Healing wounds of war in the Middle East

Ahmed was 14 years old when he lost his left arm. “I had gone out to press olives,” remembers the young Syrian. “We were on our way home. A plane flew by and dropped a barrel bomb that exploded, and shrapnel hit my hand. It felt like there was something dripping on my leg. I looked at my arm. It was completely torn off. There was one thread that held my arm to my body. I asked myself, ‘What’s going to happen to me now? It’s finished. I’m dead.’”

Ahmed was eventually taken to a hospital run by Doctors Without Borders/Médecins Sans Frontières (MSF) in Amman, Jordan. Through the hospital’s reconstructive surgery program, Ahmed was among the first patients to receive a custom-designed prosthetic arm created by a 3-D printer. The multi-part device was printed layer by layer, from shoulder socket to fingertips, to fit the teenager’s body and personal requirements. The new arm also goes through an iterative process of testing and refinement to make sure it works well.

For Ahmed, it’s a step towards a future he once thought had been robbed from him. “When I grow up, I would love to become an engineer and build a house,” he said. “Just as soon as I go home to our country. I want to live a proper life. A beautiful life. That’s it.”

MSF’s reconstructive surgery program in Amman responds to the mounting needs across the Middle East, as thousands of people have suffered grievous war-related injuries in the course of the region’s widening spirals of violence. In Syria, Iraq, Yemen, and the Occupied Palestinian Territories (OPT), where years of conflict and political unrest have overwhelmed local health systems, war wounds tend to go untreated and can worsen as a result. Caring for patients whose lives have been shattered by bullets, shrapnel, or severe burns is often a long and complex process.

The reconstructive surgery program was established in 2006 to treat victims of the Iraq war. Now, more than ten years later, the program is housed in an independent hospital that provides care to war-wounded patients from across the region. 

The eight-story hospital has 148 beds, an operating theater with three surgery rooms, physiotherapy and psychosocial departments, and a microbiology lab. In 2017, the MSF Foundation introduced the 3-D printing project to develop prosthetics. Over the past decade, the hospital has become a hub for medical innovation, offering a holistic package of services and cutting-edge solutions to the extraordinary medical challenges facing its patients.

TESTING 3-D PRINTED PROSTHETICS

Off-the-shelf prosthetics can be prohibitively expensive and are generally one-size-fits-all. But no two patients are alike—from lifestyle to skin tone to aspirations, each has different needs when it comes to the prosthetic design that will benefit them most.

This is where 3-D printing comes in.

Using digital imaging techniques and software, the MSF team at the Amman hospital can quickly and inexpensively design customized prosthetics for patients undergoing treatment for war wounds. Using a combination of plastics, 3-D printers fabricate modular prosthetics tailored to a patient’s anatomy and needs. 

Where traditional prosthetics can cost hundreds of dollars and require extensive maintenance, custom prosthetics can be 3-D printed for as little as $30 and fabricated in 24 hours.

The goal is to increase access to prosthetics,” explained Safa Herfat, a biomedical engineer and technical coordinator of the 3-D prosthetics project. 

The focus is mainly on upper-limb prosthetics, for which there are few other available options. Herfat works alongside a physiotherapist to explore solutions geared to the individual. “For each patient we sit down and interview them to determine their current condition and the specific activities they would like to return to in their lives — such as driving a car, working in the field, or working at home.”

Herfat and the team work with the Irbid Fab Lab to test scanning and modeling software programs, configure and calibrate the printers, and optimize biocompatible materials for the prosthetics. “We are looking to design devices … that can be delivered to patients in austere environments or areas where there is limited or no access to prosthetic care,” said Herfat. The initiative is still a work in progress but will hopefully expand to meet the needs of other MSF projects in the future.

A HOLISTIC APPROACH

Of course, patients need much more than prosthetics: they need comprehensive solutions and support to help them rebuild their lives. 

