This month, I had the honor of delivering a Grand Rounds presentation to my hospital’s Department of Surgery as part of an annual tradition to display the passions, accomplishments, and career goals of the graduating resident class.
Below is the presentation I delivered but in a slightly elongated form as there is no time constraint here. Each paragraph represents a slide in the presentation. I have included relevant images and photographs directly referred to during the presentation.
The title of my presentation is War: Perspectives of a Surgical Trainee.
Here, I will share the circumstances that propelled me toward a career in medicine and then, more specifically, the circumstances that shaped my trajectory toward trauma surgery and surgical critical care. I will also share what I imagine my future will look like as well as the lessons I carry with me every day as I continue my surgical training.
Before I go further, I would like to make two prefacing remarks. First, although this is a Grand Rounds presentation that is couched in science, it is also a personal and at times vulnerable presentation, and independent of your position on the subject matter, I hope you will keep this context in mind. Second, I am firm in my belief that medicine is political. We are made to believe in medical school that medicine is apolitical, that it is the last frontier somehow unencumbered and uncompromised by politics. But the majority of the world lacks access to steady, reliable, high quality medical and surgical care. We do not live in a utopia. So until we do, until everyone has access to the reliable high quality care we train for years and decades to deliver, the mere act of caring for a single person – someone who is ill, who is afraid, who is vulnerable – is a radical and, therefore, political act. This philosophy informs how I approach and practice medicine.
Personal Course into Medicine
Rooftops in the Remal district of Gaza City, 2011
This is a photograph I took in my family’s neighborhood in Gaza City in 2011. Sadly, the buildings here are no longer standing. But I start with this image because in order to understand me, it is important to understand my family and where I come from.
I am the child of immigrants who were both born and raised in that neighborhood in Gaza City. My mother’s and father’s lives were hallmarked by violence and oppression. Their educational, work, and social opportunities were limited or cut short by Israel’s occupation. Many of their basic liberties were limited. My father ultimately managed to leave the Gaza Strip after high school and pursued higher education in Cairo. My mother was a college student when her university was struck by an Israeli missile. The airstrike caused enough damage to force the university to shut down the campus and prematurely end the academic year. My mother’s role then transitioned from student to caretaker as she joined her parents in taking care of and supporting her many older brothers who were reeling from the effects of abuse, confinement, and even torture in Israeli detainment centers and black sites.
Ridealong in my father’s cab, #2992, 2012
Ultimately my parents married and moved to the United States where they settled in the City of Chicago. Their goal was to create for their children opportunities that had been denied to them. They also wished to lead by example. My mother learned the English language by immersion, supported herself through community college, graduated from a premier university in Chicago, and later earned her M.B.A. My father worked a taxi driver, and while driving the cab, he pursued a Master’s degree in accounting and earned his C.P.A. He would routinely study from books he kept in the passenger seat as he waited between fares. This is a photograph of a ridealong I did with my father in his taxi over a decade ago. He still drives the cab when he can – he finds something so fulfilling about the work.
More than anything else, the two lessons that my parents worked hard to impart on me and, later, to my younger sister were the following. First, educate yourself. Education is the one thing that cannot be taken from you. Second, whatever you learn, whatever skills or knowledge you pick up along the way, use it all in the benefit of your community. This value was particularly apt as my parents had left everything and everyone behind when they moved to the United States. Our next-door neighbors, our local grocers, the people we met in our apartment buildings – these people became our community, our second family. It was our family’s goal to impact this community positively.
As a child, I struggled to translate these values into a meaningful lifelong pursuit. I wanted so desperately to become an astronaut. It was all I could think about. I stuck glow-in-the-dark stars to my bedroom ceiling. All my books in my modest collection were about space. I could get lost for hours watching videos about planets or galaxies, and I could almost melt into photographs of deep space. I loved the night sky.
In August of 2000, during a family visit to Gaza, my aunt asked me what I wanted to be when I grew up. I told her that I wanted to become an astronaut. She looked at me kindly and said that it was a nice idea, but how, she asked, would I help people? We need you to help your people, she said.
