February 20, 2009

More than 5,000 people in the Gaza Strip were wounded during attacks by the Israeli army between December 27, 2008, and January 18, 2009. Many are now entering post-operative care in order to reduce the risk of complications and recover as much mobility as possible. Patients receive care in three MSF post-operative clinics in the Gaza Strip and also through MSF mobile clinics. Michèle Beck, MSF medical coordinator in the Gaza Strip, describes post-operative care needs as reflecting the “changing temperature” of the conflict in the Gaza Strip.

What kinds of injuries are you seeing among patients who entered the program since the ceasefires on January 17 and 18?

Nine out of every 10 new patients have injuries related to bomb explosions—primarily fractures and wounds. Nearly half the 196 patients admitted into MSF’s post-operative treatment programs since the ceasefire are being treated for one or more limb fractures, often involving the legs. We are also seeing lots of burns, which is new. Today, more than one of every 10 new patients is treated for burns, with 10 to 15 percent of the surface of the skin affected. Many civilians have been wounded. More than one-third of patients admitted since mid-January are children under the age of 15, women, and the elderly.

Since the program opened in July 2007, work in this area has varied based on the nature and level of the violence. When it involves clashes among Palestinian groups, we treat primarily young men with bullet wounds. During Israeli offensives, we treat patients with multiple wounds, both male and female and of all ages. The key difference between the latest Israeli military operation in late December and early January and that of last March, for example, is the very high number of wounded, particularly the number of civilians. Otherwise, the nature and severity of the wounds are similar.

During the war, Palestinian medical aid organizations and international medical aid groups on the ground criticized the serious obstacles to reaching the wounded. Are you now seeing the impacts of delayed treatment?

There is no question that the wounded were often unable to receive necessary medical treatment. With regard to post-operative care, it is hard to say whether the consequences we see related to the delay between injury and initial treatment or resulted from leaving the hospital too soon (itself a result of the need to quickly free up beds for the newly wounded). However, 25 percent of every 100 new patients have infected wounds and an additional 45 percent have a high risk of infection.

Since reopening the post-operative programs, the number of new patients who needed their wounds dressed is three times the average. There are so many wounded patients that we have changed our strategy. Those with less serious wounds and patients seen earlier who are nearly recovered are sent to health centers. Wounded patients who need only physical therapy are placed on a waiting list. While that treatment may be less urgent, the longer the delay, the harder it will be for patients to recover muscle strength and increase their mobility. On February 8, we opened a third rehabilitation clinic in the northern Gaza Strip. In total, we have 337 patients in the MSF post-operative programs.

Can you determine the number of wounded who will experience long-term disability?

Wounded patients are receiving treatment in a range of medical facilities, so only a large-scale epidemiological survey could answer that question.

The information provided by MSF’s post-operative treatment program does not represent all wounded patients because inclusion criteria target the seriously wounded. Those with very serious wounds were often sent abroad for treatment. What we can see is that among the patients in post-operative care, half of those who are in physical therapy will experience after-effects of varying severity.

The disability among those who have undergone amputation is obvious. Twenty patients now in the program have lost one or more limbs. Following post-operative care, other organizations will take over from MSF to provide prostheses, for example. More than 30 patients will experience significant disability resulting from loss of function in a joint—whether ankle, wrist, elbow, or knee. Approximately 20 patients have lost sensation in one or more areas. This can be treated in some cases, but treatment lasts between six months and one year and does not always produce the hoped-for results. If the nerve has been severed, surgery is required. However, there are no doctors in Gaza today who specialize in that kind of neurological surgery.

Today, we face a particularly difficult situation—a large number of patients with multiple wounds who will ultimately have multiple disabilities. I’m thinking of a patient with multiple fractures to the right leg, left leg, and one arm, and another who underwent a bilateral amputation and was also wounded in the abdomen. We discuss the diagnosis gradually with patients and also work with the MSF psychosocial program team to provide psychological support to those patients who need it.

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