I remember clearly the day I became a thief.
For a surgeon, the concept of stealing as part of clinical practice seems antithetical, yet it struck me as the best available option on that sweltering evening of June 6, 2014.
Since early April of that year, I had been serving with Médecins Sans Frontières (Doctors Without Borders; MSF) at a hospital in Ramtha, Jordan, caring for victims of the Syrian civil war who had been streaming across the northern Jordanian border 1 kilometer away. On any given day, we were operating upon 10 to 12 patients and performing rounds and wound care on another 40 war survivors housed in our inpatient facility. The wounds were bloody, devastating, and horrific, most caused by explosive munitions (such as artillery rounds and barrel bombs). Since the start of the war in early 2011, the Syrian government had declared opposition medical facilities as legitimate terrorist targets, bombing them whenever discovered. Most Syrian hospitals had closed, their doctors killed or, if lucky, becoming refugees in other countries.
That first Friday in June was a holiday for most -- al-Jumaʿah, the weekly Islamic day of attending mosque. But as our hospital's only surgeon, I still had to make ward rounds to inspect amputation stumps, change dressings on gaping wounds, monitor for fever and infection. June is hot and dry in northern Jordan, with just a slight breeze to make it pleasant, yet most of us expats -- 11 international MSF staff from countries as far away as India, Kenya, the Netherlands, and the USA -- spent the afternoon in our local residence house, catching up on laundry, Skyping family, and cooking together our weekly communal dinner.
By 11:00 p.m. I was preparing for bed when my cell phone rang: a fresh trauma arrival from the Syrian border. I grabbed a driver and made the ten minute ride into the hospital ER, where I found the ward physician, Dr. Hussein Al-Qudah, attending to an injured youth of ten years. "What happened?" I asked.
Hussein finished placing an intravenous line and looked up. "This afternoon, this boy and his three brothers found an unexploded cluster mine in their backyard," he said. "According to the father, they thought it was something to play with." He shook his head. "Then it went off, and all four were hurt like this one."
I approached the boy (who I'll call "Adham" for confidentiality) to examine him. He was conscious, with a good pulse, but breathing rapidly due to anxiety and pain. A thorough head-to-toe appraisal only elicited two injuries -- complex tibial fractures at both ankles, with most of the soft tissue completely blown away.
After giving the patient some morphine, our ER nurse and I redressed the wounds, while Hussein called in the rest of the operating room team. I knew it would take a number of hours to properly clean his wounds and stabilize his fractures under good anesthesia, and even then we might not be able to save his lower legs. Amputating would be quickest, but this youth deserved a chance to keep his feet. So much for a good night's sleep. Then something occurred to me.
"Hussein, where are his brothers?"
"Two are still in Syria with the father. The border guards would only let the most critically injured, this one and his younger brother, cross over and come to our hospital."
"So where's his little brother?" I asked.
Hussein, usually the epitome of cool efficiency, swallowed with difficulty and cocked his head. "The five-year-old, 'Tarek,' arrested twice on his way here. The ambulance attendants on the way from the border were able to restart his heart each time, but, since we have no ICU beds right now, we had nowhere to put him but the last monitored bed in the Jordanian wing of the hospital." MSF rented space from the Jordanian hospital to run our trauma center for the Syrian casualties. On occasion, we ran out of intensive care beds, and we pleaded with our Jordanian partners for an extra bed and the staff to handle the overload.
Hussein and I stared at each other. We both knew that the Jordanian hospital staff had a different standard of care from MSF, and the potential ramifications for little Tarek. At this point I had to make a decision: do I trust them to take proper care of the child, or do I play "meddlesome OCD American surgeon" and assure their ICU was taking the right steps to keep him alive? It took about five seconds to decide.
"Our OR crew won't be ready for 15 minutes," I said to Hussein. "Since we have time, let's go eyeball little Tarek."
When we arrived at his bedside, the ICU was dark, quiet and mostly deserted. No vigorous resuscitation, flurry of activity, or beeping heart monitors. Tarek, covered in blood-soaked bandages, lay still, barely breathing. Hussein studied his bedside chart as I touched the child's skin -- cold and clammy. Blood slowly pooled beneath his legs on the sheets. I saw no intravenous lines, no monitor wires, no oxygen.
"His hemoglobin's three," Hussein said. Blood thinner than Kool-Aid, I thought. His ICU nurse heard us and approached.
"What's the plan?" I asked through Hussein, who translated into Arabic for me. "IV, blood resuscitation, OR tonight?"
After a brief consultation with the nurse, Hussein turned to me and explained. "She said their surgeon thinks his case his hopeless. He went to get some rest, but if Tarek is still alive in the morning, he will give him blood and take him to surgery."
As Hussein finished speaking, I saw a look in his eyes that conveyed frustration, anger, but, mostly, sadness. His eyes also seemed to be pleading to me, as if I should do something.
So I did something. Something I hope I'll never to have to repeat. For the first time in my life, I stole a patient.
I reached down, scooped Tarek up in my arms, and turned to the ICU nurse. "We're taking this child to the MSF operating room," I said. "Our team's all here, we're operating already, and we can take care of Tarek right now. So just let your surgeon sleep."
Hussein and I turned and strode briskly from the dark ICU. Thinking only of the surgery ahead, I refused to look back.