Ambulance crew in Ramallah, from the Yousef Qutob collection, 2000
The next month, September 2000, marked the start of the Second Intifada. It also marked a turning point for me as I quickly faced many harsh realities about the world. For the next few years, I was inundated with images such as these – of clashes, suffering, explosions. And then these ambulances would swoop in and whisk away the injured and the dead. I found these medics and ambulance drivers to be so brave and impactful, and for the first time, I found something tangible I wanted to become.
Discovering the field of medicine and considering a career in it meant that I would fulfill the two major values taught by my parents. It meant a lifetime of education. It also meant directly impacting communities around me.
Three years later, in 2003, my grandmother’s building was hit by an Israeli missile strike. My grandmother and uncle were in the apartment at the time. Thankfully both of them survived. But the physical and mental toll the strike took on my grandmother as well as the chronic conditions she battled and could not quite overcome as a result of medication restrictions imposed by occupying Israeli forces meant that she lived a very difficult final year of her life. She died before I could see her again. Her death – and the suffering that led up to it – sat heavily with me and sits with me still. It committed me even more to a career in medicine so that one day I might be able to spare another family from having to experience what my family did.
Pursuit of Trauma and Critical Care
The following are two vignettes that pushed me to consider specifically a career in trauma surgery and surgical critical care.
We begin in Chicago, Illinois. This is the shot heard around town.
It is August 15, 2010. I am an undergraduate student at the University of Chicago, in between my first and my second year. Damian Turner, an eighteen-year-old male, just one year younger than me, is shot in the back.
This occurs just after midnight. He is shot near the intersection of 61st and Cottage Grove, just a few blocks from the University of Chicago Medical Center which shares a campus with the university campus. Over the next few minutes, he stumbles to his sister’s home. It is now 12:10 A.M. His nieces and nephews call 911, and E.M.S. arrives to his sister’s home at 12:17 A.M.
For spatial awareness, he is about four city blocks away from the entrance to the hospital, a little over a half of a mile.
But the University of Chicago does not have an adult trauma center, and he is too old for the pediatric trauma center. So instead, Turner is transported to Northwestern Memorial Hospital, and shortly thereafter, at 1:23 A.M., he is declared dead.
The trip – from his sister’s home to Northwestern Memorial Hospital – is just over eleven miles.
A brief history of trauma at the University of Chicago. The University did in fact have a trauma center in the mid-1980s. From 1986 to 1988, it served the city’s south side. But the project was shut down for a variety of reasons, including cost and the fact that the trauma center served a population the University was not necessarily accustomed to caring for. In 1990, the University opened a pediatric trauma center which it has since maintained. In 2010, Turner was shot. But at age eighteen, he was too old to be evaluated and treated at the University of Chicago. In fact, anyone in the south side of Chicago over the age of fifteen who required evaluation at a trauma center required transport to Northwestern toward the north, Cook County in the West, or even Advocate Christ in the south suburbs.
Turner’s death, as you can imagine, led to a tremendous fallout between the University of Chicago and the surrounding community. Community members had already for years pressured the University administration and the City of Chicago to establish a trauma center that would service the south side. Turner’s shooting was yet another catalyst in this drawn-out campaign. Almost immediately there were protests on campus and even within the hospital.
Eventually, in 2014, the University of Chicago agreed to increase the age threshold of its pediatric trauma center from fifteen to seventeen. In 2015 it announced its decision to open a trauma center for adults, and its doors opened officially in 2018. It is now the busiest trauma center in Chicago, outpacing the legendary Cook County Hospital.
Turner’s death directly impacted Chicago’s trauma landscape. It also had a more personal impact. It was largely through his case that I learned about the war at home. I learned about poverty and violence in medicine and about the food deserts that existed in our own backyards. I learned about the historic neglect of the south side by the City of Chicago. I also learned that I existed in my university’s bubble. I was surrounded by the University of Chicago’s beautiful gothic architecture and well-manicured lawns. I lived in state-of-the-art dormitories and ate at buffets in our dining halls. Just on the other side of Cottage Grove was desolation.