Since the program opened, the hospital’s Iraqi and Lebanese doctors — a team including four orthopedic surgeons, a maxillofacial surgeon, and a plastic surgeon — have performed more than 10,000 surgeries for more than 4,500 patients. Now with a decade of experience, the surgical team is uniquely equipped to treat complicated war wounds.

The orthopedic surgeons specialize in the complex techniques necessary to manage both bone and soft-tissue injuries, especially the delicate operations needed to treat damaged nerves and tendons. Plastic surgery aims to repair skin and joint problems resulting from burns and bombings that can impede a patient’s ability to move, eat, or speak. And patients who arrive at the hospital with maxillofacial injuries undergo intricate operations for neck, face, or jaw wounds, often including reconfiguration of the mouth or jaw with plates and skin grafts.

Surgery is just the first step in the path to recovery — physiotherapy and psychosocial care are also core elements of the process. After undergoing reconstructive surgery, patients begin personalized physiotherapy regimens to rebuild strength and regain functionality. A large space at the hospital is dedicated to physiotherapy equipment, including a parallel bar, exercise bike, and treadmill. 

The psychosocial care unit provides support to patients — many of whom have experienced deep emotional trauma in addition to their injuries. Teams offer mental health care, occupational therapy, and music and art classes. In 2016 alone, the reconstructive surgery program conducted more than 3,500 physiotherapy sessions and 3,000 psychosocial consultations.

One patient, Faleeha, lost one of her legs and suffered terrible injuries to her hands when she stepped on a land mine while working in her garden outside of Baghdad. At the MSF hospital in Amman, she underwent surgery for her hands to repair damaged nerves and elongate the tendons to restore mobility. She was also referred to a prosthetics specialist to be fitted with an artificial leg. Now she is working with the physiotherapy team, learning to walk again and 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,” Faleeha said. “Since the surgeries and physiotherapy, I can do everything myself…. I am hoping that with more physiotherapy I can return to my home in Iraq walking independently.”

CONFRONTING THE THREAT OF ANTIMICROBIAL RESISTANCE

More than 50 percent of patients arrive at the Amman hospital with chronic infections, and more than 60 percent of these are multidrug-resistant. Drug-resistant infections can pose a deadly threat to patients already suffering from complex injuries.

The high level of drug resistance stems in large part from the collapse of sterilization, hygiene, and infection control measures in the strained health systems of countries gripped by conflict and from the improper use of antibiotics. “When people are wounded, they are likely to develop skin and bone infections, and this leads to an increase in antibiotic consumption,” said Dr. Conor Bowman, who works on the antibiotic stewardship program at the Amman hospital, in a February interview with Al Arabiya. “In unstable places, where there are no resources to test the bacteria for resistance, antibiotics are essentially selected without knowing whether they will work or not.”

MSF launched the antibiotic stewardship program at the Amman hospital to help promote the safe use of antibiotics and fight the growing global threat of drug resistance.

The hospital also features a microbiology lab to test for antibiotic resistance and inform treatment options. “In the lab we test bone and tissue samples from the operating theater for infection and provide an antibiogram to the doctors so they can appropriately target the infection without causing more resistance,” said Kate Baldwin, who was on assignment as the microbiology lab manager last year.

MSF physicians and pharmacists work together to tailor drug regimens to individual patient needs and follow up to ensure drug effectiveness. The team promotes the “Four Ds” of antibiotic stewardship: correct drug, correct dose, correct duration, and de-escalation of antibiotic therapy. This stewardship program serves as a model for both regional medical providers and MSF hospitals around the world with high levels of antibiotic use and resistance.

What began as a trauma project more than a decade ago has evolved into something much bigger. As conflict continues across the Middle East, the dedicated team and innovative approaches pioneered at the reconstructive surgery program will only become more important. “Every day here, the patients are supported,” said Marc Schakal, MSF head of mission at the Amman hospital. “Month after month, sometimes for years, we are helping them recover functionality, movement, and dignity.”