Images of Aleppo, Syria, showing the impact of multiple rocket attacks.
Courtesy of Samer Attar, MD

AAOS Now

Published 10/1/2013
|
Samer Attar, MD, FACS

Crisis in Syria: An Orthopaedic Surgeon’s Perspective

Since March 2011, Syria has been engulfed in a fierce civil war that has cost more than 100,000 lives and displaced millions. Caught between the opposing forces are people who have lost lives, limbs, homes, and loved ones. As refugees, they risk death, disease, starvation, and homelessness. At home, they risk bullets, shrapnel, or incineration. Some refuse to leave their homes out of principle or because they are too poor or sick to travel.

Medical personnel and basic medical resources are in short supply. Hospitals and ambulances have been targeted and destroyed. Medical personnel in particular have been subject to incarceration, torture, and even execution for treating “the other side.” This situation has resulted in an underground healthcare system with provisional hospitals and clinics in secret locations.

The Syrian American Medical Society (SAMS) was founded in 1998 by American doctors of Syrian origin. They have helped to fund and establish many of these underground hospitals. In 2012 alone, they delivered more than $5 million in equipment and resources. They have supported local personnel who have decided to stay in Syria. They have also assisted physician volunteers willing to travel to Turkey and Syria to treat the wounded.

Earlier this year, SAMS coordinated and facilitated my 2-week surgical mission trip to a SAMS-funded field hospital in Aleppo. Aleppo, the largest city in Syria, is approximately 40 miles south of the Turkish border. For years, it had been a peaceful, exotic, cosmopolitan city. Today, it is scarred with ruins and remnants of unrestrained devastation and destruction. It is an apocalyptic setting in some areas: collapsed buildings and burnt-out vehicles; people surviving amid the rubble and debris.

The fighting here has been intense, and military bombardment has continuously pounded civilian communities. Airstrikes and shelling are random and indiscriminate. Sniper fire from rooftops above is rampant and discriminate.

The field hospital is in a nondescript, undisclosed location close to the front lines. Rules were very simple. Do not walk too far outside. Do not walk on the roof because of snipers. Do not use real names.

While surprisingly very well-run and equipped, the hospital has no emergency medicine physicians. The emergency department is run by 20-something senior medical students—who, at great cost, have learned years of trauma medicine within months. Horrific injuries were a daily, expected occurrence: open abdomens with exposed viscera, severe head trauma with exposed brain matter, obliterated faces and limbs.

Mortar blasts and gunfire were constant. It took about 3 nights before I started sleeping through them. The running joke was that as long as you heard rockets and did not see them, you were fine. On two occasions, they came within 200 meters—close enough that we felt the hospital shake. The staff showed me where a missile hit the adjacent building a couple months prior, shattering the hospital’s windows. When bombs hit nearby homes, families would pour into the hospital carrying their bloodied loved ones. People would pile at the front door because there were no rooms for them. Sometimes, there would be so many wounded, patients would lie on the floor. There were days it felt like the screaming never stopped.

One night, a large blast reverberated through the hospital. A rocket had landed on a market stocked with clothes and supplies meant for the poor—with hundreds of families searching and shopping. Scores were injured, most with high-energy open wounds from shrapnel. At one point, we were pulling shards of bone out of a little boy’s arms and legs. The shards of bone were not his own—but from a boy standing next to him who died in the blast.

It was Ramadan at the time—a holy month in which Muslims fast with no food or drink from sunrise to sunset. Staff spent day and night performing vascular bypasses, exploratory laparotomies, and irrigation/débridements with external fixation. Some doctors would work until sunrise without a full meal and then fast for another 14 hours until the next sunset.

Every now and then, there would be a reprieve or a lull for 3 or 4 hours—sometimes a little longer—but never long enough. I do not know how they can do this for so long without any burnout. Some of the staff members have been at the hospital for months and have not seen their families for more than a year. Some have no families to go back to. One of the surgeons would spend every night staring at his cell phone pictures of his wife and daughters.

Orthopaedics was the busiest service. Bullets, shrapnel, crushes, and burns were the most common reasons for injury. Every day we would apply or remove external fixation devices and recycle them. Most of the time we explored wounds, débrided tissue, repaired tendons, ligated vessels, stabilized fractures, and performed amputations—lots of amputations.

Some of the amputations were immediate, some delayed, many on children. Missiles would crash through the roofs of homes while the people slept. I met a little boy who lost his whole family—mother, father, and siblings. He was the only one who survived—but he lost both lower limbs above the knee. I met a father and a son who had been sleeping together in the same room when a rocket blasted into their home. They both had crushed legs and both father and son required bilateral lower limb amputations.

Some patients would come to us with infected tibial nonunions, with exposed necrotic bone and pus pouring out of their wounds. One patient had been living like this for months and begged for an amputation because he could no longer bear living in this manner.

Many of the injuries were due to sniper bullets; most of the victims were children or the elderly. Snipers in Aleppo intentionally target the vulnerable. Many children were brought in dead on arrival—with gunshot wounds to the head. Many of the fractures we treated were from bullets shattering bone and obliterating soft tissues.

The urologists spent most of their time addressing projectile injuries to the bladder and genitals. Within 4 days, the urology team had performed five bladder repairs on children and young adults shot in the abdomen by snipers. Even the hospital security guard had lost an eye to a sniper. It seemed as though the intent was to maim, mutilate, disable, and terrorize.

A trip to Syria will show you the worst happening in humanity. It will also show you the best humanity has to offer in the face of crisis and catastrophe. The doctors, the nurses, the support staff—they have all been living in crisis and emergency mode for months. They all have stories to tell of loss. The risk of rooftop sniper fire, indiscriminate mortar blasts, and the threat of execution if caught are ever prevalent and palpable.

In spite of these horrors and hardships, they demonstrate an unfailing hope and perseverance; they all express an overwhelming sense of obligation and duty. They could leave anytime, but choose to stay. Many have sacrificed lucrative medical practices in other countries to care for those left behind and caught between. They live together under one roof, sleeping on the floor, cooking and sharing food as a family.

Everyone helps out. No task is too big or too small. There are no egos and no overwhelming, overbearing personalities. They all find peace in their faith. In a war zone, there is no better place to wash up for prayer than at a surgical scrub sink. The Quran says “if anyone saves a life, it would be as if he saved the life of all mankind.” All the people at that hospital exemplified and held fast to this scripture.

On my final day, the last thing the chief of staff said to me, in his broken English, was “You are one of our brothers. Please come back, and send more help.” Five days later, at home, I received a text: “Today is hard, a massacre near [the hospital] and many were injured and killed. Pray for us…people under ruins.”

For more information about SAMS, visit www.sams-usa.net

Samer Attar, MD, FACS, is an assistant professor in orthopaedic surgery at Northwestern University’s Feinberg School of Medicine.

Additional Information
Dr. Sam Attar offers firsthand account of Syrian civil war