In the decade to follow, Turner’s death and stories like his compelled me to think about trauma systems and how they should be developed to optimize care for everyone in a community. A 2012 study by Dr. Mary Crandall, who was a trauma surgeon in Chicago at the time, examined ‘trauma deserts’ and found that patients who sustained gunshot wounds more than five miles from a trauma center were associated with a significantly greater risk of mortality compared to those injured within five miles from a trauma center that could care for them.
His death also encouraged me to think about race in medicine. This was a topic I was drawn to throughout medical school and into residency, and during my dedicated research years at MetroHealth Medical Center, I was fortunate to study one aspect of it. Here, our group was able to demonstrate that black patients had significantly lower rates of mortality in high black-serving hospitals compared to those who were treated at low black-serving hospitals, suggesting at least some degree of racial bias.
We now return to the Gaza Strip.
It is January 18, 2009, the end of a twenty two-day assault on Gaza. Operation Cast Lead.
All in all, twelve hospitals were damaged or destroyed as were dozens of health clinics. Dozens of ambulances were destroyed or were left with lasting damage.
As a result of fuel restrictions along Gaza’s militarized and blockaded borders, hospitals experienced twelve to eighteen hour power outages every single day. Nearly two dozen medics were killed. Hundreds of medications were either depleted, expired, or on low supply.
Palestinian boys climb concrete slabs where homes once stood, Gaza Strip, 2011
I returned to Gaza in 2011. During that time, I documented the rebuilding process, including areas not yet rebuilt.
Destroyed villa along the Gaza coast, 2011
Here is a damaged villa along the coast.
“Z” survived an airstrike but with grave injuries, 2011
I also interviewed people who had been injured during the assault. Here is “Z”, a little older than me when I met him. He survived an airstrike but with serious injuries. He lost one of his legs and sustained internal bleeding. He was in the ICU for about twenty days.
A box of examination gloves donated to Al-Shifa Hospital, 2011
I met with physicians at Al-Shifa Hospital, Gaza’s largest hospital. Al-Shifa is a few blocks away from our family’s homes and I have imagined working and even teaching there.
By the end of the assault, it was estimated to take three to five years and two billion dollars to rebuild the Gaza Strip’s medical infrastructure. Even more effort, including international diplomacy, would be needed to evacuate patients to hospitals outside of Gaza and to coordinate the restocking of equipment and medications sent in from outside of the besieged territory.
But that was in 2009. You have all heard of Gaza in the news, I am sure. The situation today is so much more dire.
Over one hundred thousand are injured. Twelve thousand are in need of medical evacuation. There are no fully functional hospitals – just a handful of hospitals functioning at reduced capacity. Over one hundred ambulances have been destroyed, and about four percent of the healthcare workforce has been killed. This includes nurses, pharmacists, clinical educators, and physicians and surgeons like yourselves.
One year ago, Gaza maintained an estimated one hundred and forty to one hundred and fifty operating rooms. There are now only twelve remaining in service. There are no cancer centers anymore. There are no limb reconstruction centers either.
The medical infrastructure is crumbling in the setting of severe resource shortages. Anesthetics are in short supply. There are reports of entire surgeries, including amputations and laparotomies, being performed without or with limited anesthesia. Antibiotics are also on short supply. Dressing supplies are fashioned from whatever is available. Airway supplies might have to be reused. Chest tube kits and tourniquets – things we take for granted in hospitals and even in our own trunks – must also be fashioned with whatever materials are nearby.
When we think of war, we tend to appreciate those suffering from acute injuries – gunshot wounds, blast injuries. But also suffering are those with chronic conditions whose care has been cut short. There is a relatively high prevalence of hypertension and kidney disease in Gaza for a variety of reasons, and dialysis is instrumental in this population’s care. There is limited access to dialysis machines now. Cancer care is entirely interrupted, meaning no chemotherapy, no radiation therapy, no follow up. Infectious disease is on the rise, including polio. Neonatal and maternal compromise are major concerns, as is malnourishment and even starvation.
