely will continue to do so for a long time, I did not dwell on it and I just followed their lead," Dr. Attar explained.

Dar al-Shifa Hospital, Aleppo, northern Syria, destroyed in November 2012.

Dr. Attar spent most of his time in a field hospital that was primarily funded and supplied by the Syrian American Medical Society (SAMS), which was founded in 1998 by American physicians of Syrian descent. "I owe it to them for coordinating and facilitating my trip and for getting me safely in and out of Syria," he explained.

Since Dr. Attar's return to the United States, he has worked closely with SAMS to raise awareness of the situation in Syria and to provide practical assistance as well.

"In September 2013 I went to Turkey with a number of other SAMS physicians. SAMS organized a teaching/training conference on trauma/intensive care for Syrian field medics who crossed the border," Dr. Attar said.

"They have done this a number of times in the past 2 years. It is a chance for Syrian healthcare personnel to get out of Syria and take a break for a few days and obtain academic and hands-on equipment training such as with chest tube insertions and [focused assessment with sonography for trauma] ultrasounds. The equipment then gets donated and brought back into Syria by the participants," Dr. Attar added.

Donated Equipment, Training for Fracture Treatment

"I asked Dr. Lewis Zirkle, an orthopedic surgeon from Washington state and the founder of SIGN Fracture Care International to come along, and he organized a SIGN nail conference within the SAMS conference for about 10 Syrian orthopedic field surgeons who were present. He then personally donated the equipment used to teach at the course, and the surgeons brought it back into Syria," Dr. Attar said.

"[The] SIGN nail is an intramedullary nail which can be used without the need for intraoperative C-arm fluoroscopy. I had actually seen it used before when I volunteered in Bhutan and Burma. I noticed that a lot of Syrians were being treated definitively with external fixation who otherwise were great candidates for internal intramedullary fixation, but there are not enough intramedullary nail systems [instruments and implants] in Syria for surgeons to use," Dr. Attar explained.

"I thought the SIGN nail would be great for Syria, so I actually emailed Dr. Zirkle while I was working in Aleppo in August. He did not hesitate to respond, and we hammered out the details when I got back stateside. I really commend Dr. Zirkle for going out of his way to help out," Dr. Attar said.

Dr. Attar still has vivid memories of the horrors he witnessed there. "There are innocent men, women, and children who are sick, starving, displaced, or injured and who are cut off from the rest of the world — either from deliberate humanitarian blockades or because of fighting within and around civilian areas," he said.

"It is a lot to take in and then come back home knowing it is still going on and that there are still healthcare and humanitarian workers operating under these conditions," Dr. Attar concluded.

Dr. Attar has disclosed no relevant financial relationships.

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