King’s College Hospital (KCH: lead UK partner), London. The orthopaedic department at KCH will be host to the fellows and deliver the training. The department has close links to IDEALS and HRDD (see below) and is committed to supporting the long-term development of trauma/orthopaedic services in Gaza.
Human Resources Development Directorate (HRDD), Gaza. HRDD is based at Shifa hospital, Gaza city, and is managed directly by the Palestinian Ministry of Health. It is responsible for the training/development needs of all Ministry employees in the Gaza Strip. HRDD has been closely involved in the development of this project, helped recruit the fellows and will provide support for the introduction of routine data collection and audit within the trauma units in Gaza.
International Disaster & Emergency Aid with Long-term Support (IDEALS). In partnership with HRDD and MAP (see below), the charity IDEALS has been responsible for a number of successful projects in Gaza over the past four years, including the introduction of Primary Trauma Care (PTC) training for medical and ancillary staff at all levels, and a series of rehabilitation projects for persons with disability. As the managing agent, IDEALS will have overall responsibility for the monitoring, coordination and financial management of the project.
Medical Aid for Palestinians (MAP). This charity has provided financial and logistic support for the work of IDEALS in trauma care and rehabilitation in Gaza. MAP will continue to provide logistic support for this project and assist in obtaining visas for the fellows.
A brief background to the project:
• Gaza consists of five provinces and a population of 1.6 million, of whom 70% are refugees. The population is concentrated in seven towns, 10 villages and eight camps, with a total area of only 360 sq. km.
• Health care in Gaza is delivered by four main providers: the government; UNRWA (the UN agency providing services for registered Palestinian refugees); non-governmental organisations (NGOs: local and international); and the private sector.
• Of the 27 hospitals in Gaza 13 are managed by the Palestinian Ministry of Health (with a total of 1,500 beds), with the private sector and NGOs managing the remainder (with a total of 500 beds). Most of the hospitals are small, specialist units, with only three Ministry of Health facilities having the capacity to manage major trauma: Shifa hospital, in Gaza city, and the Nasser and European Gaza hospitals in Khan Younis.
• Traumatic injuries account for 35-50% of all emergency admissions to these hospitals. The most common cause of serious injury or death is the ongoing conflict, followed by road traffic accidents and social violence. Airstrikes, incursions and levelling operations continue to threaten the population, with these activities killing 50 civilians and injuring a further 1,612 in 2011 alone.
• Hospital emergency departments and trauma surgeons have struggled to cope with the magnitude of the problem, with professional isolation, a lack of resources (primarily consumables because of the blockade) and limited use of standardised care pathways reducing the impact of available services.
• The quality of care provided for major trauma victims has been impossible to monitor or evaluate because of the lack of routinely collected data regarding the nature/severity of the injuries sustained and the eventual outcome. The lack of such data precludes meaningful audit of major trauma care.
• Despite the lack of routinely collected data, senior surgeons at Shifa, Nasser and European Gaza hospitals have confirmed that major limb injuries pose particular problems within Gaza. Reconstructive surgery following initial emergency treatment is not available, forcing patients to wait months for permission to leave and undergo surgery elsewhere. Unfortunately there is no mechanism for monitoring the quality of such interventions and no follow-up care is available once the patient returns to Gaza. This results in a high incidence of long-term complications (poor healing of fractures, chronic bone infections and deformity), ultimately compromising the physical, psychological and social well-being of patients. Both local and KCH surgeons believe the basic infrastructure and equipment are available in Gaza, but lack of specialist skills and management systems have prevented the development of limb reconstruction services.
This project intends to offer training to Palestinian surgeons in the management of major trauma and in post traumatic limb reconstruction. These areas are a particular strength of KCH, designated as one of only four major trauma centres in London.
Three Palestinian orthopaedic surgeons from the three main trauma hospitals in Gaza will be invited to come to KCH for a seven month training fellowship. Each fellow will be attached principally to the limb reconstruction team, with access to the upper limb and pelvic trauma teams. Each will have a job plan and a timetable detailing out-patient commitments, ward rounds, theatre lists and trauma/departmental meetings. Day to day activities will be supervised by consultant orthopaedic surgeons at KCH, principally by the limb reconstruction specialists Miss Sarah Phillips and Mr Graeme Groom (both also IDEALS’ trustees). Each fellow will be encouraged to attend relevant regional/national meetings and external training courses.
As well as developing new surgical skills the fellows will gain a greater understanding of the overall management of trauma/orthopaedic patients. In parallel with the training fellowships, additional work will be conducted to introduce routine audit/review into the management of major trauma in Gaza.