Altogether, these vignettes in Chicago and in Gaza have given me purpose and, over time, have compelled me to pursue what I hope will be a meaningful career in trauma surgery and critical care.
Looking Ahead
Stories are nice when they come full circle. I am grateful to have a full circle moment myself. I have the great honor of returning to the University of Chicago, this time as a fellow in adult trauma and surgical critical care at a trauma center that did not exist but was sorely needed when I was a student there.
During this fellowship, I look forward to the opportunity to serve neglected communities – ones that I have even neglected myself – and to contribute to its mission. I also look forward to building a skillset that I can apply in future endeavors.
More specifically, I intend to emulate austere conditions during my training. A number of faculty members have experience in these conditions and may even have military or combat experience. When safe, of course, I will try to complete parts of a case with only a knife, for example, as opposed to using electrocautery which may be a luxury in resource-poor settings. I will also get to spend time with E.M.S. staff. I intend to learn about the logistical challenges they face and the stresses of caring for people during their ‘golden hour’ so that I may be better informed of what pre-hospital care looks like and requires. During my second fellowship year, which will be an adult trauma year, I plan to formally study Chicago’s trauma landscape and to learn strategies that I can then apply to future efforts in designing or optimizing trauma networks. And during my first year, which will be a critical care year, I will learn to be a comprehensive surgical intensivist which will prepare me to be self-sufficient, as I can imagine being in circumstances in which I only have myself to depend on.
And at the end of the day, my goal is to become a war surgeon.
I hope to apply the skills and knowledge that I have learned here, under your guidance, and in fellowship to directly impact communities I am serving. I also hope to build, optimize, or support infrastructure that can sustain itself without my presence.
I am particularly interested in pre-crisis and pre-incident preparedness. Another niche interest is the development of mobile surgical units. This idea is not novel – these units have been deployed in many parts of the world although they pose a unique set of challenges that I wish to take on. I wish to also maximize and employ remote support, which is especially apt in today’s telemedicine era.
The idea of remote support to benefit those in austere environments already exists in practice. In a 2024 paper by Dr. Khaled Alser in the Lancet, his group shares a series of cases to demonstrate that peer-to-peer telemedicine can certainly assist surgeons in high-risk, low-resource environments. They share details behind a WhatsApp group involving over a thousand physicians from at least fifteen medical specialties all guiding surgeons in Gaza to manage problems they are not formally trained in managing.
I have the great privilege of being part of this WhatsApp group. Here are representative screenshots of the conversations. Typically, a surgeon in Gaza will present a case or a challenge and people from all over the world will share their expertise. This compels me to think of a phone app with verified volunteers who will be on call for a day or a week and who, during these times, can respond to urgent or emergent calls for help from parts of the world they are assigned to. Of course, this requires a functional phone and internet access – two things that are not guaranteed in conflict or disaster zones. There are challenges, but the idea can still be executed.
Lessons I Carry
The first lessons I carry with me are the two imparted by my parents: educate yourself – pursue education – and pursue impact. Second, do not neglect your backyard. We tend to think of problems and inefficiencies and resource-limitations as external to us, but they are here, too. And finally, problems like war and neglect are manmade, so their solutions must also be manmade. We are the solutions. It is up to us to make this world a better place.
I return to what my aunt told me in the year 2000. “We need you to help your people.”
This is her from just a few months ago in what is left of her home. She is safe, she is alive. I hope she will be proud of me.
Date of presentation: October 23, 2024
Sources:
World Health Organization
United Nations Office for the Coordination of Humanitarian Affairs
Healthcare Workers Watch
The Lancet
Canadian Medical Association Journal
Save the Children
Médecins Sans Frontières
Conflict and Health (Journal)
Journal of Trauma and Acute Care Surgery
American Journal of Surgery
American Journal of Public Health
Crain’s Chicago Business