In 2016, the Syrian Center for Policy Research reported that 470,000 Syrians had died due to the civil war since it started in March 2011. Forty percent of these were women and children, most killed by indiscriminate government bombing using artillery-launched cluster munitions (each shell carries 40 or more scatter mines, like the one that injured Adham, Tarek, and their brothers) and barrel bombs (petroleum drums filled with explosives and shrapnel and detonated over civilian population centers). Another 1.9 million have been injured, 4.8 million have fled the country as refugees (especially to Turkey, Lebanon, Jordan, and to the EU via the dangerous trans-Mediterranean routes from Libya and Turkey), and 7.6 million -- half the population -- are internally displaced, forced from home due to the war with nowhere else to go.
To date, 1 in 10 Syrians have been wounded or killed in their civil war. Syrian life expectancy has dropped from 71 years to 55 years.
Since 2011, Physicians for Human Rights has documented 336 attacks by government forces on medical facilities, with the resultant deaths of 697 medical personnel. MSF operated 6 hospitals within Syria from 2011 to early 2014, but due to repeated bombing by government forces as well as kidnapping of 5 expats by ISIS in 2013, MSF no longer possesses facilities within Syria, only along its borders. However, it continues to support existing Syrian medical facilities with money, supplies and equipment. In 2015 alone, MSF reported 94 attacks on the 60+ hospitals it supports in Syria. Twelve were totally destroyed, and 81 medical workers were killed or injured.
Hussein and I rushed Tarek into our MSF operating room and Elma, our British anesthesiologist, rapidly put him off to sleep and administered blood as I put tourniquets on both legs and his right arm, then a tube into his right chest, since some of the mine's shrapnel had injured the lung on that side.
Next I took the bandages off of his legs, and nearly fainted.
An Army trauma surgeon for 20 years, I'd seen my share of horrific, grotesque injuries. All else paled in compared to seeing this sweet child's mutilated legs, ripped to shreds by the mine's explosion as if both had been run through a meat grinder then singed with a blowtorch.
I took a few deep breaths, held on the operating table for support, then willed myself to continue with surgery. After everything he had been through, I could not fail Tarek now: he needed resolve, not pity.
In quick order, I amputated both legs at the knee: most of the bone and soft tissue was gone or destroyed, but there was enough posterior skin and gastrocnemius to make flaps. On his right hand, all the fingers were destroyed, but I was able to save the palm, which could come in handy for him down the road.
By 2 a.m., Tarek's surgery was done and he was stable enough for a regular ward bed. No need for the ICU again! But then I had to address his brother's wounds. That took two hours, cleaning all the dead tissue and dirt but trying to leave enough to save Adham's feet. At the end, I had little confidence he would ever walk on those feet again.
We finished right at 4:30 a.m., confirmed by the chorus of muezzin broadcasting the Fajr -- the morning prayer -- from the minarets of every mosque in the city. After two months in Jordan, I had finally trained myself to sleep through it, but listening to it now, I felt the urge to pause a moment and give thanks to the Lord myself.
I arrived back at the expat residence house just as the sun was rising, and, as was my usual routine, I made a pot of coffee and drank a large mug. One by one, the other awakening expats straggled into the kitchen, shuffling their feet like the undead. After choking down my coffee with some Nutella-laden pita, I finally got some sleep myself. But only three hours: Elma and I had eight operations to complete that afternoon.
Image: Tarek learning to walk with prosthetic legs. Photo by Dr. Hussein Al Qudah
My first MSF mission to Jordan ended five days later. Tarek and Adham both survived, although they'd need many more operations by my successor in the weeks ahead. The work in Ramtha seems never to let up.
Investing so much emotion and effort in their initial care, I asked my Jordanian MSF colleagues to keep me posted on Facebook with updates on Tarek and Adham. Through messages and photos, it was heartwarming and reassuring to see their progress -- wounds closed, birthdays celebrated, Tarek's prosthetics received, Adham's feet saved, and, finally, both walking again. A year later, I returned to Ramtha for another two-month surgical mission and was fortunate to see the brothers, who had also returned from a Syrian refugee camp for a checkup. Their vitality and smiles made me ponder the question: Would I steal again, risking reputation and professional standing, to save the life of a patient?
The answer came easily:
In a heartbeat.
With humanitarian medical care of underserved populations their only mission, MSF physicians vigorously defend the rights of the sick and injured to unobstructed, quality health care. Readers wishing to donate to or volunteer with Doctors Without Borders/Médecins Sans Frontières and help support them in providing emergency medical care to populations in distress around the world can do so at doctorswithoutborders.org.
A graduate of the U.S. Military Academy, West Point, and the Medical College of Virginia, Richmond, Dr. David Elliott completed a residency in general surgery at Walter Reed Army Medical Center in 1988, and a fellowship in trauma and critical care at the R. Adams Cowley Shock Trauma Center in Baltimore in 1993. Colonel Elliott served as trauma surgeon and intensivist for the US Army for twenty years, and, most recently, he has served as a general and trauma surgeon on eleven missions with MSF, in South Sudan, Nepal, the Central African Republic and on the Syrian border of Jordan.
Previously published in the Richmond Times-Dispatch. All patient information shared with permission.