Orthopaedics Around the world

I vividly remember when war broke out in Iraq in 2003. While I was looking forward to attending college, many of my peers were heading to the Middle East.

The situation in Iraq has changed greatly in the past 15 years. Although the enemies and alliances have shifted multiple times, the fighting remains intense. I never dreamed that, as I was poised to graduate from residency and begin my practice, the turmoil in Iraq would still be front-page news and present an opportunity for me to contribute.

With two children under the age of 3 years and another on the way, convincing my wife that my limited vacation time as an orthopaedic chief resident would be best spent in Baghdad, Iraq, was a hard sell. Like most orthopaedic programs, my training was intense. I spent the past five years at one of our country’s busiest trauma centers and recently completed a fellowship in osseointegration in Australia. It was there that I met Australian surgeon Dr. Munjed al Muderis, who had been invited by the Iraqi Prime Minister, Haider al-Abadi, to gather a team of orthopaedic professionals to provide otherwise unavailable and much needed treatment for the Iraqi soldiers who had been fighting ISIS. Many of the injuries were chronic malunions, nonunions, and high-level amputations.

Based on my experiences with trauma and with osseointegration, I felt ready to take on the challenges that war injuries present. A focus of our mission was to bring cutting-edge osseointegration technology and techniques to those who had lost limbs due to gunshot and blast injuries. We had the opportunity to implant medullary devices that attached directly to a prosthetic limb, allowing some patients their first chance of using a prosthetic limb and others the ability to gain significant function.

When we arrived on Dec. 10, 2017, Prime Minister Abadi had just announced ISIS had been fully eradicated from Iraq, and a grand military parade was underway. Amidst the celebration, however, the reality of my situation set in. We were loaded into armored vehicles replete with bullet holes, top-mounted machine guns, and detonator scramblers. The trip from the airport to the Green Zone was a blur, both literally and figuratively, and thoughts of worst-case scenarios raced through my head as our vehicle sped 100 mph down the “Highway of Death.” After stopping at several checkpoints (with a few smirks at my American passport), we eventually arrived at the prime minister’s guest house, where his delegation welcomed us enthusiastically. As I was led through an opulent foyer of gold and marble, I remember thinking, “I hope we can live up to their expectations.” After a 15-hour journey, I was given just enough time to shower and change into scrubs before we headed to the hospital.

I spent the next eight days at the Ibn Sina Hospital in Baghdad’s Green Zone. For months, hundreds of patients had been anticipating our arrival. Ibn Sina was built in the mid-1960s and was expanded and refurbished at various stages during the rule of Saddam Hussein, who used it as a personal hospital. When American forces occupied Iraq in the 2000s, it was used as one of the main hospitals to treat critically injured soldiers and became a busy trauma center where many orthopaedic surgeons served during their time in the military.

Arriving at the hospital in the heart of the eerily quiet Green Zone, I was brought to the third floor, where four operating rooms (ORs) were located. The head nurse gave me the grand tour with a lit cigarette in his hand. On the surface, the hospital and the ORs were suboptimal. Doors, overhead lights, computers, and other modern amenities were noticeably absent. But as we began to operate, I was pleased to find that much of the surgical equipment was modern and similar to what I was accustomed to working with at home, even if we had to customize the length of a screw or two with bolt cutters. Ultimately, it was the dedication of the staff to our shared mission that I found most reassuring.

Considering that I only speak about two words of Arabic, I was unsure how well I would be able to integrate into the team of Iraqi surgeons, residents, and nurses who work year-round at the Ibn Sina Hospital. Fortunately, the doctors and head nurses spoke wonderful English. It was fascinating to speak with all of them. One of the residents told me that he had spent about 10 months in the United States, but ultimately returned to Baghdad because it was home. He had witnessed war and atrocities his whole life, and he was proud to be back as a shining example of hope for the future.

Dr. Doherty stands in front of the hospital at 3 a.m. waiting for his convoy home.

One of the most memorable days of the trip was Friday, when the hospital closed in observance of the Muslim Sabbath. We took the opportunity to tour the Baghdadi markets, which were alive with thousands of people shopping, eating, enjoying performances, and giving political speeches. The six of us traveled with a 25-man security force provided by Prime Minister Abadi.

As the only American in the group, it was almost surreal to imagine the experiences of my countrymen in these exact locations just a few years before. Many of the buildings bore the unmistakable signs of war. I wondered how the townspeople would receive me, but I quickly discovered their effusive hospitality. I was offered more cups of tea than I could count, and I was asked to join in many of the selfies they love to take. I think I appeared on more Iraqi social media pages that afternoon than I ever have at home.

At the end of our day exploring the streets of Baghdad, our team leader, Dr. Al Muderis, who grew up in Baghdad, admitted how nervous he had been all day, as he felt responsible for our safety. He had fled Iraq 18 years earlier when Saddam Hussein commanded him and his surgical colleagues to mutilate the ears of army deserters. He watched the execution of one of his mentors for refusing the order. Dr. Al Muderis knows first-hand the brutality that exists in this part of the world and has often told me that many see the cost of a life as the cost of a bullet. I told him that I felt safe and welcome in Baghdad and that I appreciated its historic beauty. I think it gives him hope to see that the city he once called home might finally be entering a new era of peace.

Looking back, I’m proud of what we accomplished during our trip to Iraq. Four surgeons, myself included, completed 190 surgeries over the course of eight grueling 18-hour days. Many were complex reconstructions, and 62 were osseointegration surgeries. Many of our patients had not walked since their injuries, some for years, and as a result, were considered outcasts from society.

I have loved every moment of my brief career in orthopaedic surgery and have experienced some truly special moments treating patients. My time in Iraq was very rewarding, and it showed me a new level of incredible feats that our profession empowers individuals to accomplish.

David B. Doherty Jr, MD, is a chief resident of orthopaedic surgery at the University of Texas Health Science Center at Houston. He will begin a fellowship in adult reconstruction at Duke University in August before returning to Houston to practice.

Editor’s note: This article is the first of a two-part series detailing Dr. Doherty’s experience in Iraq. The next installment will be published in the July issue of AAOS Now.